Feasibility and acceptability of culturally adapted cognitive behavioural therapy for patients with Cannabis use disorder in tertiary care hospitals in Peshawar, Pakistan: A multi-methods study protocol

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Cognitive Behavioral Therapy (CBT) has been shown as an effective intervention for CUD in High-Income Countries, but its implementation may be limited in Low- and Middle-Income Countries due to cultural differences. Cultural adaptation of CBT may enhance its appropriateness, acceptability, and feasibility in diverse populations where cannabis use is prevalent with limited treatment options. Methods and Analysis This study follows a multi-method approach. The first phase will involve focus group discussions and In-depth Interviews to explore cultural beliefs, treatment preferences, and contextual barriers. Findings will inform three co-adaptation workshops with patients, caregivers, clinicians, and community stakeholders. These workshops will guide the development of a culturally adapted CBT (CA-CBT) manual. The manual will be piloted in a pre-post feasibility study. The study will assess acceptability, appropriateness, and feasibility of the intervention using indicators such as recruitment, retention, adherence, and patient engagement. Preliminary outcomes on cannabis use frequency and dependence severity will also be examined. Qualitative data will be analyzed through framework and thematic analysis, whereas quantitative data will be evaluated using descriptive and inferential statistical methods. Ethical approval has been obtained from institutional review boards in Khyber Medical University, Pakistan and the Keele University, United Kingdom. Significance of the Study The study contributes to the literature by documenting a systematic process for adapting CBT for CUD in Pakistan, where access to structured psychological treatments is limited and treatment needs remain unmet. It explains how interviews, focus groups, stakeholder involvement, and feasibility testing will shape the adaptation. The study offers practical guidance for researchers and practitioners developing culturally relevant interventions for substance use in low-resource contexts. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-897/v1", "name": "Feasibility and acceptability of culturally adapted cognitive behavioural..." } } ] } Home Browse Feasibility and acceptability of culturally adapted cognitive behavioural... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ullah S, Paudyal P, Ahmad F et al. Feasibility and acceptability of culturally adapted cognitive behavioural therapy for patients with Cannabis use disorder in tertiary care hospitals in Peshawar, Pakistan: A multi-methods study protocol [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :897 ( https://doi.org/10.12688/f1000research.168207.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Feasibility and acceptability of culturally adapted cognitive behavioural therapy for patients with Cannabis use disorder in tertiary care hospitals in Peshawar, Pakistan: A multi-methods study protocol [version 1; peer review: awaiting peer review] Safat Ullah https://orcid.org/0000-0002-2152-7261 1,2 , Priyamvada Paudyal 1 , Fayaz Ahmad 3 , [...] Asad Ullah 2 , Muhammad Firaz Khan 4 , Ghasem Yadegarfar 1 , Farooq Naeem 5 , Saeed Farooq 1 Safat Ullah https://orcid.org/0000-0002-2152-7261 1,2 , Priyamvada Paudyal 1 , [...] Fayaz Ahmad 3 , Asad Ullah 2 , Muhammad Firaz Khan 4 , Ghasem Yadegarfar 1 , Farooq Naeem 5 , Saeed Farooq 1 PUBLISHED 10 Sep 2025 Author details Author details 1 School of Medicine, Keele University, Keele, England, ST5 5BG, UK 2 Office of Research Innovation and Commercialization, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 3 Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 4 Institute of Mental Health and Behavioral Sciences, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 5 University of Toronto Department of Psychiatry, Toronto, Ontario, Canada Safat Ullah Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Priyamvada Paudyal Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Review & Editing Fayaz Ahmad Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Asad Ullah Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Muhammad Firaz Khan Roles: Supervision, Writing – Review & Editing Ghasem Yadegarfar Roles: Supervision, Writing – Review & Editing Farooq Naeem Roles: Methodology, Supervision, Writing – Review & Editing Saeed Farooq Roles: Funding Acquisition, Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Addiction and Related Behaviors gateway. Abstract Background Cannabis use is associated with an increased risk of Cannabis Use Disorder (CUD). Cognitive Behavioral Therapy (CBT) has been shown as an effective intervention for CUD in High-Income Countries, but its implementation may be limited in Low- and Middle-Income Countries due to cultural differences. Cultural adaptation of CBT may enhance its appropriateness, acceptability, and feasibility in diverse populations where cannabis use is prevalent with limited treatment options. Methods and Analysis This study follows a multi-method approach. The first phase will involve focus group discussions and In-depth Interviews to explore cultural beliefs, treatment preferences, and contextual barriers. Findings will inform three co-adaptation workshops with patients, caregivers, clinicians, and community stakeholders. These workshops will guide the development of a culturally adapted CBT (CA-CBT) manual. The manual will be piloted in a pre-post feasibility study. The study will assess acceptability, appropriateness, and feasibility of the intervention using indicators such as recruitment, retention, adherence, and patient engagement. Preliminary outcomes on cannabis use frequency and dependence severity will also be examined. Qualitative data will be analyzed through framework and thematic analysis, whereas quantitative data will be evaluated using descriptive and inferential statistical methods. Ethical approval has been obtained from institutional review boards in Khyber Medical University, Pakistan and the Keele University, United Kingdom. Significance of the Study The study contributes to the literature by documenting a systematic process for adapting CBT for CUD in Pakistan, where access to structured psychological treatments is limited and treatment needs remain unmet. It explains how interviews, focus groups, stakeholder involvement, and feasibility testing will shape the adaptation. The study offers practical guidance for researchers and practitioners developing culturally relevant interventions for substance use in low-resource contexts. READ ALL READ LESS Keywords Cannabis Use Disorder, Cognitive Behavioural Therapy, Cultural Adaptation, Multi-methods study, Feasibility and Acceptability Corresponding Author(s) Safat Ullah ( [email protected] ) Priyamvada Paudyal ( [email protected] ) Close Corresponding authors: Safat Ullah, Priyamvada Paudyal Competing interests: No competing interests were disclosed. Grant information: This study is the first author's PhD project under the “CogNitive Therapy for DepRessiOn in TubercuLosis patients” (CONTROL) programme, specifically within the capacity development component, funded by the National Institute for Health Research (Award ID: NIHR201773) The author acknowledges the resources and opportunities provided by NIHR, which have significantly facilitated this research endeavour. