F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.164165.1 Research Article Articles Community-based Participatory Action Research Approach for the Development of an Arabic Culturally Sensitive Pain Neuroscience Education: A Qualitative Focus Group Study with Physical Therapists and Individuals with Chronic Low Back Pain in Lebanon.

[version 1; peer review: 1 approved with reservations]

 Najem Charbel Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Software Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-2639-6560 a 1 2 3 A.J Wijma Formal Analysis Methodology Writing – Original Draft Preparation 3 4 5 M. Meeus Conceptualization Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0002-2022-5114 1 3 6 B Cagnie Methodology Writing – Review & Editing 1 AL Achek Mikel Formal Analysis Investigation Methodology Writing – Review & Editing https://orcid.org/0009-0009-4776-5821 2 F Ayoubi Methodology Writing – Review & Editing https://orcid.org/0000-0002-6659-285X 2 7 Oosterwijck J Van Methodology Writing – Review & Editing 1 3 6 8 K De Meulemeester Methodology Writing – Review & Editing 1 3 C.P Van Wilgen Conceptualization Formal Analysis Methodology Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-0688-4172 3 4 5 Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Ghent University, Ghent, Flanders, Belgium Department of physiotherapy, Antonine University, Baabda, Mount Lebanon Governorate, Lebanon Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, 1031090, Belgium PAIN – VUB Pain in Motion Research Group, Department of Physiotherapy, Vrije Universiteit Brussel, Brussels, Brussels, Belgium Transcare Transdisciplinary Pain Management Center, Groningen, The Netherlands MOVANT Research group, Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Flanders, Belgium Department of physiotherapy, Lebanese University, Beirut, Beirut Governorate, Lebanon Research Foundation Flanders, Brussels, Brussels, Belgium Charbel.najem@ua.edu.lb

No competing interests were disclosed.

 22 9 2025 2025 14 959 13 9 2025 Copyright: © 2025 Najem C et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

This study aimed to co-design culturally adapted pain neuroscience education (PNE) materials for a Lebanese population. The developed material aimed to enhance patients’ understanding of pain and its influences, offer strategies for self-management, and promote healthier lifestyles.

 Methods

Employing a community-based participatory action research (PAR) approach, insights were gathered from PTs and male and female patients with chronic low back pain (CLBP), who were the end users of the co-designed product. PAR, rooted in bridging universities and communities, emphasizes the active involvement and actions of individuals within impacted communities, fostering collaboration and engagement throughout the research process. Data from the PAR groups were subjected to reflexive thematic analysis.

 Results

Twelve individuals with CLBP, and eight PTs, participated in the interviews. They represent diverse educational backgrounds, religious affiliations, and regions across Lebanon. Three key themes were identified by exploring the cultural adaptation of PNE material: the ecological validity model (EVM) dimensions, implementation challenges, and lived experiences of CLBP patients, shedding light on their personal and religious perspectives on pain.

 Conclusion

This study emphasizes the need for ongoing refinement and collaboration to effectively implement PNE in diverse populations. Utilizing frameworks such as EVM and the Barrera model ensures alignment with cultural norms while addressing specific cultural contexts such as appearance, pain beliefs, and religious influences. alignment with cultural norms while addressing specific cultural contexts such as appearance, pain beliefs, and religious influences.

 Pain cultural adaptation pain neuroscience education Lebanon cultural beliefs. The author(s) declared that no grants were involved in supporting this work. Introduction

Chronic pain (CP) is a common, challenging, and distressing problem that affects both society and individuals. 1 Chronic pain is caused by complex interactions among biological, psychological, and social factors. Understanding chronic pain in a biopsychosocial model (BPS) context will help develop treatment plans and prevention strategies. PNE is an evidence-based intervention that incorporates the multidimensionality of a pain experience and helps patients re-conceptualize pain through the understanding of the multiple neurophysiological, psychosocial, and physical components that may be involved in their individual pain experience. 2– 5 However, the existing PNE materials are limited to a few languages and cultural backgrounds. Many cultures have distinct cultural beliefs regarding the meaning, origin, and role of pain, which can affect how a patient interprets and perceives pain. 6– 9 Moreover, a growing body of research has indicated that behavioral interventions aligned with the norms and values of a specific cultural group are more effective than interventions in their original form. 10– 12 Therefore, evidence-based pain management strategies developed by clinicians in one culture may not necessarily be understood, appropriate, or effective in another.

Cultural adaptation is an effective approach for developing effective PNE materials for subcultural groups. Cultural adaptation is “the systematic modification of an evidence-based treatment (or intervention protocol) to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meaning, and values”. 13

Several models have been proposed to guide cultural adaptation have been proposed. 13 Although these models appear to have been developed independently, they exhibit considerable consensus. In one of the early stage models, Barrera and Castro (2006) proposed a sequence of four intervention adaptation stages: (a) information gathering, (b) preliminary adaptation design, (c) preliminary adaptation tests, and (d) adaptation refinement.

The first stage of the adaptation model, which includes information gathering from end users of the material, including patients and physical therapists, was completed in two qualitative studies 14 to comprehend and analyze barriers and facilitators for the implementation of PNE in the Lebanese physical therapist’s healthcare approach and to understand the illness perception of Lebanese patients suffering from chronic low back pain (CLBP).

The results from the latter studies expressed a need for PNE implementation, since both the patients’ illness perception and the Lebanese physical therapist’s approaches and perceptions are based on a biomedical explanatory model.

Lebanese physical therapists lack knowledge of CP. 14 Further, several factors greatly influence Lebanese culture, and they do not follow Western cultural traditions. Lebanese people tend to develop strong family relationships that help them with alternative distress problems and depend on family members for support and assistance. 15– 16 In addition, the Lebanese community values an individual’s honor and respect dramatically. Lebanese people expect respect for their traditions, values, and religions. 17, 18 The materials used must consider these values and traditions. To develop PNE materials that address these issues, it is essential to involve end users in the development process to ensure that initial efforts are relevant to the individuals who will ultimately use them, which inevitably are individuals with CP and physical therapists.

This study’s most crucial objective and aim is co-designing culturally adapted PNE material for the Lebanese population. A culturally adapted PNE design means that the material would apply to all people in Lebanon regardless of sex, age, education, religion, and other identity factors. To the best of our knowledge, this adaptation has never been performed before. Another objective was to assess the ecological validity of the newly designed PNE material. This paper discusses the preliminary adaptation design, tests, and refinement. The developed PNE material should help patients understand the nature of pain and the factors that influence pain experiences and provide them with self-management strategies for mitigating pain and promoting healthy and active lifestyles.

 Methods Design

A qualitative community-based participatory action research (PAR) approach 19 was employed to gather comprehensive insights from physical therapists, male patients, and female patients with CLBP, all of whom served as end users of the co-designed product. PAR development is a product of intellectual and activist work bridging universities and communities. 20 PAR is a meaningful approach that plays a vital role in community development by highlighting the active involvement and actions of individuals within the communities affected by research. 21, 22 This co-design methodology fostered active collaboration and engagement with the stakeholders (physical therapists and patients) throughout the research, ensuring that their valuable input and perspectives were integrated into the development of health services. 23 The data collected from the PAR groups were subjected to reflexive thematic analysis, 24 combining both deductive and inductive thematic analyses. This study involved three PAR focus groups: eight physical therapists caring for patients with CP, six male patients, and six female patients with CLBP. Each gender was grouped together to facilitate more comfortable communication and honor cultural considerations. Two semi-structured questionnaires, one for patients and the other for physical therapists, were used to gather information during the focus groups. The interviews were transcribed verbatim first and then translated from Arabic to English by a professional translator. The leading researcher (C.N.) double-checked the transcripts for accuracy.

