3.3. Observed pain estimates
Mean values and SDs are presented in Table 3. Consistent with hypothesis I, the 3 (control vs misuse vs undertreatment) × 2 (nursing vs nonhealth professional students) × 2 (older vs younger patients) mixed-model ANOVA demonstrated that observers endorsed significantly higher observed pain estimates towards older patients compared with younger patients, F1,159 = 384.13, P < 0.001, partial η2 = 0.71. There was also a significant interaction between patient age (younger vs older patients) and observer type (nursing vs nonhealth professional students), F1,159 = 7.40, P = 0.007, partial η2 = 0.04. No other significant effects were found.
Simple effect tests were conducted to clarify the identified 2-way interaction (patient age × observer type). Nonhealth professional students' ratings were significantly higher when evaluating pain expressions of older adults, M = 4.79, SD = 1.45, as compared to younger adults, M = 3.29, SD = 1.20, F1,159 = 250.64, P < 0.001, partial η2 = 0.61. Similarly, nursing students' ratings were significantly higher when evaluating pain expressions of older adults, M = 4.76, SD = 1.24, as compared to younger adults, M = 3.62, SD = 1.29, F1,159 = 141.53, P < 0.001, partial η2 = 0.47. In general, this interaction effect demonstrates that, although both nursing students and nonhealth care professional students rated observed pain higher in older adults as compared to younger adults, nursing students trended towards having higher ratings towards younger adults than nonhealth care professionals.
3.4. Sympathy and help estimates
Mean values and SDs are presented in Table 3. Consistent with hypothesis I, the 3 (control vs misuse vs undertreatment) × 2 (nursing vs nonhealth professional students) × 2 (older vs younger patients) mixed-model ANOVA demonstrated that observers reported significantly higher sympathy and help estimates towards older patients compared with younger patients, F1,159 = 415.17, P < 0.001, partial η2 = 0.72. There was also a significant interaction between patient age (younger vs older patients) and observer type (nursing vs nonhealth professional students), F1,159 = 15.91, P < 0.001, partial η2 = 0.09. No other significant effects were found. Simple effects tests were conducted to clarify the identified 2-way interaction (patient age × observer type).
Simple effects tests were conducted to clarify the identified 2-way interaction (patient age × observer type). Nonhealth professional students' ratings were significantly higher when evaluating pain expressions of older adults, M = 5.44, SD = 1.64, as compared to younger adults, M = 3.58, SD = 1.57, F1,159 = 299.07, P < 0.001, partial η2 = 0.65. Nursing students' ratings were also significantly higher when evaluating pain expressions of older adults, M = 5.63, SD = 1.57, as compared to younger adults, M = 4.83, SD = 1.74, F1,159 = 133.11, P < 0.001, partial η2 = 0.46. Moreover, nursing students provided significantly higher ratings when judging younger adults than nonhealth professional students, F1,159 = 9.64, P = 0.002, partial η2 = 0.06.
3.5. Valence ratings
Results demonstrated significant main effects for each independent variable (priming condition, observer type, and patient age). That is, participants rated videos of older adults significantly more positive than videos of younger adults, F1,159 = 55.69, P < 0.001, partial η2 = 0.26; nursing students reported significantly greater positive valence than nonhealth professional students, F1,159 = 7.20, P = 0.008, partial η2 = 0.04; and, valence ratings significantly differed depending on which priming text observers received, F2,159 = 7.61, P = 0.001, partial η2 = 0.09. In addition to these main effects, a 3-way interaction across priming conditions, observer type, and patient age was also observed, F2,159 = 3.43, P = 0.035, partial η2 = 0.04. Simple effects tests were conducted to clarify this 3-way interaction (patient age × observer type × priming condition).