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Ullah S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ullah S, Paudyal P, Ahmad F et al. Feasibility and acceptability of culturally adapted cognitive behavioural therapy for patients with Cannabis use disorder in tertiary care hospitals in Peshawar, Pakistan: A multi-methods study protocol [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :897 ( https://doi.org/10.12688/f1000research.168207.1 ) First published: 10 Sep 2025, 14 :897 ( https://doi.org/10.12688/f1000research.168207.1 ) Latest published: 10 Sep 2025, 14 :897 ( https://doi.org/10.12688/f1000research.168207.1 ) Introduction Cannabis is the third most common psychoactive drug used globally due to its sedative and analgesic properties. 1 “The United Nations Office of Drugs and Crime (UNODC)” reported 209.2 million (149.4 million – 265.0 million) people (15 – 64 years) use cannabis worldwide. 2 The report also states that global drug use increased by approximately 22% between 2010 and 2020, with increased hospitalisations, suicides, and mental illnesses associated with cannabis use. 2 Cannabis use has also become a growing concern in Pakistan. No recent report is available, but according to the UNODC report published in 2012, the overall prevalence of cannabis use in Pakistan was 3.60% (6.70% among males and 0.20% in females). 2 However, it is important to note that due to the illegality of cannabis use for recreational purposes, many cannabis users may not report their use, leading to an underestimation of the true prevalence rates. 3 , 4 Evidence suggests that frequent use of cannabis can lead to CUD or cannabis dependence; however, majority of the users are in denial about the dependence. 2 “American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders” defined CUD as mild, moderate, or severe based on symptoms like frequent use, persistent desire, seeking cannabis, cravings, recurrent use despite psychosocial and/or interpersonal harms, increased dosage, and manifestation with withdrawal symptoms. 5 Data on CUD prevalence is incomplete. However, almost 22 million cannabis users globally meet the CUD criteria. 6 Research suggests that 22% to 33% of cannabis users develop CUD. 7 CUD is reported to be highly comorbid with other mental illnesses, including anxiety, depression, and psychosis. 8 , 9 Due to the significant global prevalence of cannabis use, CUD represents a considerable proportion of those seeking treatment for drug use disorders. 10 Several studies have been conducted to test the effectiveness of different pharmacological and non-pharmacological interventions in reducing cannabis use or CUD. 11 – 14 Previous systematic reviews reported that cannabis use and cannabis-associated health problems could be significantly reduced with the use of CBT and motivational enhancement therapy (MET). 10 , 11 , 15 CBT is an evidence-based psychological therapy primarily targeted to treat depression, anxiety, and other mental illnesses. 16 It is a patient-centred approach utilizing the principles of behavioural and cognitive psychology. 17 , 18 The core principles of CBT revolve around feelings or emotions producing different thoughts that lead to a specific behaviour. It focuses on changing negative thoughts and altering faulty behaviours by empowering the targeted patients with coping skills and cognitive restructuring to overcome their problems. 19 These thoughts, feelings, and behaviours are developed by the underlying core beliefs, which play an important role in CBT. 20 CBT, having its origin in Western culture, direct implementation may not be appropriate for the diverse culture and context of LMICs. 21 Several studies have shown that CA-CBT is feasible and acceptable for mental health conditions and substance use. 22 – 24 Cultural adaptation is key to improve the acceptability and accessibility of the intervention by incorporating and addressing the cultural factors influencing it. 25 Local norms, beliefs, and culture influence a person’s attitude toward understanding health and disease, expressing their disease or illness, developing coping mechanisms, seeking care, adhering to treatment or therapy, and satisfaction with the health care provided. 26 It is noteworthy that these norms and beliefs should be addressed in designing an intervention for any health problem, including mental illness or addiction, where patients and providers can equally contribute to the development of culturally tailored interventions. 17 , 27 CBT has been extensively adapted for different cultures and diverse health conditions. 17 , 28 – 31 Studies have been conducted on the cultural adaptation of CBT for different mental illnesses in Asian and LMIC contexts. 24 , 32 – 35 Despite the increasing prevalence of cannabis use among young people in Pakistan, culturally adapted and systematically evaluated treatment options for CUD remain limited. 36 CBT is an effective intervention for reducing cannabis use and promoting abstinence in adults; however, its application has primarily been studied in Western populations with a need-based session structure. 