 Ethical approval

The study protocol was approved by the Antonine University, Lebanon (reference number: 1063-2023, 5-7-2023). All the participants in the focus group signed an informed consent form. Confidentiality was guaranteed. To ensure anonymity, the participants were assigned an identification code. Physical therapist participants were assigned the identifier PT#, and participants with CP were assigned the identifier MP# for male participants or FP# for female participants.

 PNE material

(C.N.) developed a draft of the PNE teaching material. The core material for the culturally sensitive PNE program was based on specific guidelines 25, 26 and books “Explain Pain” 27 “Why Do I Hurt”. 28 Based on the current knowledge of PNE, the culturally sensitive Lebanese PNE material was designed by (C.N.) and an illustrator to explain the well-known core concepts of PNE: the differences between acute and chronic pain, the neurophysiology of pain, central sensitization, factors related to the increased sensitivity of the nervous system, and the role of stress. However, different female and male characters were developed, each with their own characteristics and stories of acute and chronic pain, to make the educational programme more interactive. The EVM 29 used during adaptation was chosen for its comprehensive consideration of the culturally sensitive dimensions in the design. Thus, it provides a holistic framework for the PNE design and adaptation. Eight culturally sensitive dimensions of intervention were explored (language, persons, metaphors, content, concept, goal, methods, and context) in the design of the first draft of the culturally sensitive PNE material to ensure that the designed material was understandable, acceptable, and relevant for the Lebanese population.

Teaching materials were tailored separately for Lebanese individuals based on their gender and ethnic background. There were 45 slides designed specifically for men, encompassing the diversity of Lebanese men. In Lebanon, men exhibit similar physical characteristics regardless of their religious or ethnic backgrounds. Additionally, separate sets of 45 slides each were prepared for women, with one set representing Christian women and the other set representing Muslim women.

The first drafts of the PNE materials were prepared in English to ensure clarity and comprehension by a co-researcher group from Ghent and Antonine universities. All eight researchers (C.N., A.W., M.M., B.C., P.V.W., K.M., J.V.O., and F.A.) were physical therapists experienced in PNE programs and publications. Two of them are native Arabic speakers familiar with Lebanese culture and background (C.N., F.A.). Feedback from the co-research group was used to enhance the first draft of PNE. Following this, a professional translator translated all the materials into Arabic, which was then checked by (C.N.). A professional graphic designer performed all drawings in the materials based on the feedback of (C.N.) and co-researcher group.

 Participants

Physical therapists

A focus group interview with practicing physical therapists was conducted in July, 2023. Purposive sampling was utilized to achieve diversity and to obtain a representative sample from different governorates and religious backgrounds. 30 Physical therapists from various governorates across Lebanon were selected to ensure comprehensive representation. Physical therapists were recruited through social media and contact with the order of physical therapists in Lebanon. Physical therapists were eligible if they had at least three years of experience working with individuals with CP. Eight practicing physical therapists were contacted for this study.

The physical therapists’ demographic data were covered by answering questions related to age, sex, highest degree obtained, years of experience, current area of work, practice setting, and the number of patients with chronic pain seen in practice.

Participants with CLBP

Participants with CLBP were recruited from three private physical therapy clinics. One clinic was located in Mount Lebanon’s governorate and two clinics were in Beirut. Two homogeneous focus groups were organized according to gender (female or male), age, ethnic TECHNbackground, and participants’ perceived native location, ensuring representation in both rural and urban areas. Therefore, six female patients (three Christians and three Muslims) and six male patients (three Christians and three Muslims) were recruited. Qualified participants were individuals between 30 and 50 years old, mandated to be Lebanese citizens, with a medical diagnosis of CLBP persisting for at least six months, and could communicate effectively in Arabic. Participants in the patient focus groups provided written informed consent and were offered a small honorarium for their transportation fees and time to participate. Basic demographic information (age, sex, marital status, and highest education level) was collected from patients with CLBP.

Researchers

Data analysis was performed by four researchers, three of whom had training in qualitative research (C.N.), a physiotherapist, and a manual therapist (MSc.), and Ph.D. researcher in chronic pain living in Lebanon. The second researcher (M.A.), a Lebanese physiotherapist (DPT), assisted with data collection and analysis. The third researcher (A.W.) was a physical therapist scientist (MSc.) with a doctoral (Ph.D.) focusing on chronic pain, qualitative research, biopsychosocial factors, and PNE. The fourth researcher (P.V.W.) was a physiotherapist, psychologist, and epidemiologist (MSc. Ph.D.), focusing on CP, PNE, and qualitative research. Both (A.W.) and (P.V.W.) were obtained from the Netherlands. A co-researcher group from Ghent and Antonine universities was established to work with the research team in all stages. This co-researcher group was involved in the development of the research protocol and first PNE draft.

Procedure

The focus group with physical therapists was conducted in one of the Antonine University classrooms. A quiet conference room within one of the private rehabilitation clinics was used for the focus group.

The focus groups were led by (C.N.), who provided a general introduction to the purpose of the session. They then encouraged participant engagement, questions, and prompts as required and ensured that all participants could contribute. A second researcher (M.A.) ensured that all participants had the opportunity to express their views and take charge of audio recordings. The assistant moderator (M.A.) was in the best position to record information about the level of consensus and dissension during the focus group of physical therapists using a micro-interlocutor analysis approach. 31

During the focus groups, the moderator (C.N.) started the session by introducing PNE and its effectiveness as an evidence-based approach. The participants were then shown the design material. The material was designed around several sections (acute pain, pain neurophysiology including pain modulation, chronic pain, psychosocial factors related to CP, central sensitization, role of stress in chronic pain, and lifestyle modifications). Cognitive interviews were conducted. Cognitive interviewing 32 is an approach used to provide insight into learners’ perceptions, in which individuals are invited to verbalize thoughts and feelings as they examine information.