Nonhealth professional students in the misuse condition reported significantly higher valence towards older adults, M = 2.41, SD = 1.86, than younger adults, M = 1.53, SD = 1.86, F1,159 = 10.06, P = 0.002, partial η2 = 0.06. Also consistent with hypotheses, both nursing students and nonhealth professional students reported significantly higher valence towards older adults, Mnonhealth professional = 3.80, SD = 2.62, Mnursing = 4.85, SD = 2.68, than younger adults in the undertreatment prime, Mnonhealth professional = 1.91, SD = 2.70, Mnursing = 4.17, SD = 2.84; F1,159, nursing = 5.75, P = 0.018, partial η2 = 0.04; F1,159, nonhealth professional = 44.07, P < 0.001, partial η2 = 0.22. Moreover, nursing students in the undertreatment priming condition reported higher valence towards older adults, F1,159 = 7.53, P = 0.001, partial η2 = 0.09, and younger adults, F1,159 = 6.78, P = 0.001, partial η2 = 0.08, than nursing students in the misuse condition, Molder = 2.39, SD = 2.22, Myounger = 1.90, SD = 1.73. Also, nursing students in the control condition reported significantly more positive valence to older adults, M = 3.49, SD = 2.21, than younger adults, M = 2.75, SD = 2.18, F1,159 = 7.16, P = 0.008, partial η2 = 0.04. Finally, nonhealth professional students in the undertreatment priming condition reported significantly lower valence towards younger adults than nursing students in the undertreatment priming condition, F1,159 = 13.16, P = 0.008, partial η2 = 0.08.
3.6. Mediation analysis: indirect effect of valence
Following the procedure described by Hayes and Preacher,36 a bootstrapping method (with 5000 resamples and 95% confidence intervals) was used to test valence ratings as a mediating variable in the relationships between the priming conditions and outcomes. Given that no main effects of observer type (nursing vs nonhealth professional students) were found on these outcomes, observer type was combined for analyses (ie, all responses were analyzed together). Before analyses were conducted, the multicategorical predictor variable (ie, priming condition) was coded using indicator coding procedures.36 Subsequently, 2 mediation analyses were conducted, one for observed pain estimates and one for sympathy and help estimates.
As displayed in Figure 1 and Table 4, results were in line with findings by De Ruddere et al.17 Bootstrapped analyses for valence as a mediator in the relationship between priming conditions and observed pain estimates did not demonstrate a total effect, c1 = −0.04, SE = 0.23, NS; c2 = 0.13, SE = 0.23, non-significant (NS). That is, relative to the control condition, neither the misuse condition nor the undertreatment condition was a significant predictor of observed pain estimates. A relative direct effect of undertreatment priming condition and valence ratings was identified, a2 = 1.02, SE = 0.43, P = 0.02, indicating that participants in the undertreatment condition reported more positive valence towards the individual in the video than those in the control condition. By contrast, a relative direct effect of the misuse priming condition on valence ratings was not found, a1 = −0.60, SE = 0.42, NS.
A relative direct effect of the priming condition on observed pain estimates was not found, c′1 = 0.09, SE = 0.22, NS; c′2 = −0.09, SE = 0.22, NS. Nonetheless, a direct effect of patient valence on observed pain estimates was found, b = 0.22, SE = 0.04, P < 0.01, showing that more positive valence was related with greater pain estimates. The relative indirect effect of the undertreatment priming condition on observed pain estimates through valence ratings was significant, as the bootstrapped confidence interval excluded zero, a2b = 0.22, SE = 0.12, 95% CI = 0.03 to 0.48. Yet, the relative indirect effect of the misuse priming condition on observed pain estimates through valence ratings was not significant, as the bootstrapped confidence interval did not exclude zero, a1b = −0.123, SE = 0.08, 95% CI = −0.31 to 0.03.