37 Its effectiveness within the Pakistani cultural context remains unexplored, 38 as the core principles of CBT may not fully align with local cultural values, beliefs, and norms. The proposed study aims to culturally adapt CBT and evaluate its feasibility and acceptability in tertiary care hospitals in Peshawar, Pakistan. Given the rising cannabis use and the lack of culturally tailored interventions, it seeks to align CBT with local norms. This protocol outlines the study design, methodology, and outcome measures to ensure transparency and reproducibility. The findings from this study will be helpful in determining whether CBT should be recommended for efficacy testing as an effective treatment option for individuals struggling with CUD in Pakistan. Methods A structured approach has been undertaken to culturally adapt CBT for patients with CUD in a tertiary care setting. As an initial step, a systematic review was conducted to assess the effectiveness of CBT for CUD, identifying relevant randomized controlled trials and evaluating their outcomes (the review manuscript has been submitted for publication elsewhere). The findings indicated that while CBT demonstrated certain benefits, its overall impact on cannabis use frequency remained inconsistent, emphasizing the necessity of adapting and integrating CBT with culturally relevant treatment approaches. Informed by the above systematic review, a well-established CBT manual developed by the National Drug and Alcohol Research Centre, Australia, has been selected as the foundation for adaptation (ref ). This manual provides a structured, session-based framework specifically designed to address cannabis use, incorporating key therapeutic components such as cognitive restructuring, behavioural self-monitoring, coping skills training, and relapse prevention. Detailed guidance is included for both therapists and patients, ensuring a standardized approach to treatment delivery. Practical exercises, psychoeducational content, and structured worksheets support skill development and enhance patient engagement throughout the therapeutic process. The adaptation of this manual will ensure alignment with cultural norms, language preferences, and treatment expectations of patients in Peshawar, optimizing its effectiveness within the local clinical context. A multi-method study will be conducted to culturally adapt the CBT manual for patients with CUD seeking treatment in tertiary care hospitals in Peshawar ( Figure 1 ). This will be achieved by conducting; 1) qualitative interviews to explore the treatment needs of patients and healthcare providers, as well as examining cultural beliefs, norms, attitudes, and treatment preferences related to CUD; 2) co-adaptation workshops with stakeholder engagement to ensure that collective decision-making informs the adaptation process, development of a culturally adapted CBT (CA-CBT) manual tailored for healthcare providers to enhance the treatment of patients with CUD in this setting; and 3) a pre-post study to assess the feasibility and acceptability of implementing CA-CBT for patients with cannabis use disorder (CUD) in tertiary care hospitals in Khyber Pakhtunkhwa, where rehabilitation services are available. Figure 1. Project plan including all three phases. Theoretical framework The Southampton Adaptation Framework (SAF) is a structured approach developed by Naeem et al. (one of the co-authors of this study) to guide the cultural adaptation of CBT for use in non-Western contexts. 38 The SAF emphasizes the importance of considering cultural and religious factors in mental health interventions to ensure their relevance and effectiveness in diverse cultural settings. 38 The framework comprises three core themes: “awareness of culture and religion,” “assessment and engagement,” and “adjustment in therapy,” each with several subthemes. 38 SAF has been utilized by several studies to develop different psychosocial interventions for a variety of mental health conditions. 38 Interventions such as CBT, 39 – 41 Dialectical Behaviour Therapy (DBT), 42 family-based interventions, 43 and others like learning through play, psychoeducation, and problem-solving interventions 38 have been developed using SAF, for conditions including depression, 44 psychosis, 40 , 45 schizophrenia, 43 obsessive-compulsive disorders, post-traumatic stress disorders, suicidal ideation, schizophrenia, and self-harm. 38 The SAF facilitates the cultural adaptation of CBT interventions, promoting effectiveness and acceptability in diverse cultural settings. By integrating cultural awareness and sensitivity into the adaptation process, mental health professionals can provide inclusive and responsive care that meets the needs of individuals from various cultural backgrounds. 38 Phase 1: Qualitative study This phase of the study uses a phenomenological approach. The phenomenological qualitative component includes focus group discussions (FGDs) and in-depth interviews (IDIs) to explore cultural, social, and religious factors influencing cannabis use and CUD. The qualitative phase ensures a comprehensive understanding of both collective and individual perspectives. Sample size The sample size for this qualitative study will be determined using both saturation and information power. Saturation refers to the point at which no new themes or insights emerge from additional interviews, 46 while information power is a prospective approach that considers study aim, sample specificity, theoretical grounding, dialogue quality, and analysis strategy to determine an adequate sample size. 47 The study will initially set the sample size based on information power, given its specific focus on the cultural aspects of cannabis use and treatment. Data collection will continue until saturation is achieved. Two FGDs, each with six to eight participants and at least 15 IDIs, will be conducted. Recruitment Participants will be recruited through purposive and snowball sampling to ensure representation from key stakeholder groups. Healthcare professionals will identify individuals with CUD and their caregivers. Efforts will be made to include individuals of diverse ages, socioeconomic backgrounds, education levels, and geographic locations. Patients with CUD and their family members will participate in FGDs and IDIs, while mental health professionals, local leaders, and religious scholars will provide additional perspectives through IDIs only. Mental health professionals will include psychiatrists and psychologists working in tertiary care hospitals. Religious scholars will offer insights into faith-based views on cannabis use and treatment. Locally elected leaders will provide their perspectives on community policies and social attitudes concerning cannabis use. Written informed consent will be obtained from all adult participants prior to their inclusion in the study. Study information will be provided as detailed in Annexure B (Supplementary document 1), and written consent will be documented using the form in Annexure C (Supplementary document 1). Eligibility Participants must be 18 years or older and residents of