Data handling and analysis

Aligned with the objectives of the study, the transcribed content from focus groups underwent reflexive thematic analysis. The coding process was facilitated using (QSR NVivo version 12.0), which is computer-assisted qualitative data analysis software. A combination of deductive and inductive thematic analyses was used. Inductive analysis codes the data without fitting them into a pre-existing coding frame. 33 A deductive approach involves coming to the data with preconceived themes that you expect to find reflected based on theory or existing knowledge. 34 Therefore, to achieve the objectives of this study, a combination of empirically controlled and theory-driven themes was used in the analysis. This study conformed to the Standards for Reporting Qualitative Research (SRQR). 35

The coding procedure comprised several steps: (1) researchers (C.N.) and (M.A.) immersed and familiarized themselves with all transcribed texts. (2) To ensure dependability, interview coding was performed independently and blindly by both the researchers. Comparative reviews and discussions have led to consensus on the codes. The first phase of coding, open coding, involved an inductive approach to identify and categorize words, sentences, and paragraphs. During the axial coding phase, a hybrid approach was employed, incorporating both inductive and deductive methodologies. Additionally, they encouraged the identification of categories and codes through an inductive approach, demonstrating receptiveness to emerging themes, alongside their deductive framework. (3) Postcode generation: the focus shifted to sorting codes with similar meanings to the initial subthemes. The three rounds of discussion aimed to enhance the development of these initial subthemes. (4) Discussions between researchers (C.N.) and (A.W.) refined the initial subthemes, organized them, and identified relationships, eventually arranging them into themes. (5) Three researchers, (C.N.), (A.W.), and (P.V.W.), agreed on refining and naming themes. (6) (Finally, they produced the results by agreeing on the order in which to present the themes, select examples of data to illustrate each theme, and analyze those examples .

Trustworthiness

The criteria outlined by Lincoln and Guba 36 were employed to ensure the quality of the study. Several measures were implemented to address credibility, including the use of a semi-structured interview guide, audio recording of the focus groups, verbatim transcription, fostering an open and non-judgmental focus group environment, peer debriefing for coding, and collaborative theme development by (C.N), (M.A), (A.W), and (P.V.W). A comprehensive description of the data was provided to enhance the transferability. Dependability was maintained through continuous monitoring and close auditing of the research process by the second and last authors, in conjunction with other team members. Conformability was established through ongoing discussions among the first, second, third, and last authors, which led to the generation of the definition of themes.

 Results Participants characteristics

Four of the eight physical therapists in the focus group were male and the remaining were female. The average age was 31.75 years. 23– 40 The total years of experience as a physical therapist ranged from one to more than 15 years, with two reaching a bachelor’s degree in physical therapy and six achieving a clinical doctorate in physical therapy. This degree differs from a Ph.D. with three years of postgraduate studies, preparing students with the competencies required to enter clinical practice. 37 Most physical therapists have experience in musculoskeletal pain, seeing at least five–ten patients per month with CP.

The physical therapist chose various governorates who deemed them the most accurate representation of their cultural heritage.

Twelve CLBP interviewees, evenly split between males and females, aged 32 to 56 years (average age: 38.5 years), were selected. Seven were married, with a full number completing high school; four held a bachelor’s degree, two had a master’s degree, and two held a PhD. Religiously, six were Muslims and six Christians, reflecting Lebanon’s diverse demographics. Participants were from the Beirut, Mount Lebanon, Beqaa, and South Lebanon regions. All participants were employed, except for one female participant, who considered herself a housewife.

Three prominent themes were developed to explore the cultural adaptation of PNE material for the Lebanese population through a co-design approach and focus groups involving physical therapists and patients.

 Theme 1: The EVM

The first theme revolves around EVM, encompassing eight dimensions (language, people, metaphor, content, concept, goal, methods, and context).

 Language

Despite the similarity between the spoken Lebanese and written Arabic, the participants recognized the need for adjustments in the Arabic Language used in the PNE material for effective communication and a better understanding. FP8: “ I believe that we should pay attention to the Arabic language because untrained users will be reading off of the material written in Arabic.”

Those adjustments were structured around a few linguistic nuances, such as:

Encouragement language: To enhance the acceptability of educational information, participants suggested adapting the language to be more positive.

FP5: “ Choose words that have positive connotations for the patient.”

FP2: “Instead of saying the way to recovery is painful, we can say the recovery is possible and safe.”

Softening of the used language. The participants suggested “softening” the language for a more approachable and user-friendly communication style. Some comments were about the choice of words or expressions to align better with Lebanon’s cultural expectations and communication styles. Softening the language aims to create a welcoming educational experience.

PT5: “We could say the lady wounded her finger instead of she cut her finger.”

Clarity Enhancement: Another critical insight from the participants was the need for increased clarity in the language used. PNE explanations in Arabic were perceived as redundant and heavy when spoken. Participants’ comments were structured around simplifying complex terms and ensuring that the spoken language aligned with the preferred communication style within the Lebanese cultural context, making it more digestible and engaging.

Original PNE Statement: “ The nervous system’s capacity to handle restricted and extensive activities

Adapted Clarity Enhancement: “A capacity for physical and psychological activities?”

Character or persons

The “person” dimension from the EVM model involves examining how well the cultural adaptation resonates with the Lebanese population, particularly regarding representation and identification with the characters used in the PNE materials.

Male and female characters.All: All participants commented that the male character was culturally adapted to resemble a Lebanese male patient, reflecting features standard to Christian and Muslim males in Lebanon. However, most agreed to portray him without suits. Participants believed that a male character without a suit would be more representative of the majority of Lebanese culture. MP1: “Taking off the suit is more common.”

Most participants commented positively on the inclusion of a Muslim woman wearing a hijab and a Christian woman without a hijab. They mentioned how this reflected an understanding of Lebanon’s religious and cultural diversity and how individuals could relate to and engage with the presented information. PT5: “ A Muslim patient wearing a hijab would be more motivated, more interested in the material.” PT8: “I like the idea of the hijab; they can relate to it.” FP5: “I believe that the character can be exhibited in a certain way depending on the community. Hence, the individuals in this community will be more concerned about the topic and can identify with the character.”

Metaphor

Another dimension of the EVM model is metaphors, which refer to the use of symbolic images to communicate complex ideas. Positive comments from the participants suggested that the metaphors resonated well with them. This implied that the chosen metaphors were culturally acceptable and relatable to some extent. FP1: “The kettle is associated with the Lebanese traditions.”

However, some participants suggested modifications, indicating room for improvement in making the metaphors more universally understandable, particularly across different age groups. FP4: “I have a comment regarding the clay pitcher since we are the last generation that used a clay pitcher. The participants suggested using a different metaphor or replacing the clay pitcher with a glass pitcher. Some comments on modifying metaphors were not directly related to cultural aspects but focused on enhancing overall acceptability and attractiveness by suggesting enhancement of the idea, color, or dimensions of a metaphoric scene. The following are some considerations for this aspect:

FP2: “ Flags are not recognized as symbols for ideas. Therefore, I prefer the symbol of an arrow with a cloud.”

Goal

The goal dimension within the EVM focuses on assessing whether the intervention or the designed material, such as the culturally adapted PNE, achieved its intended purpose for physical therapists and patients within the Lebanese population. Based on positive comments from physical therapists and patients, the PNE material seemed effective in reaching its goal. PT1: ’ I found the material interesting, and it covers all the aspects of pain education that the patient can understand. PT5: “This approach, “PNE,” can be the beginning of helping patients achieve their goals.” Physical therapists found that this approach could help improve communication with patients. PT7: “They will interact with us 100%.”

The PNE material met the expectations of both the physical therapists and patients. FP5: “The material is a combination of the biological and psychological causes of pain, and it is the first time since it has been that clear.”

Participants believed that the PNE material was applicable and relevant to real-world situations in Lebanon and in the context of the Lebanese healthcare system. MP4: “If this slide had been displayed at the beginning of the treatment, it would have solved 50% of the problem.”

