Addictive Behaviors During the 2022 FIFA World Cup: A Qualitative Study of Patients and Healthcare Staff at a Substance Use Disorder Facility

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript is a tightly focused inquiry on how current patients in a substance use treatment facility within a country with low availability of alcohol interpret the experience of a sporting mega-event, and how it challenges their recovery efforts.  Heightened excitement levels, greater availability of abusable substances (opioids, alcohol, amphetamines), decreased supervision levels and other environmental factors were among the challenges.  The facility in which the research took place was also reported to be proactive in supportive activities to attempt to guard against relapse.  The individual interviews with patients and focus groups held with providers produced text for qualitative analysis, including brief illustrative quotes.  Conclusions (including study limitations) were reasonably presented and the small study may be of interest to some of the journal's readers.

Minor and fixable issues:

Abstract:

Lines 40-41 on p. 1: "...SUDs were participated in semi-structured patients' interviews.  Additionally, focus groups discussion..." should be "...SUDs participated in semi-structured patients' interviews.  Additionally, focus group discussions..."

line 45 patients-maintained should be patients maintained

P. 2 onward.  reference numbers should follow, not precede punctuation.  e.g., influences². should be influences.²   Most references need to be moved behind punctuation marks.

P. 3 a reference should accompany reflexive thematic analysis to describe it.

P. 4 line 113, insert a comma after criteria.

P. 4. - lines 143-152, section 2.6  - No references for this section.

P. 5 line 157: add a semicolon after analysis.  

p. 5 line 158: was should be were.

P. 5 table heading: Patient's should be Patients.

p. 6 In Figure 2, most but not all words are capitalized: why?  These should be made consistent.

p. 7 line 223: period should precede quote marks.

p. 8 Increase the space between columns on Tables 2 and 3.

p. 9 lines 273 and 278 : Including should be , including

p. 10 the left margins of the columns in Table 4 should be standardized.

p. 11 line 355 tournament, should be tournament; 

p. 12 lines 408, 430-434 Be consistent about capitalization in these journal titles.

Author Response

We would like to express our deep gratitude to the reviewer for their time and expertise that definitely substantially contributed to improving the quality of our manuscript.

Reviewer Comments: This manuscript is a tightly focused inquiry on how current patients in a substance use treatment facility within a country with low availability of alcohol interpret the experience of a sporting mega-event, and how it challenges their recovery efforts.  Heightened excitement levels, greater availability of abusable substances (opioids, alcohol, amphetamines), decreased supervision levels and other environmental factors were among the challenges.  The facility in which the research took place was also reported to be proactive in supportive activities to attempt to guard against relapse.  The individual interviews with patients and focus groups held with providers produced text for qualitative analysis, including brief illustrative quotes.  Conclusions (including study limitations) were reasonably presented, and the small study may be of interest to some of the journal's readers.

• Author Response: Thank you very much for the careful reading of our manuscript and for the constructive feedback. All suggested revisions and corrections have been implemented in the revised manuscript. Please find below the detailed responses to your specific comments:

Abstract: Lines 40-41 on p. 1: "...SUDs were participated in semi-structured patients' interviews.  Additionally, focus groups discussion..." should be "...SUDs participated in semi-structured patients' interviews.  Additionally, focus group discussions..."

• Author response:

Thank you for pointing this out. We agree with this comment. Therefore, we have updated the abstract.

• Action taken: “Methods: we purposively sampled 32 participants that were present at Naufar Center during the 2022-FWC (i) thirteen adults SUD patients that were receiving treatment and (ii) nineteen healthcare practitioners. Semi-structured patients’ interviews were conducted, and focus groups discussion were held with a multidisciplinary team, including psychologists, nurses, and physicians”

line 45 patients-maintained should be patients maintained

• Author response: We do agree, thanks for the comment.
• Action taken: Correction was made

2. 2 onward.  reference numbers should follow, not precede punctuation.  e.g., influences². should be influences.²   Most references need to be moved behind punctuation marks.

• Author response: We do agree, thank you for identifying this punctuation issue.
• Action taken: Correction was made

1. 3 a reference should accompany reflexive thematic analysis to describe it.

• Author response: We do agree, thanks for the comment.
• Action taken: One references has been added.

• 29. Sarfo JO, Debrah TP, Gbordzoe NI, Afful WT, Obeng P. (2021) Qualitative Research Designs, Sample Size and Saturation: Is Enough Always Enough? Journal of Advocacy Residual Education. 8(3):60-65 DOI:10.13187/jare.2021.3.60

1. 4 line 113: insert a comma after criteria.

• Author response: Thank you
• Action taken: Correction was made

4. 4. - lines 143-152, section 2.6: No references for this section.

• Author response: Thank you
• Action taken: Reference was added

1. 5 line 157: add a semicolon after analysis.

• Author response: Thank you
• Action taken: Correction was made

1. 5 line 158: was should be were.

• Author response: Thank you
• Action taken: Correction was made

1. 5 table heading: Patient's should be Patients.

• Author response: Thank you
• Action taken: Correction was made

1. 6 In Figure 2: most but not all words are capitalized: why?  These should be made consistent.

• Author response: We agree with your comment, thank you
• Action taken: However, when working on the amendments, we decided to replace figure 2 with a table which is probably more relevant to the results of our study.