Peshawar. CUD users must have a confirmed diagnosis of CUD using the Cannabis Use Disorder Identification Test (CUDIT), prior cannabis use, or experience supporting individuals with CUD. Mental health professionals must have experience in treating substance use disorders. Religious leaders must be actively delivering sermons in community mosques, and local leaders must hold an elected position. Individuals who are not Pakistani nationals, healthcare professionals working exclusively in private clinics, religious leaders residing outside Peshawar, or former local leaders no longer in office will be excluded. Family members no longer in contact with the patient will also be ineligible to participate. Settings FGDs will take place in community settings such as the “Hujra,” a traditional gathering place for discussions, with locations finalized in consultation with participants. IDIs will be conducted in locations preferred by participants to ensure privacy. Informed consent and voluntary participation Participants will voluntarily decide whether to join the study. An information sheet in Urdu will outline the study’s purpose, potential benefits and risks, audio recording details, payments, confidentiality, withdrawal rights, and researcher contact information. Participants will receive the sheet in advance and will have the opportunity to ask questions. Before participation, they will be given a written consent form in Urdu, and any concerns will be addressed. Only those who fully understand the study and provide informed consent will participate. Incomplete or unsigned forms will indicate non-consent (Supplementary document 1). Data collection The interview process will be conducted by the researcher and a note-taker will be present to document the process. Participants will be contacted in advance to receive the information sheet, provide consent, and schedule interviews. All necessary materials, including a voice recorder, notepads, and pens, will be arranged beforehand. Availability will be confirmed before each session, and upon arrival, the researchers will introduce themselves and build rapport with participants. FGDs will begin once all participants are present, following a structured discussion guide. The note-taker will document key points, and recordings will be securely saved. FGDs will last 60–90 minutes, while IDIs will take 30–45 minutes. Topic guides The topic guides for FGDs and IDIs are based on the SAF framework and previous work on culturally adapting CBT. 17 These are tailored to cannabis use, participant type, and interview method, ensuring alignment with the study’s theoretical framework. The guides include open-ended and semi-structured questions with relevant probes, translated into Urdu and reviewed by a qualitative expert (Supplementary document 1). Data analysis Data from qualitative interviews will be subjected to framework analysis, 48 ensuring a structured identification of key cultural themes. Transcriptions of recorded interviews will be translated into English while maintaining the integrity of cultural idioms and expressions. Data analysis will follow a deductive approach utilizing the pre-established Southampton Adaptation Framework while allowing for inductive insights if new themes emerge. NVivo (version 14) software will be used to code and manage qualitative data to ensure consistency and reliability. A codebook will be developed to define each thematic category operationally and undergo expert review to ensure accuracy. Inter-coder reliability will be assessed using Cohen’s kappa coefficient, with a threshold of 0.80 considered an indicator of excellent agreement. Triangulation of data from IDIs and FGDs will enhance the reliability of findings, offering a comprehensive understanding of the cultural factors influencing CBT adaptation for CUD patients in Peshawar. Phase 2: Co-adaptation workshops Study design Co-adaptation workshops will be conducted in three separate sessions lasting two to three hours each, and will be held at 15-day intervals, following a participatory action research (PAR) approach. 49 This approach will ensure that key stakeholders actively contribute to modifying and refining CBT techniques in a culturally sensitive manner. Participant recruitment and sampling A co-production group of approx. 12 participants will be established to ensure a multidisciplinary perspective in guiding the adaptation process. This group will include two individuals currently using cannabis, two individuals who have successfully quit, two caregivers supporting patients with CUD, two therapists experienced in addiction treatment, and two researchers specializing in psychological interventions. Additionally, one local leader and one religious scholar will contribute to ensure that the intervention reflects broader cultural and societal perspectives. Participants will be identified through hospital networks, therapist referrals, and community outreach programs. Written informed consent will be obtained from all group members prior to participation. An information sheet will be provided before enrolment, and sufficient time will be given for participants to consider their decision. Workshop setting and procedures The workshops will be conducted at Khyber Medical University (KMU), which provides an academic and professional environment conducive to research collaboration. The adaptation process will integrate findings from the systematic review and qualitative interviews, ensuring that the intervention remains evidence-based while being aligned with local beliefs and treatment practices. The workshops will incorporate discussions on culturally relevant treatment strategies, language preferences, and social perceptions of cannabis use and recovery. Each session will include structured discussions, hands-on adaptation of CBT components, and review of previously discussed modifications. The staggered schedule will allow sufficient time between sessions for participants to reflect on discussions and for preliminary refinements to be incorporated before the next session. Discussions will focus on how therapeutic concepts can be conveyed in a culturally meaningful way, ensuring that local idioms of distress, community support mechanisms, and social norms are considered in the adapted intervention. Audio recordings of discussions will be maintained for accuracy, while detailed field notes will be taken to document emerging themes and key recommendations. Eligibility criteria The eligibility criteria for participation in the co-adaptation workshops will align with those established