# Development, Cultural Adaptation, and Content Validation of Urdu Pain Neuroscience Education Materials for Low Back Pain in Pakistan

## TL;DR

This paper describes the creation and validation of Urdu pain education materials for low back pain in Pakistan, ensuring they are clear and culturally appropriate.

## Contribution

The novel contribution is the development and cultural adaptation of Urdu-specific pain neuroscience education materials for low back pain in Pakistan.

## Key findings

- Urdu PNE materials were judged clear, relevant, and culturally appropriate by clinicians and individuals with LBP.
- All seven domains of the materials exceeded the minimum content validity ratio threshold.
- Cultural appropriateness and content accuracy showed the highest agreement in validation assessments.

## Abstract

Background: Pain neuroscience education (PNE) can support understanding of low back pain and facilitate engagement with active care. Most PNE materials have been developed in English, and there is little culturally adapted content for Urdu-speaking populations. Locally relevant educational resources may help improve clarity, acceptability, and communication in clinical settings. Objective: To develop, culturally adapt, and content-validate Urdu PNE materials for individuals with LBP and for use by healthcare professionals in Pakistan. Methods: A four-stage adaptation process was used. Phase 1 involved drafting a ten-module English PNE booklet and clinician guide based on contemporary pain-science literature. Phase 2 included forward–backward translation into Urdu and cultural adaptation by translators and a bilingual pain researcher. In Phase 3, three focus-group sessions with clinicians and a person with LBP informed iterative revisions. In Phase 4, a multidisciplinary panel (clinicians and individuals with LBP, n = 32) assessed seven domains of the final Urdu materials for clarity, relevance, and cultural appropriateness using Lawshe’s content validity ratio (CVR). Results: Focus-group feedback led to simplification of Urdu phrasing, refinement of metaphors, and adjustments to illustrations. All seven domains exceeded the minimum CVR threshold (0.30) for n = 32, with a mean overall CVR of 0.69 ± 0.12. Cultural appropriateness (CVR = 0.88) and content accuracy (CVR = 0.86) showed the highest agreement. Conclusions: The adapted Urdu PNE materials were judged to be clear, relevant, and culturally appropriate by clinicians and individuals with LBP. These materials may be useful for supporting pain-related education in clinical and community settings. These findings establish preliminary content validity; further studies are needed to evaluate feasibility, implementation, and clinical outcomes.