Table 2: Psychological Resilience and Vulnerabilities

Feature	Protective Factors (Resilience)	Risk Factors (Vulnerabilities)
Social	Group outings, NA* meetings, and "safe" celebrations.	Old friend groups, environmental availability.
Psychological	Integration through sports, taking therapist advice.	Depression, family stress, and "free time."
External	Structured Naufar environment.	Financial pressure, legal issues, and overstimulation.

* (NA: Narcotics Anonymous).

1. 7 line 223: period should precede quote marks.

• Author response: Thank you
• Action taken: Correction was made

3. 8: Increase the space between columns on Tables 2 and 3.

• Author response: Thank you
• Action taken: Correction were made. For instance, table 3 now read as follows:

 

 

Table 3: Patients’ Perception on Naufar Strategy during the 2022-FWC

Service Type	Strategy Implemented	Patient Impact
Accessibility	24/7 "Open Door" policy and messaging application groups.	Reduced anxiety; P13 felt "accepted with open arms" without an appointment.
Holistic Care	Spiritual trips, gym activities, and volunteering.	Shifted focus from the past to the present; improved mood (P1, P6).
Peer Support	Integration of NA* meetings and recovery coaches.	Created accountability and a "safety in numbers" mentality (P7, P11).

* (NA: Narcotics Anonymous).

1. 9 lines 273 and 278: Including should be, including

• Author response: Thank you
• Action taken: Correction was made

1. 10: the left margins of the columns in Table 4 should be standardized.

• Author response: Thank you
• Action taken: Correction was made, and table 4 now reads as follows:

Table 4: Comparative Analysis of Institutional Strategy vs. Patient Outcome

Institutional Strategy	Clinical Intent	Patient-Reported Outcome
In-House Fan Zones	Risk mitigation and controlled exposure to festivities.	High engagement; felt "included" without needing tickets or facing triggers (P8, P12).
"Total Environment" Staffing	Constant supervision and immediate craving intervention.	Improved "therapeutic alliance"; patients felt cared for by off-duty staff (P7).
Low-Barrier Access	Proactive outreach (WhatsApp/Calls) to prevent isolation.	Reduced anxiety; felt "accepted with open arms" even without appointments (P13).
Diversified Programming	Mood stabilization through gym, spiritual trips, and sports.	Shifted focus from "the past" to present relief and healthy distractions (P1, P6).
Cognitive Reframing	Labeling external temptations as "traps" rather than "pleasure."	Increased resilience; patients adopted a "sober joy" mindset (P7).

 

 

1. 11 line 355: tournament, should be tournament;

• Author response: Thank you
• Action taken: Correction was made

1. 12 lines 408, 430-434: Be consistent about capitalization in these journal titles.

• Author response: Thank you
• Action taken: Correction was made

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the paper “Addictive Behaviors During the 2022-FIFA World Cup: A Qualitative Study of Patients and Healthcare Staff at a Substance Use Disorder Facility.” This paper discussed an interesting topic which is the influence of the 2022 FIFA World Cup on substance use patients. The paper is based on qualitative interviews. 
The authors provide a strong and well-structured background, and the methods are clearly described. The overall research procedure appears appropriate and well streamlined. However, a key limitation is the very small patient sample size (N = 13) drawn from a single treatment center, which substantially limits the significance and generalizability of the study relative to the ambitions outlined in the introduction.
In addition, the results section is difficult to follow. There appear to be two repeated parts of patient interview findings and the focus group insights, with closely related but not identical content presented in separate sections. Several subsections read more like a collection of patient quotations than an analytical synthesis, with limited interpretation or higher-level insights drawn from the data. Many of the quotations consist primarily of positive comments about the services, which offer limited insight into the specific impact of the sports event itself. While at the same time, the focus group findings are presented largely as summaries without supporting verbatim quotations, which makes it harder to assess how the conclusions were derived from the underlying data. 

Author Response

Journal: IJERPH (ISSN 1660-4601)

Manuscript ID: ijerph-4064632

Type: Article

Title: Addictive Behaviors During the 2022-FIFA World Cup: A Qualitative Study of Patients and Healthcare Staff at a Substance Use Disorder Facility

Authors: Khalifa Al Kuwari , Izzeldin Ibrahim * , Abdulaziz Farooq , James England , Perla ElMoujabber , Rama Kamal , Karim Chamari , Vidya Mohamed-Ali , Mohammad Al-Maadheed

We would like to express our deep gratitude to the reviewer for their time and expertise that definitely substantially contributed to improving the quality of our manuscript.

Author responses to Reviewer-2 comments

Reviewer Comment: “A key limitation is the very small patient sample size (N = 13) drawn from a single treatment center, which substantially limits the significance and generalizability...”

• Author Response: We acknowledge the reviewer’s concern regarding the sample size and the single-center nature of the study. While N = 13 is common in qualitative pilot studies to reach thematic saturation, we agree that it is limiting the broad generalizability of the findings.
• Action taken: We have added a dedicated " Study Limitations" section (page 12) where we explicitly discuss the constraints of the small sample size and the single-center setting.