in the first phase. Participants must be 18 years or older, have prior experience related to CUD either as a patient, caregiver, or professional, and be willing to participate in all three workshop sessions. Healthcare providers and researchers must have relevant clinical or academic experience in addiction treatment or psychological interventions. Religious leaders must be active sermon deliverers in mosques, and local leaders must hold an elected position. Informed consent and ethical considerations Participants will receive comprehensive information about the purpose, objectives, and structure of the workshops. Invitations will be sent via email, formal letters from KMU, and WhatsApp messages at least one month before the workshops, with follow-up reminders sent 15 days and one week before each session. Before participation, individuals will have an opportunity to ask questions and clarify any concerns. Written informed consent will be obtained from all participants prior to their involvement (Supplementary document 1). Data collection The workshops will be moderated by the researcher along with a note-taker. Audio recordings will capture detailed stakeholder discussions, while research team members will take extensive field notes. Participant feedback forms will be used to gather insights on the perceived acceptability, feasibility, and clarity of the adapted CBT intervention. These data sources will support an iterative refinement process, allowing for continuous modification and improvement of the intervention based on participant feedback. Topic guides Topic guides will be developed to facilitate discussions during the workshops. These guides will be informed by multiple sources, including the original CBT manual, findings from qualitative interviews and focus group discussions, and insights from the systematic review. The guides will address key areas such as local perceptions of cannabis use, barriers to treatment engagement, culturally resonant coping strategies, and the integration of religious and community-based support systems. Data analysis Thematic analysis will be conducted to analyze data from the co-adaptation workshops (ref ). Audio recordings will be transcribed verbatim, and field notes will be systematically reviewed. The analysis will follow a structured coding framework, beginning with an initial coding phase to identify prominent themes and patterns. These themes will be further refined through iterative discussions among the research team, with key findings categorized into conceptual areas such as cultural adaptation, treatment acceptability, and feasibility of implementation. A triangulation approach will be used, integrating feedback from different stakeholder groups to ensure a balanced and comprehensive adaptation process. The findings from this analysis will directly inform revisions to the CBT manual, ensuring that the intervention remains both scientifically grounded and culturally relevant. The finalized adaptation will undergo further review by experts and stakeholders before proceeding to the feasibility study in the next phase. Phase 3: Pre-post feasibility study The third phase of the study will assess the feasibility and acceptability of implementing CA-CBT for patients with cannabis use disorder (CUD) in tertiary care hospitals in Khyber Pakhtunkhwa, where rehabilitation services are available. This phase aims to explore the feasibility and acceptability of CA-CBT among patients and therapists in tertiary care hospitals in Peshawar. The study will also evaluate its impact on reducing cannabis use, explore patient and therapist experiences, and identify potential barriers and facilitators to its adoption in practice. Findings will help refine CA-CBT to better meet the needs of the local population. Methods A pre-post study will be conducted. Patients with CUD will be provided with CA-CBT intervention and assessed for the desired outcomes. The goal is to gain a deeper understanding of how CA-CBT is experienced in real-world settings and to seek guidance from the study for conducting pilot feasibility and/or definitive trial. Study settings The study will be conducted in three government tertiary care hospitals in Peshawar. There are three functional government tertiary care hospitals in Peshawar: Lady Reading Hospital (LRH), Khyber Teaching Hospital (KTH), and Hayatabad Medical Complex (HMC). These tertiary care hospitals are being chosen purposively based on having a specialized psychiatry unit providing drug abuse rehabilitation services. Permission will be obtained from the hospitals for the study’s implementation. Eligibility Patients aged 18 years or older who present at the facility will be assessed using the CUDIT. Those who score more than 12 on the CUDIT will be considered patients with CUD and included in the study. Additionally, patients who self-confirm current cannabis use will be assessed on CUDIT, and after confirmation of a score above 12, will be included. Similarly, psychiatrists/psychologists who are engaged in treating patients with CUD in these tertiary care hospitals will be included in this study. Patients will be excluded from the study if they have a physical or mental impairment that hinders their ability to provide informed consent, are currently on psychotic drugs or receiving medications for drug addiction, are currently suicidal as defined in the Mental Health Gap Action Programme (mhGAP) intervention Guide 50 or have made a suicidal attempt within the past two years. Pregnant women will be excluded from this study and will not receive CA-CBT. Recruitment Participants will be identified and recruited with the help of hospital staff and psychiatrists working in tertiary care hospitals. Patients seeking treatment for cannabis use will be screened for eligibility based on inclusion and exclusion criteria and included in the study after obtaining written informed consent. Patients having difficulty in reading or writing will be informed, and verbal consent will be taken from them in the presence of a witness. The witness will not be a part of the research team or hospital staff (Supplementary document 1). Sample size Sample size was estimated using a traffic light progression framework to inform decisions on advancing to a full trial. This framework incorporated a green lower limit indicating thresholds for progression, a red upper limit suggesting discontinuation, and an intermediate amber range where progression may be considered with adjustments. 