Participants acknowledge that the PNE material can impact pain beliefs and attitudes.

PT2: “It is a scientifically proven way to change the patients’ beliefs.”

Delivery methods

One important dimension to consider when culturally adapting PNE for the Lebanese population is the delivery method.

The participants’ comments on the use of slides and PowerPoint presentations were positive. The agreement on this delivery method suggests that the participants found it effective and culturally appropriate. PT2: “Some people like to use PowerPoint since it is more interactive.”

However, some participants raised concerns about the availability of technology. PT8: “Laptops will not always be available in clinics or at the patient’s house.” Participants agreed to use printed cards with explanations either next to or behind them to deliver the PNE.

Consensus was reached regarding both delivery methods. PT2: “The material is great, for sure; it can be used in two different ways: through PowerPoint or cards.”

Participants agreed to eliminate the use of leaflets as a delivery method. The rationale provided was that having a healthcare professional explain that the information is preferred over patients reading it alone at home. PT2; “In my point of view, the patient should not be taking home the PNE material.”

The participants proposed integrating PNE into the curriculum for entry-level physical therapy students. PT1: “PNE should be integrated into the curriculum for students to be prepared and trained for if they had to work with the material one day”.

The participants agreed that the success of the delivery method in PNE was closely tied to the skills of the therapists facilitating the sessions. PT3: “The person presenting the material is more important than the material itself; he should be engaging with the story that he is telling.”

Therapists should have a deep understanding of the material and possess practical communication skills to convey information in a culturally sensitive manner. PT7: “The physical therapist should have certain skills, such as good communication.”

Context

Context is an essential dimension within the EVM model that plays a crucial role in understanding how well the designed PNE material fits the daily lives and routines of the target population. Participants’ comments regarding the context during the focus group discussions can be classified into two main categories: acceptance of the presented context, and modification and adjustment of the context.

Some participants expressed positive remarks regarding the contextual elements presented in the adapted PNE material.

PT3: “The stories also sound good because they are understandable and real.”

MP4: “The last slide with the ship in th sea is important to understand because it explains everyone’s problem.”

PT8: “Topics such as stress, financial issues related to banks and COVID-19, topics in which the stress response is also concerned, it becomes relatable to Lebanese patients only.”

However, some participants provided feedback indicating the need for modifications and adjustments to the presented context.

FP4: “A picture of a family or a group of friends spending the night gossiping in the living room could be a good image to reflect cultural habits in spending pleasant time and activities.”

PT5: “Use the corniche picture for the sports context. It is a more accurate representation of the Beirut sports environment.”

Concept

The dimension of “concept” within the EVM is crucial for understanding if the designed PNE’s core ideas align with the Lebanese participants’ culture and perspectives. Analyzing the comments made by participants on the concept showed positive feedback, and they all agreed that the material used was aligned with Lebanese cultural nuances.

PT1: “Many pain beliefs mentioned are embedded in our culture.”

MP3: “The Lebanese community is heavily affected by social factors. For example, when you tell someone your back hurts, they respond with, “Oh! You have a back disc. May God help you.”

FP3: “The stories mentioned in the material resonate with our case. The stressful situation in Lebanon with the economic crisis can significantly influence our pain.”

Content

The content dimension is crucial in assessing how well the designed PNE resonates with participants’ experiences, values, and societal norms.

PT7: “I felt like the content is more than enough to be presented to the people regardless of the details.” PT2 : “The material is great.”

FP3: “I relate to the power point because I experience pain when I’m emotionally unstable.”

MP3: “The message was very well delivered. I’m experiencing the same chronic pain as the character. I did multiple MRI scans that came back clear, and I am still in pain.”

However, comments were collected from participants to make the content more culturally appropriate and sensitive. Remarks were made regarding the advertisement for the new content pictures.

MP1: “We can add a point in which we explain that patients should not search for the causes by themselves and that not every piece of information on the internet is true.”

MP4: “We can also add that patients in pain might need to talk to a psychologist.”

Other remarks were made to change the order, colors, and background of the slides.

 Theme 2. Implementation challenges

Participants highlighted several hurdles that may impede the effective integration of PNE within the Lebanese cultural context. However, several challenges have been identified.

Time constraints. Delivering PNE means spending additional time with the patient, which ultimately reduces the time available for the actual working session.

PT2: “Time factor could be a barrier to the implementation of PNE,”

Lack of knowledge among physical therapists. The participants expressed that physical therapists’ lack of knowledge could hinder the delivery of PNE. They emphasized the importance of a thorough explanation of the material and advocated training sessions to equip physical therapists for effective delivery.

PT5: “Physical therapists should be well trained on this material correctly. PT2: “A physical therapist should develop his skills and knowledge.”

Attitudes of resistance towards psychological factors.

PT5: “Patients might not accept a physical therapist telling them that their pain is linked to psychological factors.”

PT1: “You tell them that the brain is stimulating the pain; the patient will think their pain is psychological.”

Misunderstanding of the material. Misinterpreting PNE material could hinder its implementation, particularly if it is not well delivered or explained, as patients may struggle to comprehend its content.

PT8: “Misunderstanding the material could be considered a barrier to implementation.”

Theme 3. Exploring lived experiences of Lebanese patients with CLBP: personal and religious perspectives

During the focus group, the patients shared their lived experiences with pain, digging into detailed descriptions, daily struggles, and the emotions of fear and anxiety that accompanied their journey. Some of the shared lived experiences also reflected participants’ perceptions of pain.

MP4: “Once I knew my diagnosis, I became more cautious. At the same time, there is a point where caution starts to be more harmful than beneficial”.

MP4: “I started googling my symptoms and getting paranoid.”

MP3: “I was afraid that I might have uncontrollable urinary reflexes; it was my biggest obsession. I was thinking about it all the time as I prefer to be paralyzed instead of not having full control over my bladder”.

The narratives showed evidence that religious beliefs significantly shaped individuals’ perceptions and experiences of pain. Participants shared varied interpretations of pain, ranging from viewing it as a divine punishment or test to a consequence of negative energies, underscoring the complexity of cultural beliefs surrounding pain within the Lebanese context.

FP2: “I was relieved that everything was under control, yet I was afraid of future surprises that I might face and cannot deal with. But one moment, I recalled a Quranic verse: “Allah does not charge a soul except [with that within] its capacity.” I have Faith in God, and I knew He would not burden me with anything beyond my capabilities; I think at this point, it was the end of all the pain I experienced. I am back to the normal course of life”.

PT1: “The first thing I say is that many people think pain comes from being jinxed, and you cannot ignore this fact even if you do not believe in it because it is embedded in our culture. The same goes with negative vibes as well as God’s punishment”.

MP4: “People pray out of fear, not to mention that they do not have the full knowledge on how to pray correctly. We all resorted to praying when we were in extreme pain. We blamed God for the pain that was inflicted on us”.

The participants shared what they believed to be the role of prayer and spirituality in pain management.

FP1: “Once you share your thoughts and fears with God, they vanish instantly, leaving you serene.”

FP3: “Faith provides serenity. Serenity is related to the nervous system. It can soothe the pain.”