“Study Limitations”

“While this study provides valuable preliminary insights into addictive behaviors during the 2022-FIFA World Cup, some limitations must be acknowledged. Despite achieving thematic saturation, the small, single-center sample (N = 13) limits broader generalizability and strong statistical representation. As a pilot study, the findings are specific to this cultural and institutional context. Furthermore, the reliance on self-reported data introduces potential social desirability bias regarding clinical services ³⁰. Future multi-center, longitudinal research with larger cohorts is required to validate these themes and assess long-term impacts."

Reference 30 has been added as follows:

30 - Poudel, N., Kavookjian, J., & Scalese, M. J. (2020). Motivational Interviewing as a Strategy to Impact Outcomes in Heart Failure Patients: A Systematic Review. The patient, 13(1), 43–55. https://doi.org/10.1007/s40271-019-00387-6

Reviewer Comment: “The results section is difficult to follow. There appear to be two repeated parts of patient interview findings and the focus group insights...”

• Author Response: We truly appreciate this observation. The previous structure led to unnecessary redundancy and confusion regarding the data sources.
• Action taken: Accordingly, we have made major modifications to the results section to follow a thematic structure rather than a source-based structure. We have merged the "patient interview" and "focus group" findings into cohesive thematic categories. This eliminates repetition and allows for a more streamlined comparison of perspectives between the two groups. (Results section, Page 12 – see below in the present document)

Reviewer Comment: “Several subsections read more like a collection of patient quotations than an analytical synthesis... Many quotations consist primarily of positive comments about the services...”

• Author Response: We agree that the initial version relied too heavily on descriptive quotations, which limited the analytical depth of the findings. While our intention was to preserve participants’ voices, we recognize that stronger interpretive synthesis is necessary for qualitative analysis.
• Action taken: We have revised the Results section to ensure each subsection begins with a clear analytical claim. We have also audited the quotations to remove those that were purely "service-complimentary" without specific relevance to the sports event’s impact. The revised text now focuses on the mechanisms of change identified in the data. (Results section, Page 12 – see below in the present document)

Reviewer Comment: “Focus group findings are presented largely as summaries without supporting verbatim quotations...”

• Author Response: Thank you for pointing this out.
• Action taken: We have integrated verbatim quotations from the focus group transcripts into the revised Results section. These quotes serve to ground our summaries in the participants' actual words, providing a clearer audit trail for our conclusions. (Results section, page 12 - see below in the present document)

The restructured results section now reads:

Thirteen male patients receiving SUDs treatment at Naufar center (mean age: 35.2 years (SD: ±8.7) were recruited. The most common drugs used by the participants were opioids (69.2%), alcohol (15.4%), and methamphetamines (Shaboo) (15.4%). Detailed information about the participants is presented in table-1a. Nineteen healthcare practitioners participated in the focus group discussion as shown in table 1b. Based on the research objectives, the results were organized around two core thematic pillars related to the interventions: Theme-1: “The Impact of the 2022-FWC on patients’ addictive behavior”. Theme-2: “Naufar’s institutional strategies during the 2022-FWC”.

Table 1a: Demographic characteristics of interviewed patients. (N=13)

Characteristic	Category	n	%
Age/years	18 – 28	4	30.7 %
	29 – 39	6	46.2 %
	40 and above	3	23.1 %
Marital status	Married	1	07.7 %
	Single	9	69.2 %
	Divorced	3	23.1 %
Education level	Elementary	3	23.1 %
	Preparatory	2	15.4 %
	Secondary	7	53.8 %
	University	1	07.7 %
Employment status	Employed	7	53.8 %
	Unemployed	6	46.2 %
Primary Substance Used	Alcohol	2	15.4 %
	Methamphetamine	2	15.4 %
	Opioids	9	69.2 %

 

Table 1b: Demographic and Professional Characteristics of Focus Group Participants (N=19)

Characteristic	Category	n	%
Gender	Male	17	89.5 %
	Female	2	10.5 %
Professional role	Physician	7	36.8 %
	Clinical Psychologist	3	15.8 %
	Nursing Staff	9	47.4 %
Years of clinical experience with SUD patients	0–5 years	4	21.0 %
	6–10 years	9	47.4 %
	>10 years	6	31.6 %
Primary clinical setting	Inpatient Rehabilitation	12	63.2 %
	Outpatient Clinic	7	36.8 %

 

Theme 1: The Impact of the 2022-FWC on Patients’ Addictive Behavior

The 2022-FWC served as a dual-edged catalyst for patients in recovery. While the structured environment of the Naufar center and the communal spirit of the event acted as protective "social scaffolding," the environmental overstimulation and availability of substances (particularly alcohol) presented significant psychological hurdles for the patients.

1. Behavioral Patterns: Abstinence vs. Environmental Triggers

Most patients (9/13) maintained sustained abstinence throughout the tournament. For some patients, the FWC period was a milestone of "normalcy," with participants (P2, P3, P13) describing it as their first experience of fulfilling life without substance use.

However, clinical insights from focus groups added a layer of complexity to these reports. While inpatient participants felt successful, physicians and psychologists observed increased emotional instability and "restlessness" triggered by the desire to join public celebrations.

• The "Alcohol Factor": While patients focused on general recovery, clinicians noted that alcohol was the most consistently craved substance, particularly among those in long-term recovery who may have underestimated the power of external triggers.
• Medication & Compliance: Nurses identified that "craving behavior" wasn't always a physical urge to use, but manifested as logistical friction, such as requests for home medication or missed appointments.