51 A normal approximation method was applied, with alpha set at 0.05 and beta at 0.2. A single-arm allocation was considered, and expected recruitment was set at 40%. Progression criteria specified a green lower limit of 0.50 for eligibility and 0.75 for retention, acceptability, appropriateness, and feasibility. Red upper limits were set at 0.20 for recruitment and eligibility, and 0.50 for the remaining feasibility outcomes. Based on these parameters, the required number of patients to be assessed was 68 at the population level. The required number of patients to receive the intervention was 27. The sample size was considered sufficient to detect feasibility indicators exceeding the red thresholds with a statistical power of at least 80%. Thus, a total of 27 patients will be recruited across three sites, with nine patients enrolled per site. The findings are expected to inform the design of a larger, more definitive trial in the future. At each study site, one therapist will be trained (three therapists in total) to deliver CA-CBT. These therapists will be purposively selected, having previous experience in treating drug abuse patients. Patients will be conveniently selected based on the eligibility criteria ( Figure 2 ). Figure 2. Sample size calculation using SS-PROGRESS . Training of the therapists Three psychologists currently working in the mental health and drug abuse departments of tertiary care hospitals will receive training (six days, as per the identified manual). These psychologists are directly involved in providing services to patients dealing with drug abuse, making them ideal candidates for implementing the CA-CBT intervention. The training will cover various aspects of CA-CBT, including its theoretical foundations, practical application, and specific techniques tailored for treating patients with cannabis use disorder. CA-CBT intervention The format and mode of the intervention will be informed by the cultural adaptation process above. The intervention will consist of a structured CA-CBT program designed to help individuals with CUD in Khyber Pakhtunkhwa, Pakistan. Based on the literature, we predict that it will include six to eight therapy sessions, each targeting specific aspects of cannabis dependence and its management. The program will begin by helping participants understand their cannabis use patterns and set personalized goals through motivational enhancement training. Subsequent sessions will teach practical strategies for coping with cravings, managing withdrawal symptoms, and addressing negative thought patterns that may hinder progress. Participants will also learn how to plan for quitting, identify triggers, and navigate high-risk situations while building a supportive network of people who can aid in their recovery. In the final sessions, participants will learn relapse prevention techniques and be encouraged to adopt a healthier lifestyle. Each session will be interactive, using culturally relevant examples, and will be delivered through a combination of psychoeducation, skill-building exercises, and practical homework assignments to reinforce learning and support behaviour change. Outcomes The study will primarily focus on assessing the intervention’s feasibility, appropriateness, and acceptability. The secondary outcomes include cannabis use frequency and amount of cannabis use. Table 1 outlines the metrics and tools used to evaluate CA-CBT for cannabis use. It includes measures for CUD, cannabis use frequency, and the amount consumed, alongside the feasibility and acceptability of the intervention (Supplementary document 1). Table 1. Outcome measures of the pre-post study. Outcomes Operational definition Indicators Tools/questionnaires Stage of assessment Demographic information Age Gender Education Area of residence Average monthly income Income spent on cannabis purchase Self-reported Pre-study Cannabis Use Disorder (CUD) Problematic cannabis use as per CUDIT Scores > 12 is considered CUD Use of cannabis Stoned (Under the influence of cannabis) Desired effects of cannabis Use cannabis in the morning Guilt of using cannabis Lack of concentration Harm to others Cannabis Use Disorder identification test (CUDIT) Pre and Post Cannabis Use Frequency The number of times cannabis is used within a week Number of days cannabis is used in a week Number of episodes cannabis used per day Self-Reported Pre and Post Amount of Cannabis Use The quantity of cannabis consumed during each episode, measured in grams or tolas * Average quantity of cannabis used per episode of use Average quantity of cannabis used per day Self-reported Pre and Post Feasibility of CA-CBT The extent to which the CA-CBT intervention can be successfully delivered and utilized within the target population and setting Recruitment rates Engagement rates (attendance/participation) Retention rates Adherence rates Recruitment: Number of participants approached, recruited and screened Engagement: Session attendance records Retention: Follow-up completion rates Adherence: Session completion logs, Feasibility of intervention measure During and Post study Acceptability of CA-CBT The degree to which participants and therapists perceive the CA-CBT intervention as suitable, satisfactory, and relevant Satisfaction scores Perceived relevance Ease of use Willingness to continue Acceptability of Intervention Measure (AIM) Open-ended questions Post study Appropriateness’ of CA-CBT The extent to which participants perceived CA-CBT as fitting, suitable, applicable, and a good match for their needs Fitting to address CUD Scores Suitable for participants’ personal circumstances scores Applicable to the cultural context scores Good match for participants’ needs scores Intervention Appropriateness Measure (IAM) Post study * A "tola" is a traditional unit of measurement for gold, silver or other commodities such as cannabis etc in South Asia. One tola is equivalent to approximately 11.66 grams. Data collection The data collection procedure will commence with the therapists’ recruitment of participants from hospitals, where informed consent will be obtained from those meeting the inclusion criteria. Initial assessments will be conducted by the researcher, using the CUDIT, to identify symptoms of cannabis use disorder, and self-reported data on cannabis use frequency and amount of use will be collected using questionnaires. During the intervention phase, when participants engage with the CA-CBT, the researcher will closely monitor adherence and session attendance. At the end of the intervention, the researcher will carry out the follow-up assessments, including re-administration of the CUDIT and the collection of updated self-reported data on cannabis use. Feasibility metrics, such as follow-up completion rates and adherence, will be evaluated. Additionally, acceptability will be assessed using the Acceptability of Intervention Measure (AIM) and open-ended feedback from participants and therapists. The open-ended feedback will be obtained using the following questions. 