FP2: “For believers, praying is one of the necessary factors that help with the pain.”

They commented on the PNE material, suggesting modifications to enhance communication regarding the pain experienced with the divine.

MP3: “The communication with God should be respectful. You could add slides that display how to communicate better with God”.

MP1: “You must explain to the patient that they cannot rely on praying only as a treatment method.”

MP3: “Just include one picture related to God that has nothing to do with religion.”

Discussion

The primary objective of this study was to develop culturally adapted PNE material for the Lebanese population. Successful cultural adaptation requires stakeholders to contribute. 12, 38, 39 Lebanese physical therapists and patients participated in the study. The development process described in this study contains helpful information for researchers in pain science contains helpful information for researchers in pain science. Previous PNE adaptation studies have used different approaches 40, 41 including Delphi studies, to culturally adapt PNE. To the best of our knowledge, this is the first time that the EVM 29 and Barrera model 13 have been used for the PNE cultural adaptation process.

The first theme, based on the EVM, showed active engagement from the participants with the material, where they expressed either approval or proposed modifications to enhance cultural sensitivity. Patients and physical therapists have contributed valuable perspectives, emphasizing the need for adjustments to address cultural norms, beliefs, and healthcare practices specific to the Lebanese context. The dimensions of EVM, such as context, concept, and content, were analyzed. Contextual elements such as stories and topics specific to the Lebanese experiences, such as the Beirut blast in 2020 and the economic crisis, were positively acknowledged, emphasizing its importance at both the mental and physical levels. 42– 44 These remarks highlight a commitment to improve cultural sensitivity and appropriateness in the material, including adjustments to content details, order, and visual elements, to meet the needs and preferences of the Lebanese population. For instance, in exploring the potential correlation between pleasant activities and the modulation of nervous system sensitivity, a scene of a family sharing happy moments is illustrated. This depiction captures the importance of familial bonds in Lebanese culture, which is a source of strength during times of adversity, including illness and challenges. 15, 45 Creating distinct educational materials on PNE for males and females reflects the significance of gender differences in Arab culture. 46, 47 This will allow for better gender awareness in health care. Previous studies have shown that increasing gender awareness among health care professionals may improve gender equity in health. 47, 48

Moreover, previous studies have highlighted the variability in pain perception, emotional response, and comprehension between males and females across various cultures. 49 Educational material from Mosely 4 and Louw 50 expresses a Westernized view of what a “patient” should look like, often a white male. Considering the diversity among cultures, the physical appearances of female characters are as important as they reflect different cultural backgrounds, in this case within Lebanese society.

Participants emphasized adjusting and simplifying language to ensure that they were more easily understood and culturally sensitive to the Lebanese population. Every culture and social group has a way to express pain and distress. People use different words and actions to inform others that they are suffering. 51 In this culturally adapted PNE, a critical slide based on Kleinman’s model 52– 53 features a series of eight questions. These questions were designed to guide healthcare providers in comprehensively exploring patients’ perceptions, understanding, and beliefs about pain. This will facilitate the work of Lebanese health care providers to gain deeper insights into the cultural context surrounding pain experiences, thus facilitating more effective communication and tailored PNE delivery.

The positive feedback gathered from physical therapists and patients highlights the possibilities for implementing PNE and its effectiveness in achieving its intended goals in patients suffering from CLBP in Lebanon.

Regarding the delivery method, the findings from the focus group shed light on the nuanced considerations surrounding the delivery methods of PNE within the Lebanese population. Participants preferred interactive methods such as slides and PowerPoint presentations. This preference aligns with the existing literature suggesting that multimedia formats can enhance engagement and understanding of complex healthcare information. 54, 55 PT2’s comment emphasizes the appeal of PowerPoint owing to its interactive nature, indicating its effectiveness in capturing participants’ attention and facilitating learning. However, the concerns raised regarding the accessibility of technology, particularly laptops, in clinical settings or patients’ homes highlight essential barriers to consider. In resource-constrained environments, reliance solely on digital platforms may hinder the widespread dissemination and implementation of PNE. 40 The proposed solution of using printed cards with explanations to be used by the therapist provides a practical alternative that addresses this issue while maintaining the effectiveness of the delivery method. 40, 56

The decision to eliminate leaflets as a delivery method underscores the value of personalized interaction and guidance from healthcare professionals. The participants emphasized the importance of trained therapists in facilitating PNE sessions. PT2’s assertion that patients should not take home PNE material further underlines the significance of guided instruction and support in understanding and applying the information provided, especially because the distribution of health education leaflets does not always yield significant results 17, 18

The second theme identified challenges in delivering PNE materials to the Lebanese population. First, time constraints are highlighted as a significant barrier to the effective delivery of PNE materials. Physical therapists recognize the limited time available for patient interactions. This concern highlights the need for practical strategies to integrate PNE into clinical workflows without imposing excessive time burden on therapists or patients. The second challenge was related to a lack of knowledge among physical therapists regarding PNE. Participants emphasized the importance of adequate training to ensure that therapists possess the requisite skills and expertise to deliver PNE material effectively. Ultimately, the success of PNE delivery methods in Lebanon is contingent upon the competence and proficiency of therapists facilitating the sessions. As PT3 and PT7 emphasized, effective communication, cultural competence, and a deep understanding of the material are essential attributes for healthcare professionals involved in PNE delivery. The suggestion to integrate PNE into the curriculum for entry-level physical therapy students reflects a forward-thinking approach to enhance healthcare education and practice in Lebanon. By equipping future therapists with the necessary knowledge and skills to deliver PNE effectively, this initiative ensures a culture of professional development within the Lebanese healthcare system, similar to that in other countries. 57, 58 The inclusion of culture-sensitive pain education in the classroom and practical training for healthcare providers will help improve PNE delivery. 59

Other challenges were also identified, such as the cultural resistance of the Lebanese to the PNE concept. Both physical therapists and patients expressed concerns that the Lebanese population might be hesitant to accept the connection between pain and psychological factors. It is crucial to recognize these challenges not as insurmountable obstacles but as points of consideration for refining the delivery and implementation of PNE.

A significant third theme was defined, shedding light on the lived experiences of patients with chronic pain. Small parts of who they are and how they live in their everyday lives might affect how they feel pain. 60 This theme describes the different aspects of their life experiences and underscores the influence of religious beliefs. This theme revealed that their lived experiences were profoundly shaped by religious influences, with participants frequently referring to religious beliefs as integral to their coping mechanisms and resilience. The narratives provided by the participants offer a rich understanding of how religious faith serves as a source of relief and a coping mechanism in the face of pain. Furthermore, as mentioned here and in previous studies, some people might see their pain as a loss of faith or a punishment from God. They may turn to prayers and rituals to ask for forgiveness. 51, 60 Quotations such as those from FP2, where the recollection of a Quranic verse brings reassurance and resilience, exemplify the intertwining of religious faith with pain management strategies. Similarly, PT1’s acknowledgment of the pervasive belief that pain is associated with negative forces highlights the profoundly ingrained cultural perceptions that inform individuals’ experiences of pain. Thus, patients’ religious and spiritual concepts will affect their pain perception and pain management journey. 61 Moreover, the participants articulated the role of prayer and spirituality in alleviating pain and fostering emotional well-being. FP1’s description of sharing fear with God as a means to attain serenity reflects the profound psychological impact of religious practices on pain perception. Likewise, FP3’s connection between faith, serenity, and the nervous system underscores a holistic approach to pain management that integrates spiritual dimensions. Regarding the practical implications of integrating these spiritual factors in PNE materials, participants offered valuable suggestions for modification to enhance cultural sensitivity and relevance. MP3’s suggestion to include guidance on respectful communication with God acknowledges the importance of addressing religious beliefs in pain management interventions. Similarly, MP1’s caution against over-reliance on prayer as the sole treatment method emphasizes the need for a balanced approach that integrates the medical and spiritual dimensions. Overall, the findings shed light on the intricate interplay between religious beliefs, pain perception, and coping strategies in the Lebanese population. Incorporating these insights into PNE materials could contribute to more culturally responsive and effective interventions for pain management.