2. The Role of "Social Support" in Craving Management

Cravings during the FWC were largely described as manageable (7/13 patients), primarily due to the therapeutic atmosphere and group cohesion.

• Peer Support: P6 and P12 highlighted a "protective pack" mentality—staying in groups to navigate crowded areas like Souq Waqif or Lusail (specific areas for celebration in Doha) to ensure safety.
• Clinical Interventions: The use of pharmacological aids (Suboxone®) and structured cognitive interventions helped reframe the urge to use. As P11 noted, the interventions effectively "kept the idea away."

3. Psychological Resilience and Vulnerabilities

Our results reveal a stark contrast between those who felt protected by the "Naufar bubble" and those who felt the weight of external pressures. Shown in Table (2).

Table 2: Psychological Resilience and Vulnerabilities

Feature	Protective Factors (Resilience)	Risk Factors (Vulnerabilities)
Social	Group outings, NA* meetings, and "safe" celebrations.	Old friend groups, environmental availability.
Psychological	Integration through sports, taking therapist advice.	Depression, family stress, and "free time."
External	Structured Naufar environment.	Financial pressure, legal issues, and overstimulation.

* (NA: Narcotics Anonymous).

 

4. Lessons in Long-Term Recovery

The 2022-FWC period provided critical "lived lessons" for the participants. The most prominent takeaway was the danger of isolation and boredom, with P10 explicitly stating, "Free time is what kills a person." Patients concluded that recovery in a high-stimulus environment requires:

1. Selective Socialization: Avoiding "unsafe" environments and old peer groups (P6).
2. Integration: Using sports as a tool for societal reintegration (P13).
3. Humility: Accepting the guidance of advisors rather than relying solely on willpower (P2).

Summary of Key Findings: The 2022-FWC acted as a stress test for recovery in our participants. Success was not merely the absence of substances, but the presence of active engagement. Relapse (as seen with P5) was closely tied to environmental availability and emotional deterioration, whereas success was tied to "group-guarded" exposure to the festivities.

Theme 2: Naufar’s Institutional Strategies During the 2022-FWC

Naufar’s approach during the tournament was characterized by a shift from traditional clinical boundaries to a "Total Environment" strategy. By blending high-stakes entertainment with therapeutic control, the institution successfully neutralized environmental triggers while fostering a sense of social inclusion.

1. The "Fan Zone" as a Therapeutic Buffer

The cornerstone of Naufar’s strategy was the creation of internal Fan Zones. This innovation allowed patients to participate in the national excitement of the World Cup without the high-risk exposure to alcohol or triggering social circles found in public venues.

• Patient Experience: Participants (P8, P12) felt a sense of belonging, noting that the center provided a "beautiful atmosphere" where they could watch games regardless of ticket status.
• Clinical Rationale: Psychologists and physicians utilized these zones as controlled exposure tools, providing "positive distractions" and keeping patients engaged from "10 a.m. to 10 p.m." to mitigate the risks of boredom and isolation.

2. Adaptive Clinical and Psychosocial Services

The institution transitioned to a more fluid, accessible service model to meet the unique stressors of a mega event.

Table 3: Patients’ Perception on Naufar Strategy during the 2022-FWC

Service Type	Strategy Implemented	Patient Impact
Accessibility	24/7 "Open Door" policy and messaging application groups.	Reduced anxiety; P13 felt "accepted with open arms" without an appointment.
Holistic Care	Spiritual trips, gym activities, and volunteering.	Shifted focus from the past to the present; improved mood (P1, P6).
Peer Support	Integration of NA* meetings and recovery coaches.	Created accountability and a "safety in numbers" mentality (P7, P11).

* (NA: Narcotics Anonymous).

3. Strategic Human Resource Deployment

A defining feature of the period was the high-visibility presence of staff.

• Beyond the Call of Duty: Some patients (e.g. P7) specifically noted off-duty staff joining activities voluntarily, which humanized the recovery process and strengthened the therapeutic alliance.
• Clinical Oversight: Nurses and psychologists maintained a constant presence to manage medication timing and immediate craving interventions, ensuring that the "joyful gatherings" did not compromise clinical stability.
• A Minor Gap: one patient (P5) noted reduced medical staffing during some shifts, perceiving a lean toward "entertainment" over "treatment", suggesting a delicate balance between a festive atmosphere and clinical rigor.

4. Tailored Relapse Prevention & Innovation

Naufar’s strategies extended beyond the center’s walls through proactive outreach and lifestyle coaching.

• Environmental Modification: Clinicians encouraged patients to change phone numbers and avoid "old friends," a strategy adopted by P6 to maintain a clean break from active users.
• Cognitive Reframing: Staff helped patients reframe FWC temptations not as "missed pleasure" but as "traps", focusing instead on the superior joy of a sober life (P7).
• Employment Support: Physicians recommended flexible work hours for employed patients, recognizing that occupational stress during the tournament could serve as a major relapse trigger.

Summary of Key Findings: Naufar successfully transformed from a traditional clinic into a protective social ecosystem. By "bringing the World Cup inside", the institution eliminated the ‘fear of missing out’ that often drives relapse during major cultural events, replacing it with a structured, staff-supported "sober celebration". The success of Naufar’s intervention during the 2022-FWC was rooted in the alignment between clinical intent and patient perception. The table below (table 4) illustrates how specific strategies translated into recovery milestones.