1. “Can you describe your overall experience with the CA-CBT sessions and what aspects of the therapy you found most helpful or challenging?” 2. “Can you share your thoughts on any specific session that you found particularly effective or less helpful? What made that session stand out for you?” 3. “How well do you think the culturally adapted aspects of CA-CBT resonated with your personal beliefs and cultural values? Can you give examples?” 4. “What suggestions do you have for improving the CA-CBT program to better meet the needs of people with similar backgrounds and experiences as yours?” Data analysis The data analysis will use descriptive and inferential statistical methods to evaluate the CA-CBT intervention. Given the small sample size (12 participants), non-parametric tests such as the Wilcoxon signed-rank test will be used to compare pre- and post-intervention CUDIT scores, and cannabis use frequency and quantity. Feasibility will be assessed using descriptive statistics (means, medians, and percentages) to summarize recruitment, engagement, retention, and adherence rates. Acceptability will be evaluated using Acceptability of Intervention Measure (AIM) scores, analyzed through descriptive statistics and Wilcoxon tests, along with thematic analysis of qualitative feedback to explore satisfaction, relevance, and ease of use. NVivo (version 14) software will be used for qualitative data analysis, applying thematic framework analysis to identify key patterns. Quantitative analysis will be conducted using Stata (Version 18.0) to ensure accurate interpretation of results. Withdrawal from the study This study is not expected to pose significant risks to participants. However, discussing personal experiences may cause discomfort for some individuals. To address this, participants will be informed that they can choose not to answer any questions that make them uncomfortable. All information will be handled with strict confidentiality to protect their privacy. Participants will have the right to withdraw from the study at any time without providing a reason, and they can request that their data not be used within a specified period. Adverse events The CA-CBT intervention has no direct impact on the physical health of the patients. However, it has known effects on the cognition and behaviours of the patients. During treatment, patients can face the withdrawal effects of cannabis. These effects will be assessed by the therapists and will be considered as non-adverse, adverse, or serious adverse events based on the nature and severity of the events. The events will be reported and treated by the therapists according to the hospital protocols. Patient and public involvement and engagement (PPIE) PPIE will ensure that the perspectives of patients, families, and health professionals are integrated throughout the research process, shaping the adaptation of the CBT intervention for CUD. PPIE members will inform the recruitment and retention strategies for FGDs, IDIs, and co-adaptation workshops, refine topic guides, and ensure cultural relevance of the study. PPIE members will also review study materials to ensure clarity and appropriateness while providing continuous feedback through structured discussions and consultations. Additionally, they will play a key role in disseminating findings through patient-friendly summaries, informal and formal discussions, and sharing results through community networks, spreading awareness about the adapted intervention. Discussion This study introduces a structured approach that culturally adapts cognitive behavioural therapy for individuals experiencing cannabis use disorder in Pakistan while addressing the cultural context of the patient population. The approach integrates local beliefs and values to align the therapeutic process with the lived experiences of those affected, a strategy that enhances patient engagement and treatment outcomes as evidenced in previous research. 52 – 54 The methodological framework, Southampton’s framework for cultural adaptation of CBT, offers notable improvements over conventional techniques that often overlook cultural dimensions. It reduces resource, cost, and time demands, making the intervention more sustainable in resource-limited settings. 55 , 56 The active involvement of local stakeholders, including patients, mental health practitioners, community leaders, and religious figures, has been instrumental in refining the adaptation process while preserving CBT’s core therapeutic components. 57 , 58 This participatory design not only supports the development of a culturally relevant intervention but also minimizes the need for extensive post-implementation modifications, as suggested by established adaptation frameworks. 17 , 59 , 60 The robustness of the adaptation protocol is supported by a rigorous, iterative process that incorporates quality control measures and expert validation, thereby enhancing reproducibility and reliability. Standardized training of mental health practitioners and the use of detailed intervention manuals ensure consistent treatment delivery, as documented in previous studies. 61 , 62 Practical implementation requires that practitioners receive comprehensive training to navigate cultural attributes and avoid common pitfalls such as misinterpretation of local values. 63 , 64 Recommendations for optimizing outcomes include ongoing supervision, careful documentation of intervention sessions, and the integration of culturally pertinent examples throughout the therapeutic process. 65 In comparison with alternative treatment approaches such as brief motivational interventions or pharmacological therapies, this CA-CBT provides a non-invasive and sustainable option. However, its success relies on sustained patient participation, a challenge in communities with limited mental health awareness. 