This same pattern of results was demonstrated with regards to sympathy and help estimates. More specifically, bootstrapped analyses for valence as a mediator in the relationship between priming conditions and sympathy and help estimates did not demonstrate a total effect, c1 = −0.10, SE = 0.30, NS; c2 = 0.18, SE = 0.30, NS. That is, relative to the control condition, neither the misuse condition nor the undertreatment condition was a significant predictor of sympathy and help estimates. A relative direct effect of undertreatment priming condition and valence ratings was identified, a2 = 1.02, SE = 0.43, P = 0.02, indicating that participants in the undertreatment condition reported more positive valence towards the individual in the video than those in the control condition. By contrast, a relative direct effect of the misuse priming condition on valence ratings was not found, a1 = −0.60, SE = 0.42, NS.
A relative direct effect of the priming condition on sympathy and help estimates was not found, c′1 = 0.12, SE = 0.26, NS; c′2 = −0.19, SE = 0.26, NS. Nonetheless, a direct effect of patient valence on sympathy and help estimates was found, b = 0.37, SE = 0.05, P < 0.01, showing that higher positive valence was related with greater sympathy and help estimates. The relative indirect effect of the undertreatment priming condition on sympathy and help estimates through valence ratings was significant, as the bootstrapped confidence interval excluded zero, a2b = 0.37, SE = 0.18, 95% CI = 0.05 to 0.73. Yet, the relative indirect effect of the misuse priming condition on sympathy and help estimates through valence ratings was not significant, as the bootstrapped confidence interval did not exclude zero, a1b = −0.22, SE = 0.14, 95% CI = −0.51 to 0.05.
These results demonstrate that valence ratings significantly and indirectly affected the relationship between the undertreatment priming condition and observed pain as well as sympathy and help estimates. That is, relative to the control condition, participants in the undertreatment priming condition reported feeling more positively towards patients, which led to higher ratings of observed pain, sympathy, and help. Valence was not found to indirectly influence the relationship between the misuse priming condition and observers' pain or sympathy and help estimates.
3.7. Exploratory analyses: patient sex
3.7.1. Observed pain
The 3 (control vs misuse vs undertreatment) × 2 (nursing vs nonhealth professional students) × 2 (female vs male patients) mixed-model ANOVA demonstrated a significant univariate within-subject effect (female vs male patients), F1,159 = 123.10, P < 0.001, partial η2 = 0.44. That is, observers' pain estimates were higher towards male patients, M = 4.43, SD = 1.23, compared with female patients, M = 3.80, SD = 1.32. No other main effects or interactions were significant.
3.7.2. Sympathy and help
The 3 (control vs misuse vs undertreatment) × 2 (nursing vs nonhealth professional students) × 2 (female vs male patients) mixed-model ANOVA demonstrated a significant univariate within-subjects effect (female vs male patients), F1,159 = 67.37, P < 0.001, partial η2 = 0.30. That is, observers' sympathy and help estimates were higher towards male patients, M = 5.00, SD = 1.50, compared with female patients, M = 4.51, SD = 1.72. No other main effects or interactions were significant.
3.7.3. Valence ratings
Based on the ANOVA test, observers' valence ratings were not found to differ as a function of patient sex, Mmale = 2.74, SD = 2.31; Mfemale = 2.85, SD = 2.45. The 2-way interaction between patient sex (male vs female) and observer type (nursing vs nonhealth professional students), F1,159 = 8.03, P = 0.005, partial η2 = 0.05, was found. No other interactions were found. Simple effects tests were conducted to clarify the 2-way interaction (patient sex × observer type). Nursing students rated male patients more positively, M = 3.01, SD = 2.40, than nonhealth professional students, M = 2.40, SD = 2.18, F1,159 = 4.03, P = 0.046, partial η2 = 0.03. In addition, nursing students rated female patients more positively, M = 3.43, SD = 2.52, than nonhealth professional students, M = 2.28, SD = 2.25, F1,159 = 10.31, P = 0.002, partial η2 = 0.06. Nursing students rated females more positively than videos of males, F1,159 = 8.83, P = 0.003, partial η2 = 0.05, whereas nonhealth professional students' valence ratings did not significantly differ as a function of the patient sex, F1,159 = 1.06, NS.