Table 4: Comparative Analysis of Institutional Strategy vs. Patient Outcome

 

Institutional Strategy	Clinical Intent	Patient-Reported Outcome
In-House Fan Zones	Risk mitigation and controlled exposure to festivities.	High engagement; felt "included" without needing tickets or facing triggers (P8, P12).
"Total Environment" Staffing	Constant supervision and immediate craving intervention.	Improved "therapeutic alliance"; patients felt cared for by off-duty staff (P7).
Low-Barrier Access	Proactive outreach (messaging application App/Calls) to prevent isolation.	Reduced anxiety; felt "accepted with open arms" even without appointments (P13).
Diversified Programming	Mood stabilization through gym, spiritual trips, and sports.	Shifted focus from "the past" to present relief and healthy distractions (P1, P6).
Cognitive Reframing	Labeling external temptations as "traps" rather than "pleasure."	Increased resilience; patients adopted a "sober joy" mindset (P7).

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you very much for this opportunity to review this paper. It has been a pleasure to read and provides some valuable learning for Drug and Alcohol clinical and recovery services across the globe. In particular, the interventions often requiring planning ahead may be applicable in wider settings - although further academic literature for exploring this significance would be required. Please see my comments below to address and improve clarity of your study:

Lines 39-40

Abstract could you clarify if the thirteen patients interviewed were purposively sampled for the organisation Naufer? In total how many participants took part including the practitioners

 

Lines 78-85

It would be helpful to understand what interventions, if any have taken place in other parts of the world – do these apply to Western countries? Perhaps reviewing global and national literature on how these interventions were innovative or transferred from other settings? This information would highlight the contribution of your very important work.

 

Lines 95-176

 

This section requires further clarity of your participant groups that may impact your results and discussion. From what can be seen you interviewed thirteen participants who were in recovery, please indicate a) how risk was managed for these participants.  b) how the practitioners were recruited, how many in each focus group etc and c) what was the total number of participants. It is unclear if there were thirteen in total or thirteen and other participants

 

Lines 177-320

I am afraid the results section requires a significant restructure. The themes require further development. Perhaps identify three key themes based around the interventions? The presentation of your work is difficult to follow with many short paragraphs and headings. In addition, your table, whilst clear could be explained further about their benefits once you have restructured the text     - it maybe you do not need as many.

You also, should move away from presenting participant numbers and present results text to state that, ‘most participants’, ‘some participants, etc. this will also improve the flow of the paper for the reader.

 

Lines 320 -369

 

This section lacks criticality and engaging with wider literature on spectacular sporting events – across the globe.

 

 

  

 

A key concern that should be addressed in the methods /results/ recommendations section is how risk was manged interviewing participants under treatment – what mechanisms did you have in place for them to ensure the triggers from conducting this research were considered and addressed.

This is a very interesting study and some rework will improve the findings significantly 

Author Response

Journal: IJERPH (ISSN 1660-4601)

Manuscript ID: ijerph-4064632

Type: Article

Title: Addictive Behaviors During the 2022-FIFA World Cup: A Qualitative Study of Patients and Healthcare Staff at a Substance Use Disorder Facility

Authors: Khalifa Al Kuwari , Izzeldin Ibrahim * , Abdulaziz Farooq , James England , Perla ElMoujabber , Rama Kamal , Karim Chamari , Vidya Mohamed-Ali , Mohammad Al-Maadheed

 

We would like to express our deep gratitude to the reviewer for their time and expertise that definitely substantially contributed to improving the quality of our manuscript.

 

Author responses to Reviewer-3 comments

Lines 39-40: Abstract could you clarify if the thirteen patients interviewed were purposively sampled for the organization Naufar? In total how many participants took part, including the practitioners?

• Author Response: Thank you for the feedback. We have updated the abstract to clarify that the thirteen patients were purposively sampled from Naufar according to our inclusion criteria. We also added details regarding the 19 healthcare practitioners (psychologists, nurses, and physicians) who participated in focus groups. The total participant (N = 32) now accurately represents both the patient and practitioner cohorts."
• Action Taken: "Methods: we purposively sampled 32 participants that were present at Naufar during the 2022-FWC (i) thirteen adults SUD patients that were receiving treatment and (ii) nineteen healthcare practitioners. Semi-structured patients’ interviews were conducted and focus groups discussion were held with a multidisciplinary team, including psychologists, nurses, and physicians.

Lines 78-85: It would be helpful to understand what interventions, if any have taken place in other parts of the world – do these apply to Western countries? Perhaps reviewing global and national literature on how these interventions were innovative or transferred from other settings? This information would highlight the contribution of your very important work.

• Author Response: According to your comment we have done our best to find robust peer-reviewed evidence showing health facilities formally organizing and studying patient gatherings around global sports events like the FIFA World Cup or World Athletics. Some clinical settings might have organized a World Cup viewing event for oncology patients, cardiac rehab patients, pediatric patients, or long-stay inpatients, but that activity has never become a journal article (up to March 12^th 2026 literature search Therefore our work appears to be a strong contribution on the effects of sport events on health services and on general psychosocial interventions in healthcare, not only on sport-event-themed patient gatherings.
• We have added this point to the conclusion section that now reads as follows:

The experience of patients at Naufar during the 2022-FWC illustrated the complex interplay between environmental factors, institutional strategies, and individual resilience in shaping the addiction scenario during major global sporting events. While major cultural events increase the risk of relapses through heightened exposure to triggers, they can also be an opportunity to strengthen abstinence and social integration when supported by proactive structured, patient-centered interventions. Our study is the first to report how proactive strategies during major sports events gathering can support patients with SUD attending specialized centers for their treatment. Future research is needed to explore how treatment facilities can optimize institutional responses during similar large-scale events, ensuring continuity of care, reinforcing recovery and promoting sustainable abstinence.