Limitation

This study has certain limitations. First, despite the initial design of the script being in English to ensure comprehensibility among all the research team members, the translated Arabic version received feedback from only three individuals. Second, the sample size was relatively small, comprising a select group of physical therapists and patients. Including a larger sample may have provided a broader range of perspectives and enriched the cultural adaptation process. The study focused primarily on the perspectives of physical therapists and patients, neglecting other critical stakeholders from the healthcare community who may also play significant roles in shaping cultural beliefs and practices related to pain management. Moreover, despite the inclusion of various dimensions, such as context, concept, and content, it is possible that certain aspects of Lebanese culture or societal norms may not have been fully captured or adequately addressed in the developed PNE material. English and Arabic differ not only in words and grammar, but also in expressions and metaphors, making translation challenging. The main researcher, with the help of the translator, attempted to maintain the essence of the original language during translation.

 Conclusion

In conclusion, the cultural adaptation of PNE material to the Lebanese population represents a significant step towards enhancing pain management strategies in patients with CP. This study highlighted the importance of continuous refinement, acknowledging that cultural adaptation is an ongoing and collaborative endeavor to effectively bring PNE to diverse populations. Utilizing models such as the EVM and Barrera models provided a structured framework for this adaptation process, ensuring alignment with cultural norms and beliefs. The findings underscore the importance of tailoring educational materials to resonate with local experiences, including addressing specific cultural contexts, such as cultural appearance, pain beliefs, and religious influences. Moreover, the study highlights the significance of employing interactive and versatile delivery methods and providing adequate training for healthcare professionals to effectively implement PNE interventions. By incorporating this understanding into healthcare education, healthcare providers can foster culturally responsive and practical approaches to pain management, ultimately improving the quality of care for individuals with chronic pain in Lebanon.

 Data Availability

Due to the nature of this qualitative study, the data supporting the findings (such as interview transcripts and audio recordings) cannot be made openly available. Participants did not provide consent for the public sharing of their full transcripts, and the data contain potentially identifiable or sensitive personal information. As such, public deposition of the raw data would compromise participant confidentiality and violate ethical guidelines. Summarised findings and representative anonymised quotations are included in the article to support the analysis. The full PNE material is available online https://doi.org/10.6084/m9.figshare.29986888.v1. 62

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0)