3.8. Overview of narrative analysis results
A coding framework was developed following Braun and Clarke's5 stepwise methods and 2 researchers coded the data independently. Percentage agreement and Cohen's kappa demonstrated good to excellent reliability (percentage agreement = 97%, κ = 0.57).9,54
Results from thematic and content analyses are displayed in Figure 2. Overall, observers indicated that their ratings varied as a function of several factors. Observers did not specify whether these factors increased or decreased their ratings. As such, the purpose of these analyses was to develop a list of factors that observers indicated influenced their ratings. Grounded in observers' responses, results were divided into 2 categories: (1) observable pain-related changes and (2) non–pain-related factors. Distinct themes emerged within each category (see supplementary materials, Appendix B for examples of quotations, available at http://links.lww.com/PAIN/A631).
3.8.1. Observable pain-related changes
Based on the results of the quantitative content analysis, observers indicated that their ratings varied as a function of numerous pain-related changes. The most frequently identified observable changes were “general pain expressed” and “facial movements.” Observers' frequently identified “pain intensity” and “general changes in patient's facial expression” as variables that influenced their ratings. Participants also specified that their ratings were influenced by other observable changes including, but not limited to, eye and mouth movements, laughing or smiling, bodily movements, and changes in breathing.
3.8.2. Non–pain-related characteristics
Based on the results of the content analysis, we identified 3 categories of potential influence: (1) patient-level personal characteristics; (2) observers' general impressions of patients; and (3) additional contextual characteristics (see supplementary materials, Appendix B for examples of quotations, available at http://links.lww.com/PAIN/A631).
3.8.3. Patient-level personal characteristics
According to quantitative analyses, observers frequently noted that their ratings varied as a function of non–pain-related characteristics of the patients. They often reported, for instance, that the patient's sex and age moderated their ratings. Observers also noted that their ratings differed as a function of the patient's general physical characteristics, such as being “well groomed.”
3.8.4. Observers' general impressions of patients
Observers reported that their ratings varied as a function of general inferences they made about the patient. In other words, they made general judgements about the patient, which then influenced their specific ratings. The most frequently identified theme was observers' general impressions of how helpless patients were in coping with their pain. Observers also inferred, as potential influences on their ratings, the extent to which patients appeared willing to receive help, how sympathetic observers felt towards patients, and their overall impression (ie, positive or negative valence) of patients. Although less frequently identified, observers noted that their ratings were influenced by the extent to which they perceived the patient as faking or exaggerating their pain experience. Finally, observers indicated that perceiving patients as withholding pain expressions or suppressing the experience also affected their ratings.
3.8.5. Additional contextual characteristics
Observers indicated that their ratings varied as a function of supplementary information as well as beliefs and attitudes. That is, additional information that extended beyond the information presented in each distinct stimulus video (eg, previous life experiences/beliefs, comparisons with others' pain, informational primes). The most frequently identified theme was observers' own personal experiences and beliefs. For example, observers noted that their previous experiences influenced their ratings of the videos (eg, whether the individual reminded them of a friend/grandparent). Although less frequently noted, participants also stated that their ratings were affected when they compared the patient's experience with previous patients' expressions. Finally, the informational priming texts were noted to influence ratings by a small number of observers.
4.1. Overview of findings
We examined the influence of contextual features on pain judgements. An important contribution of this research was the evaluation of the effect of informational primes on observers' evaluation of older persons' pain. Another novel feature was the exploration of observers' judgements of others' pain as a function of interactions across multiple contextual variables. Considering the role of several contextual factors (eg, priming information, patient age, and observer type) provides a more precise characterization of the influence of such variables on the interpretation of pain expressions.