Lines 95-176: This section requires further clarity of your participant groups that may impact your results and discussion. From what can be seen you interviewed thirteen participants who were in recovery, please indicate a) how risk was managed for these participants.  b) how the practitioners were recruited, how many in each focus group etc and c) what was the total number of participants. It is unclear if there were thirteen in total or thirteen and other participants

• Author Response: Thank you for this observation. We have made the following clarifications in the revised abstract:

1. All patient participants were currently enrolled in treatment at Naufar and were clinically stable at the time of interview. Interviews were conducted in a private clinical setting by an experienced clinical psychologist. Participation was voluntary, informed consent was obtained, and confidentiality procedures were strictly maintained in accordance with institutional ethical approval.
2. Patient Sampling: Explicitly stated that 13 patients were purposively sampled from Naufar based on adult SUD treatment criteria during the 2022-FWC.
3. Practitioner Involvement: we have added the participation of 19 healthcare practitioners in focus group discussions.
4. Participant Totals: Updated the final count to clearly include both patients and practitioners, (N=32).

• Action Taken: we have added the information below in the body of the manuscript:

Table 1a: Demographic characteristics of interviewed patients. (N=13)

Characteristic	Category	n	%
Age/years	18 – 28	4	30.7 %
	29 – 39	6	46.2 %
	40 and above	3	23.1 %
Marital status	Married	1	07.7 %
	Single	9	69.2 %
	Divorced	3	23.1 %
Education level	Elementary	3	23.1 %
	Preparatory	2	15.4 %
	Secondary	7	53.8 %
	University	1	07.7 %
Employment status	Employed	7	53.8 %
	Unemployed	6	46.2 %
Primary Substance Used	Alcohol	2	15.4 %
	Methamphetamine	2	15.4 %
	Opioids	9	69.2 %

 

 

 

Table 1b: Demographic and Professional Characteristics of Focus Group Participants (N=19)

Characteristic	Category	n	%
Gender	Male	17	89.5 %
	Female	2	10.5 %
Professional role	Physician	7	36.8 %
	Clinical Psychologist	3	15.8 %
	Nursing Staff	9	47.4 %
Years of clinical experience with SUD patients	0–5 years	4	21.0 %
	6–10 years	9	47.4 %
	>10 years	6	31.6 %
Primary clinical setting	Inpatient Rehabilitation	12	63.2 %
	Outpatient Clinic	7	36.8 %

 

Lines 177-320: I am afraid the results section requires a significant restructure. The themes require further development. Perhaps identify three key themes based around the interventions? The presentation of your work is difficult to follow with many short paragraphs and headings. In addition, your table, whilst clear, could be explained further about their benefits once you have restructured the text - it maybe you do not need as many.

• Author Response: We thank the reviewer for this constructive critique. We acknowledge that the initial presentation of the results was fragmented, which may have obscured the primary clinical insights. In accordance with your suggestions, we have:
  • Restructured the Results section around two core thematic pillars related to the interventions: Theme-1: “The Impact of the 2022-FWC on patients’ addictive behavior”, and Theme-2: “Naufar’s institutional strategies during the 2022-FWC”.
  • Synthesized the text by merging short, repetitive paragraphs into comprehensive narrative sections. This has improved the flow and reduced the reliance on excessive sub-headings.
  • Refined the Tables: We have consolidated the data into 4 key tables. We also added demographic characteristics of health care practitioners participated in focus group discussion.

We believe these changes have substantially sharpened the focus of the paper and made the findings more accessible to the reader.

Action Taken: The restructured results section now reads as follows:

3. Results

Thirteen male patients receiving SUDs treatment at Naufar center (mean age: 35.2 years (SD: ±8.7) were recruited. The most common drugs used by the participants were opioids (69.2%), alcohol (15.4%), and methamphetamines (Shaboo) (15.4%). Detailed information about the participants is presented in table-1a. Nineteen healthcare practitioners participated in the focus group discussion as shown in table 1b. Based on the research objectives, the results were organized around two core thematic pillars related to the interventions: Theme-1: “The Impact of the 2022-FWC on patients’ addictive behavior”. Theme-2: “Naufar’s institutional strategies during the 2022-FWC”.