 References Mills SEE Nicolson KP Smith BH : Chronic pain: a review of its epidemiology and associated factors in population-based studies. BJA Br J Anaesth. août 2019;123(2):e273–e283. 31079836 10.1016/j.bja.2019.03.023 PMC6676152 Marris D Theophanous K Cabezon P : The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials. Physiother. Theory Pract. 3 avr 2021;37(4):461–472. 31250682 10.1080/09593985.2019.1633714 Moseley GL : Reconceptualising pain according to modern pain science. Phys. Ther. Rev. 1 sept 2007;12(3):169–178. Moseley GL Butler DS : Fifteen Years of Explaining Pain: The Past, Present, and Future. J. Pain. 1 sept 2015;16(9):807–813. 26051220 10.1016/j.jpain.2015.05.005 Louw A Zimney K Puentedura EJ : The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother. Theory Pract. 3 juill 2016;32(5):332–355. 27351541 10.1080/09593985.2016.1194646 Al-Harthy M Ohrbach R Michelotti A : The effect of culture on pain sensitivity. J. Oral Rehabil. 2016;43(2):81–88. 10.1111/joor.12346 Davidhizar R Giger JN : A review of the literature on care of clients in pain who are culturally diverse. Int. Nurs. Rev. mars 2004;51(1):47–55. 14764014 10.1111/j.1466-7657.2003.00208.x Narayan MC : Culture’s effects on pain assessment and management. Am. J. Nurs. avr 2010;110(4):38‑47. quiz 48‑9. 10.1097/01.NAJ.0000370157.33223.6d Orhan C Van Looveren E Cagnie B : Are Pain Beliefs, Cognitions, and Behaviors Influenced by Race, Ethnicity, and Culture in Patients with Chronic Musculoskeletal Pain: A Systematic Review. Pain Physician. nov 2018;21(6):541–558. 30508984 Martinez S Mahoney A : Culturally Sensitive Behavior Intervention Materials: a Tutorial for Practicing Behavior Analysts. Behav. Anal. Pract. 30 mars 2022;15(2):516–540. 35692529 10.1007/s40617-022-00703-x PMC9120287 Okamoto SK Helm S Pel S : Developing Empirically Based, Culturally Grounded Drug Prevention Interventions for Indigenous Youth Populations. J. Behav. Health Serv. Res. janv 2014;41(1):8–19. 23188485 10.1007/s11414-012-9304‑0 PMC3595362 Sit HF Ling R Lam AIF : The Cultural Adaptation of Step-by-Step: An Intervention to Address Depression Among Chinese Young Adults. Front. Psych. 7 juill 2020;11:650. 32733296 10.3389/fpsyt.2020.00650 PMC7359726 Castro FG Barrera M Holleran Steiker LK : Issues and Challenges in the Design of Culturally Adapted Evidence-Based Interventions. Annu. Rev. Clin. Psychol. 2010;6:213–239. 20192800 10.1146/annurev-clinpsy-033109-132032 PMC4262835 Najem C Wijma AJ Meeus M : Facilitators and barriers to the implementation of pain neuroscience education in the current Lebanese physical therapist health care approach: a qualitative study. Disabil. Rehabil. 18 janv 2023;1–9. Dumit NY Abboud S Massouh A : Role of the Lebanese family caregivers in cardiac self-care: a collective approach. J. Clin. Nurs. nov 2015;24:3318–3326. 26249817 10.1111/jocn.12949 PMC4750903 Kaddoura N Sarouphim KM : Identity development among Lebanese youth: An investigation of Marcia’s paradigm. Heliyon. 23 nov 2019;5(11):e02851. 31799461 10.1016/j.heliyon.2019.e02851 PMC6881617 Hasanica N Ramic-Catak A Mujezinovic A : The Effectiveness of Leaflets and Posters as a Health Education Method. Mater Socio-Medica. juin 2020;32(2):135–139. 32843863 10.5455/msm.2020.32.135-139 PMC7428890 Ittersum MW van Wilgen CP van Schans CP van der : Written Pain Neuroscience Education in Fibromyalgia: A Multicenter Randomized Controlled Trial. Pain Pract. 2014;14(8):689–700. Cyril S Smith BJ Possamai-Inesedy A : Exploring the role of community engagement in improving the health of disadvantaged populations: a systematic review. Glob. Health Action. 1 déc 2015;8(1):29842. 26689460 10.3402/gha.v8.29842 PMC4685976 Cornish F Breton N Moreno-Tabarez U : Participatory action research. Nat Rev Methods Primer. 27 avr 2023;3(1):1–14. Reid C Gee G Bennetts SK : Using participatory action research to co-design perinatal support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma. Women Birth. 1 sept 2022;35(5):e494–e501. 34961730 10.1016/j.wombi.2021.12.005 Vlegel-Brouwer W van der Eelderink M Bussemaker J : Participatory Action Research as a Driver for Health Promotion and Prevention: A Co-creation Process Between Professionals and Citizens in a Deprived Neighbourhood in the Hague. Int. J. Integr. Care. 2023;23(4):13. 38047119 10.5334/ijic.7560 PMC10691282 Silvola S Restelli U Bonfanti M : Co-Design as Enabling Factor for Patient-Centred Healthcare: A Bibliometric Literature Review. Clin Outcomes Res CEOR. 17 mai 2023;15:333–347. Braun V Clarke V : Reflecting on reflexive thematic analysis. Qual. Res. Sport, Exerc. Health. 8 août 2019;11(4):589–597. 10.1080/2159676X.2019.1628806 Nijs J Paul van Wilgen C Van Oosterwijck J : How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: Practice guidelines. Man. Ther. 1 oct 2011;16(5):413–418. 21632273 10.1016/j.math.2011.04.005 Wilgen CP van Keizer D : The sensitization model to explain how chronic pain exists without tissue damage. Pain Manag Nurs Off J Am Soc Pain Manag Nurses. mars 2012;13(1):60–65. 22341140 10.1016/j.pmn.2010.03.001 Explain Pain by Butler DS Moseley GL : David S. Butler: Amazon.com: Books. [cité 23 janv 2024]. Reference Source Why Do I Hurt?: A Patient Book about the Neuroscience o…. [cité 23 janv 2024]. Reference Source Bernal G Bonilla J Bellido C : Ecological validity and cultural sensitivity for outcome research: issues for the cultural adaptation and development of psychosocial treatments with Hispanics. J. Abnorm. Child Psychol. févr 1995;23(1):67–82. 7759675 10.1007/BF01447045 Palinkas LA Horwitz SM Green CA : Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Admin. Pol. Ment. Health. sept 2015;42(5):533–544. 24193818 10.1007/s10488-013-0528-y PMC4012002 Onwuegbuzie AJ Dickinson WB Leech NL : A Qualitative Framework for Collecting and Analyzing Data in Focus Group Research. Int J Qual Methods. 1 sept 2009;8(3):1–21. 10.1177/160940690900800301 Willis GB Artino AR : What Do Our Respondents Think We’re Asking? Using Cognitive Interviewing to Improve Medical Education Surveys. J. Grad. Med. Educ. sept 2013;5(3):353–356. 24404294 10.4300/JGME-D-13-00154.1 PMC3771159 Nowell L Norris JM White DE : Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qual Methods. 2 oct 2017;16(1):160940691773384. 10.1177/1609406917733847 Proudfoot K : Inductive/Deductive Hybrid Thematic Analysis in Mixed Methods Research. J. Mixed Methods Res. 1 juill 2023;17(3):308–326. 10.1177/15586898221126816 O’Brien BC Harris IB Beckman TJ : Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad. Med. sept 2014;89(9):1245–1251. 10.1097/ACM.0000000000000388 SAGE Publications Inc: Naturalistic Inquiry. 2022 [cité 17 janv 2023]. Reference Source Mathur S : Doctorate in Physical Therapy: Is It Time for a Conversation? Physiother. Can. 2011;63(2):140–142. 22379252 10.3138/physio.63.2.140 PMC3076909 Abi Ramia J Harper Shehadeh M Kheir W : Community cognitive interviewing to inform local adaptations of an e-mental health intervention in Lebanon. Glob Ment Health Camb Engl. 2018;5:e39. 30637112 10.1017/gmh.2018.29 PMC6315334 Garabiles MR Harper Shehadeh M Hall BJ : Cultural Adaptation of a Scalable World Health Organization E-Mental Health Program for Overseas Filipino Workers. JMIR Form Res. 29 mars 2019;3(1):e11600. 30924784 10.2196/11600 PMC6460314 Mukhtar NB Meeus M Gursen C : Development of culturally sensitive pain neuroscience education materials for Hausa-speaking patients with chronic spinal pain: A modified Delphi study. PloS One. 2021;16(7):e0253757. 34214080 10.1371/journal.pone.0253757 PMC8253446 Orhan C Cagnie B Favoreel A : Development of culturally sensitive Pain Neuroscience Education for first-generation Turkish patients with chronic pain: A modified Delphi study. Musculoskelet. Sci. Pract. févr 2019;39:1–9. 30439644 10.1016/j.msksp.2018.10.007 El Hayek S Bizri M : Beirut blast and mental health in Lebanon: Finding ways out. Asian J. Psychiatr. déc 2020;54:102458. 33271737 10.1016/j.ajp.2020.102458 El Zouki CJ Chahine A Mhanna M : Rate and correlates of post-traumatic stress disorder (PTSD) following the Beirut blast and the economic crisis among Lebanese University students: a cross-sectional study. BMC Psychiatry. 5 août 2022;22(1):532. 35931970 10.1186/s12888-022-04180-y PMC9356397 Farran N : Mental health in Lebanon: Tomorrow’s silent epidemic. Ment Health Prev. déc 2021;24:200218. 34660191 10.1016/j.mhp.2021.200218 PMC8503814 Brady B Veljanova I Andary T : Recognising ethnocultural diversity in chronic pain assessment: validation of the Pictorial Representation of Illness and Self Measure (PRISM) for use with culturally diverse communities. Health Qual. Life Outcomes. 8 avr 2019;17(1):56. 30961623 10.1186/s12955-019-1126-9 PMC6454629 Al-Khashan HI Almulla NA Galil SAA : Gender differences in health education needs and preferences of Saudis attending Riyadh Military Hospital in the Kingdom of Saudi Arabia. J. Fam. Community Med. déc 2012;19(3):172–177. 23230383 10.4103/2230-8229.102317 PMC3515956 Shamasneh B Nemer M Abu-Rmeileh NME : Gender Awareness in Healthcare: Contextualization of an Arabic Version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS). Healthcare. 20 févr 2023;11(4):629. 36833163 10.3390/healthcare11040629 PMC9957215 Verdonk P Benschop YWM Haes HCJM de : From gender bias to gender awareness in medical education. Adv. Health Sci. Educ. Theory Pract. mars 2009;14(1):135–152. 10.1007/s10459-008-9100-z Miller C Newton SE : Pain perception and expression: the influence of gender, personal self-efficacy, and lifespan socialization. Pain Manag Nurs Off J Am Soc Pain Manag Nurses. déc 2006;7(4):148–152. 17145488 10.1016/j.pmn.2006.09.004 Louw A Zimney K O’Hotto C : The clinical application of teaching people about pain. Physiother. Theory Pract. juill 2016;32(5):385–395. 10.1080/09593985.2016.1194652 Peacock S Patel S : Cultural Influences on Pain. Rev Pain. mars 2008;1(2):6–9. 26525084 10.1177/204946370800100203 PMC4589930 Kleinman A Eisenberg L Good B : Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann. Intern. Med. févr 1978;88(2):251–258. 10.7326/0003-4819-88-2-251 Kleinman A Eisenberg L Good B : Culture, Illness, and Care. Ann. Intern. Med. 1 déc 2008 [cité 7 juill 2022];88:251–258. 10.7326/0003-4819-88-2-251 Farsi D : Social Media and Health Care, Part I: Literature Review of Social Media Use by Health Care Providers. J. Med. Internet Res. 5 avr 2021;23(4):e23205. 33664014 10.2196/23205 PMC8056296 Shaygan M Jaberi A Firozian R : Effect of a multimedia training programme for pain management on pain intensity and depression in patients with non-specific chronic back pain. Investig Educ En Enfermeria. 30 mars 2022;40(1):e13. Lepri B Romani D Storari L : Effectiveness of Pain Neuroscience Education in Patients with Chronic Musculoskeletal Pain and Central Sensitization: A Systematic Review. Int. J. Environ. Res. Public Health. 24 févr 2023;20(5):4098. Lane E Magel JS Thackeray A : Effectiveness of training physical therapists in pain neuroscience education for patients with chronic spine pain: a cluster-randomized trial. Pain. 1 mai 2022;163(5):852–860. 34354017 10.1097/j.pain.0000000000002436 PMC8816964 Mills KM Preston EB Choffin Schmitt BM : Embedding pain neuroscience education in the physical therapy management of patients with chronic plantar fasciitis: a prospective case series. J. Man. Manip. Ther. 29(3):158–167. 32933452 10.1080/10669817.2020.1821327 PMC8183540 Grewal US Abduljabar H Sulaiman K : Cultural competency in graduate medical education: A necessity for the minimization of disparities in healthcare. eClinicalMedicine. 1 mai 2021 [cité 14 mars 2024];35:100837. 33997738 10.1016/j.eclinm.2021.100837 PMC8099735 Reference Source Bhojwani M Walimbe V Malani R : Pain neuroscience education through cultural lens: insights, challenges and future implications. J. Man. Manip. Ther. 2024;1–4. Caneiro JP Bunzli S O’Sullivan P : Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz. J. Phys. Ther. 2021;25(1):17–29. 32616375 10.1016/j.bjpt.2020.06.003 Najem C : Culturally adapted PNE.Dataset. figshare. 2025. 10.6084/m9.figshare.29986888.v1 10.5256/f1000research.180630.r417057 Reviewer response for version 1 Baby Priya 1 Referee https://orcid.org/0000-0001-8988-2334 College of Nursing, National Institute of Mental Health and Neuro sciences, Bangalore, India