66 – 68 Strengths and limitations of the study This study will demonstrate methodological rigor through a structured adaptation process integrating qualitative research with a participatory approach using an established SAF for adaptation of CBT. The use of FGDs, IDIs, and co-adaptation workshops ensures that diverse perspectives, including those of patients, caregivers, mental health professionals, and community leaders, are incorporated into the intervention, through the key areas identified in SAF. This engagement will enhance the cultural relevance and acceptability of CBT, fostering greater treatment adherence. Patient and public involvement further strengthens the study by promoting transparency, trust, and alignment with community needs. The iterative adaptation process, guided by expert reviews, ensures that core therapeutic principles are preserved while modifications address cultural sensitivities. This systematic approach enhances reliability and reproducibility, making CA-CBT suitable for real-world implementation. The study provides a replicable framework for adapting psychological interventions in resource-limited settings, offering a sustainable model for improving mental health treatment accessibility and effectiveness in diverse populations. Despite these strengths, several limitations require careful consideration that may impact the study’s findings and broader applicability. The qualitative component, comprising two FGDs and 15 in-depth interviews with 27–31 participants, is designed to explore experiences rather than achieve generalizability. The study is limited to tertiary care hospitals in Peshawar, which may introduce selection bias and affect the applicability of findings to other settings. Cultural sensitivities around cannabis use, particularly its association with males, may result in limited female participation, reducing the diversity of perspectives. Recruitment may also be challenging due to the stigma attached to cannabis use. Additionally, the reliance on self-reported measures for cannabis use frequency and quantity may introduce bias or inaccuracies. While the study aims to assess the feasibility and acceptability of CA-CBT, the small sample size and specific cultural context may limit the extent to which the findings can be applied more broadly. The effectiveness of CA-CBT in reducing cannabis use may not show significant clinical or statistical improvements, but the results will provide valuable insights for refining the intervention and informing future research. Paper context • The study will assess the feasibility, acceptability, and appropriateness of a culturally adapted cognitive behavioral therapy for cannabis use disorder in a low-resource setting. • It will generate evidence on how cultural beliefs, gender dynamics, and local context influence the delivery and uptake of psychological interventions for cannabis use. • Findings will provide a pathway for definitive trial and inform policy and practice on tailoring substance use treatments to diverse populations, supporting more inclusive mental health strategies in global health systems. Ethics and consent Ethics approval for the study has been obtained from the institutional ethics review committee of the Institute of Public Health and Social Sciences (No. KMU/IPHSS/Ethics/2025/FA/239, Dated: 06/01/2025) and Keele Ethics Committee (REC Project Reference 1049, Dated: 20/05/2025). Written Informed consent will be obtained from participants/respondents before participating in the study. Personal identifiers will be removed or pseudonymized to protect the privacy of participants. Participants will be informed of their rights regarding their data, including the right to access, rectify, or erase their personal data. Any requests from participants regarding their data will be handled promptly and in accordance with GDPR regulations. Data availability statement The corresponding author, Safat Ullah, can be contacted at [email protected] for access additional information related to the study. Requests will be reviewed, by supervisory team, to ensure compliance with ethical approvals and institutional policies. Underlying data No underlying data are associated with this article. Extended data Mendeley Data: Cultural Adaptation of CBT for CUD in Peshawar: Multi-methods Protocol Supplementary Data, DOI: https://doi.org/10.17632/kmh3th9ync 69 File: Feasibility & Acceptability of CA-CBT for CUD-Protocol paper-Supplementary document 1.docx The project contains the following extended data with details available in the file: • Screening instruments (CUDIT) • Patient questionnaires • Informed consent forms • Participant information sheets • Interview and focus group guides • Co-adaptation workshop invitations • Observation checklists Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments The author expresses sincere gratitude to Abdul Latif, Muhammad Sohaib, and Nishani Fonseka for their valuable guidance and encouragement, which have been crucial in shaping this work. References 1. Gorelick DA: Cannabis use: Epidemiology, pharmacology, comorbidities, and adverse effects. 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Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 10 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 School of Medicine, Keele University, Keele, England, ST5 5BG, UK 2 Office of Research Innovation and Commercialization, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 3 Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 4 Institute of Mental Health and Behavioral Sciences, Khyber Medical University, Peshawar, Khyber Pakhtunkhwa, 25100, Pakistan 5 University of Toronto Department of Psychiatry, Toronto, Ontario, Canada Safat Ullah Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Priyamvada Paudyal Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Review & Editing Fayaz Ahmad Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing Asad Ullah Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Muhammad Firaz Khan Roles: Supervision, Writing – Review & Editing Ghasem Yadegarfar Roles: Supervision, Writing – Review & Editing Farooq Naeem Roles: Methodology, Supervision, Writing – Review & Editing Saeed Farooq Roles: Funding Acquisition, Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This study is the first author's PhD project under the “CogNitive Therapy for DepRessiOn in TubercuLosis patients” (CONTROL) programme, specifically within the capacity development component, funded by the National Institute for Health Research (Award ID: NIHR201773) The author acknowledges the resources and opportunities provided by NIHR, which have significantly facilitated this research endeavour. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 10 Sep 2025, 14:897 https://doi.org/10.12688/f1000research.168207.1 Copyright © 2025 Ullah S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. 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