Table 1a: Demographic characteristics of interviewed patients. (N=13)

Characteristic	Category	n	%
Age/years	18 – 28	4	30.7 %
	29 – 39	6	46.2 %
	40 and above	3	23.1 %
Marital status	Married	1	07.7 %
	Single	9	69.2 %
	Divorced	3	23.1 %
Education level	Elementary	3	23.1 %
	Preparatory	2	15.4 %
	Secondary	7	53.8 %
	University	1	07.7 %
Employment status	Employed	7	53.8 %
	Unemployed	6	46.2 %
Primary Substance Used	Alcohol	2	15.4 %
	Methamphetamine	2	15.4 %
	Opioids	9	69.2 %

 

 

Table 1b: Demographic and Professional Characteristics of Focus Group Participants (N=19)

Characteristic	Category	n	%
Gender	Male	17	89.5 %
	Female	2	10.5 %
Professional role	Physician	7	36.8 %
	Clinical Psychologist	3	15.8 %
	Nursing Staff	9	47.4 %
Years of clinical experience with SUD patients	0–5 years	4	21.0 %
	6–10 years	9	47.4 %
	>10 years	6	31.6 %
Primary clinical setting	Inpatient Rehabilitation	12	63.2 %
	Outpatient Clinic	7	36.8 %

 

Theme 1: The Impact of the 2022-FWC on Patients’ Addictive Behavior

The 2022-FWC served as a dual-edged catalyst for patients in recovery. While the structured environment of the Naufar center and the communal spirit of the event acted as protective "social scaffolding," the environmental overstimulation and availability of substances (particularly alcohol) presented significant psychological hurdles for the patients.

1. Behavioral Patterns: Abstinence vs. Environmental Triggers

Most patients (9/13) maintained sustained abstinence throughout the tournament. For some patients, the FWC period was a milestone of "normalcy," with participants (P2, P3, P13) describing it as their first experience of fulfilling life without substance use.

However, clinical insights from focus groups added a layer of complexity to these reports. While inpatient participants felt successful, physicians and psychologists observed increased emotional instability and "restlessness" triggered by the desire to join public celebrations.

• The "Alcohol Factor": While patients focused on general recovery, clinicians noted that alcohol was the most consistently craved substance, particularly among those in long-term recovery who may have underestimated the power of external triggers.
• Medication & Compliance: Nurses identified that "craving behavior" wasn't always a physical urge to use, but manifested as logistical friction, such as requests for home medication or missed appointments.

2. The Role of "Social Support" in Craving Management

Cravings during the FWC were largely described as manageable (7/13 patients), primarily due to the therapeutic atmosphere and group cohesion.

• Peer Support: P6 and P12 highlighted a "protective pack" mentality—staying in groups to navigate crowded areas like Souq Waqif or Lusail (specific areas for celebration in Doha) to ensure safety.
• Clinical Interventions: The use of pharmacological aids (Suboxone®) and structured cognitive interventions helped reframe the urge to use. As P11 noted, the interventions effectively "kept the idea away."

3. Psychological Resilience and Vulnerabilities

Our results reveal a stark contrast between those who felt protected by the "Naufar bubble" and those who felt the weight of external pressures. Shown in Table (2).

Table 2: Psychological Resilience and Vulnerabilities

Feature	Protective Factors (Resilience)	Risk Factors (Vulnerabilities)
Social	Group outings, NA* meetings, and "safe" celebrations.	Old friend groups, environmental availability.
Psychological	Integration through sports, taking therapist advice.	Depression, family stress, and "free time."
External	Structured Naufar environment.	Financial pressure, legal issues, and overstimulation.

* (NA: Narcotics Anonymous).

 

4. Lessons in Long-Term Recovery

The 2022-FWC period provided critical "lived lessons" for the participants. The most prominent takeaway was the danger of isolation and boredom, with P10 explicitly stating, "Free time is what kills a person." Patients concluded that recovery in a high-stimulus environment requires:

1. Selective Socialization: Avoiding "unsafe" environments and old peer groups (P6).
2. Integration: Using sports as a tool for societal reintegration (P13).
3. Humility: Accepting the guidance of advisors rather than relying solely on willpower (P2).

Summary of Key Findings: The 2022-FWC acted as a stress test for recovery in our participants. Success was not merely the absence of substances, but the presence of active engagement. Relapse (as seen with P5) was closely tied to environmental availability and emotional deterioration, whereas success was tied to "group-guarded" exposure to the festivities.

Theme 2: Naufar’s Institutional Strategies During the 2022-FWC

Naufar’s approach during the tournament was characterized by a shift from traditional clinical boundaries to a "Total Environment" strategy. By blending high-stakes entertainment with therapeutic control, the institution successfully neutralized environmental triggers while fostering a sense of social inclusion.

1. The "Fan Zone" as a Therapeutic Buffer

The cornerstone of Naufar’s strategy was the creation of internal Fan Zones. This innovation allowed patients to participate in the national excitement of the World Cup without the high-risk exposure to alcohol or triggering social circles found in public venues.

• Patient Experience: Participants (P8, P12) felt a sense of belonging, noting that the center provided a "beautiful atmosphere" where they could watch games regardless of ticket status.
• Clinical Rationale: Psychologists and physicians utilized these zones as controlled exposure tools, providing "positive distractions" and keeping patients engaged from "10 a.m. to 10 p.m." to mitigate the risks of boredom and isolation.

2. Adaptive Clinical and Psychosocial Services

The institution transitioned to a more fluid, accessible service model to meet the unique stressors of a mega event.

Table 3: Patients’ Perception on Naufar Strategy during the 2022-FWC

Service Type	Strategy Implemented	Patient Impact
Accessibility	24/7 "Open Door" policy and messaging application groups.	Reduced anxiety; P13 felt "accepted with open arms" without an appointment.
Holistic Care	Spiritual trips, gym activities, and volunteering.	Shifted focus from the past to the present; improved mood (P1, P6).
Peer Support	Integration of NA* meetings and recovery coaches.	Created accountability and a "safety in numbers" mentality (P7, P11).