Competing interests: No competing interests were disclosed.

 8 10 2025 Copyright: © 2025 Baby P 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This manuscript, “Community-based Participatory Action Research Approach for the Development of an Arabic Culturally Sensitive Pain Neuroscience Education: A Qualitative Focus Group Study with Physical Therapists and Individuals with Chronic Low Back Pain in Lebanon,” addresses an important and area. The topic is timely, relevant, and highly useful, as it combines participatory action research with cultural adaptation in pain neuroscience education.

The study is generally well written and demonstrates potential to contribute meaningfully to the literature on culturally sensitive health interventions.

However, the manuscript requires significant improvement in terms of coherence, language  and clarity.

1. There are several instances where language editing is needed to improve clarity and readability. For example,  “Several models have been proposed to guide cultural adaptation have been proposed”  should be revised for conciseness and accuracy.

2. Opening sentence of the introduction needs more emphatic beginning with academic tone.

3.Barrera and Castro (2006) proposed a sequence of four intervention adaptation stages”... requires more context. It is not clear whether the model was proposed specifically for Pain Neuroscience Education (PNE) or whether it applies more broadly to cultural adaptation of health interventions in general. Give references for its earlier use.

4. Similarly the context of Pain Neuroscience Education (PNE) may not be familiar to all readers. The manuscript would benefit from a clearer background section that introduces PNE, summarizes its applications in clinical practice, and highlights evidence from previous studies.

5.The fourth paragraph of Introduction needs considerable revision.  The meaning is not conveyed well. Complex sentence needs breaking down.

6.The statement that PTs lack knowledge of chronic pain appears abrupt. Please first acknowledge their important role in CP management, and then note the knowledge gaps.

7. While mentioning about the cultural differences in Lebanese population, mention why this would be relevant for PNE. The sentences are currently isolated comments with no context to PNE 

8. Is it crucial objective or primary objective?

9. A nother objective was to assess the ecological validity of the newly ... what is ecological validity ? give context of this before mentioning the same. If it means the context of the different cultural background introduce this term early so that while objectives are stated , the context is familiar.

10.In the design section, it may not be necessary to mention male and female participants separately in the very first sentence. This phrasing can appear non-inclusive. Instead, you could present the sample as a whole and then clarify later that, in line with cultural considerations, focus groups were conducted separately by gender.

11. study involved three PAR focus groups... Is it focus group discussions?

12 The manuscript would benefit from clarifying whether the Pain Neuroscience Education (PNE) program used is an original program. While the paper mentions the core materials for the culturally sensitive program, it is unclear whether the authors are referring to an existing PNE program or using these resources to develop a new culturally adapted version for this study.

13.The statement about preparing separate sets of 45 slides for women, with distinctions for Christian and Muslim participants, requires clarification. It is unclear whether these distinctions are based on physical characteristics, cultural/religious considerations, or content preferences. The authors should clarify why separate slide sets were necessary and ensure that the rationale does not imply biologically-based differences between women of different religions.

14. ethnic TECHNbackground.. What does this imply?

15. Where the FGDs audio recorded? 

16.The results are discussed clearly and thoroughly. However, it is unclear whether the components presented under the EVM framework are inherent parts of the framework itself or if they represent themes derived inductively from the authors’ analysis. The manuscript would benefit from clarifying which elements are deductive and which emerged from the data

17. The Discussion section is well written with well integrated participant feedback. However some complex sentences can be further changed.

18. In summary  providing additional context on PNE, the rationale for gender-based adaptations, and expanding discussion of limitations would enhance  rigor.

The paper has good scope in improving culturally responsive pain care.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Neuroscience, Nursing , pllaitive care , Stroke nursing , Traunmatic brain injuries

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References : Cultural Perspectives on Pain Assessment and Opioid Use: International Neuroscience Nursing Research Symposium Conference Proceedings. Journal of Neuroscience Nursing .2021;53(3) : 10.1097/JNN.0000000000000585 149-156 10.1097/JNN.0000000000000585