* (NA: Narcotics Anonymous).

3. Strategic Human Resource Deployment

A defining feature of the period was the high-visibility presence of staff.

• Beyond the Call of Duty: Some patients (e.g. P7) specifically noted off-duty staff joining activities voluntarily, which humanized the recovery process and strengthened the therapeutic alliance.
• Clinical Oversight: Nurses and psychologists maintained a constant presence to manage medication timing and immediate craving interventions, ensuring that the "joyful gatherings" did not compromise clinical stability.
• A Minor Gap: one patient (P5) noted reduced medical staffing during some shifts, perceiving a lean toward "entertainment" over "treatment", suggesting a delicate balance between a festive atmosphere and clinical rigor.

4. Tailored Relapse Prevention & Innovation

Naufar’s strategies extended beyond the center’s walls through proactive outreach and lifestyle coaching.

• Environmental Modification: Clinicians encouraged patients to change phone numbers and avoid "old friends," a strategy adopted by P6 to maintain a clean break from active users.
• Cognitive Reframing: Staff helped patients reframe FWC temptations not as "missed pleasure" but as "traps", focusing instead on the superior joy of a sober life (P7).
• Employment Support: Physicians recommended flexible work hours for employed patients, recognizing that occupational stress during the tournament could serve as a major relapse trigger.

Summary of Key Findings: Naufar successfully transformed from a traditional clinic into a protective social ecosystem. By "bringing the World Cup inside", the institution eliminated the “fear of missing out” that often drives relapse during major cultural events, replacing it with a structured, staff-supported "sober celebration."

The success of Naufar’s intervention during the 2022-FWC was rooted in the alignment between clinical intent and patient perception. The table below (table 4) illustrates how specific strategies translated into recovery milestones

 

 

 

Table 4: Comparative Analysis of Institutional Strategy vs. Patient Outcome

 

Institutional Strategy	Clinical Intent	Patient-Reported Outcome
In-House Fan Zones	Risk mitigation and controlled exposure to festivities.	High engagement; felt "included" without needing tickets or facing triggers (P8, P12).
"Total Environment" Staffing	Constant supervision and immediate craving intervention.	Improved "therapeutic alliance"; patients felt cared for by off-duty staff (P7).
Low-Barrier Access	Proactive outreach (messaging application App/Calls) to prevent isolation.	Reduced anxiety; felt "accepted with open arms" even without appointments (P13).
Diversified Programming	Mood stabilization through gym, spiritual trips, and sports.	Shifted focus from "the past" to present relief and healthy distractions (P1, P6).
Cognitive Reframing	Labeling external temptations as "traps" rather than "pleasure."	Increased resilience; patients adopted a "sober joy" mindset (P7).

 

 

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, 

 

Thank you very much for your comprehensive account of the amendments above. The paper is much improved, however, there remains an over reliance on bullet points in the methods (170-181) and results sections. Please could I advise you review the bullet points throughout your paper (methods and results) and present the these as narratives. In the results section you may wish to add two or three full narratives to illustrate your messages. This should not be too onerous as you have the structure. Thank you 

Author Response

Reviewer Comment: “Thank you very much for your comprehensive account of the amendments above. The paper is much improved, however, there remains an overreliance on bullet points in the methods (170-181) and results sections. Please could I advise you to review the bullet points throughout your paper (methods and results) and present these as narratives. In the results section you may wish to add two or three full narratives to illustrate your messages. This should not be too onerous as you have the structure. Thank you” 

Author response: Thank you for this helpful suggestion. We have revised the Methods and Results sections to reduce reliance on bullet points and present the findings in narrative form.

Action taken: In the Results section, we incorporated fuller illustrative narratives from participant accounts to strengthen the presentation of key themes. (Page 167 to 183)

Clinical insights from focus groups revealed greater complexity in these narratives. Many inpatients reported coping well during the FWC. However, physicians and psychologists observed heightened emotional volatility and agitation, frequently linked to patients’ anticipation of public festivities. Clinicians identified alcohol as the primary substance associated with craving, particularly among those in sustained recovery who tended to minimize external triggers. Nurses observed that indirect craving might manifest as repeated requests for home medication, missed appointments, or other disruptions to routine, rather than as an explicit urge to use substances. “The low attendance in the daily schedule, especially in the morning”. Psychologist noted that participation in fan zones inside Naufar was seen as positive, and patients were committed and disciplined within the controlled setting. “At any time, the patient can see a therapist immediately”.

Simultaneously, cravings during the FWC were often described as manageable, with 7 of 13 patients attributing this to the therapeutic environment and strong group cohesion. Peer support was particularly valued. Participants P6 and P12 described a “protective pack” approach, deliberately remaining in groups as they passed through crowded celebration areas such as Souq Waqif and Lusail to mitigate risk and enhance safety. Clinical support was also considered vital. Participants reported that pharmacological treatments, including Suboxone®, and structured cognitive methods effectively redirected and contained urges to use. As P11 stated, these interventions helped to “keep the idea away”. P8, P9 and P12 “the atmosphere in Naufar was nice”. P2 “when I come to Naufar, all the negative energy drains from me”