Table 5 summarizes central findings. Observers rated older persons as experiencing greater pain than younger adults, emphasizing the importance of examining judgements from a lifespan perspective. An unexpected relationship between observer type and patient age was also identified; nursing students ascribed greater sympathy and help to younger adults than nonhealth professional students. As hypothesized, priming observers with information about the misuse of the health care system attenuated their valence ratings of younger patients, whereas priming observers about the undertreatment of pain in older persons increased their valence ratings of older patients. Consistent with previous research,8,17,80,81 observers' valence towards patients significantly influenced their estimations of pain as well as sympathy and help. In addition, observers rated male patients' pain higher. Results of narrative data supported quantitative findings, suggesting that observers' judgements are influenced by a variety of non–pain-related factors. In general, findings enhance the specificity of theoretical understandings of pain and demonstrate that patient and observer characteristics, as well as informational primes, significantly moderate observers' judgements of pain expressions.
4.2. The role of patient age and observer type
As hypothesized,33,34,49,52 observers ascribed higher observed pain, sympathy, and help to older patients compared with younger patients. One contributing factor to this finding may be commonly held stereotypes about older individuals, such as the belief that older persons are less healthy than younger persons.37,38,40,52 These common stereotypes may increase observers' sensitivity towards older persons' nonverbal pain cues.52 Future research should aim to clarify the mechanisms that influence observers' estimates of older persons' pain.
An unexpected interaction between observer type and patient age was identified. Nursing students provided greater sympathy and help ratings to younger patients compared with nonhealth professional students. These findings conflict with results from previous investigations where practicing health care professionals provided lower estimates of others' pain compared with lay people.32,62 Several studies, however, have failed to replicate this underestimation bias.1,49,56 Prkachin et al.65 proposed that the underestimation effect was a result of health care professionals' increased exposure to high amounts of pain that, subsequently, biases them against identifying pain in others. Consequently, the limited clinical experience in the present sample may have contributed to the unexpected finding.
4.3. The role of informational primes
Ratings of valence varied as a function of a 3-way interaction across priming condition, patient age, and observer type. As expected, results demonstrated that both nursing and nonhealth professional students in the undertreatment prime condition rated older patients more positively than younger patients. In addition, nursing students in the undertreatment priming condition reported more positive valence towards older adults than nursing students in the misuse condition. These results highlight the positive influence of priming about undertreatment on observers' valence towards older patients. Moreover, findings demonstrate that, compared with nonhealth professional students, nursing students' valence was more greatly influenced by the undertreatment prime. A potential explanation is that nursing students are more sensitive to information about the undertreatment of health conditions in vulnerable populations, given that nursing students' years in training is positively related to favourable attitudes towards older persons.76
Consistent with hypotheses, nursing students in the misuse priming condition reported less positive valence towards younger adults than nursing students in the undertreatment condition. In addition, nonhealth professional students in the misuse condition reported significantly less positive valence towards younger compared with older patients. These findings are consistent with previous research, where inferring that patients' pain expressions are insincere, reduced judges' willingness to attribute pain, and offer assistance.17,47,56 Results from this study contribute to the literature by demonstrating that priming observers about the misuse of the health care system exclusively reduced positive valence towards younger patients. This is not surprising because younger adults compose most of the active work force and, therefore, are more likely to require vocational financial compensation due to missed work.77
4.4. The indirect effect of valence
Priming with information about the undertreatment of pain in older adults was associated with more positive valence towards patients. In turn, greater positive valence was correlated with higher pain, sympathy, and help judgements to all patients. This indirect relationship is in line with results from several researchers who have demonstrated the significant role of valence in pain estimates.8,17,80,81 These investigations have revealed that observers attribute higher pain, distress, and disability scores to more likable patients.8,80 Interestingly, the undertreatment prime positively influenced observers' ratings of all persons, despite this prime's specific focus on older persons' pain. Consistent with the spreading-activation theory,10,23,45 it is speculated that information about the undertreatment of older persons' pain may have activated semantically related concepts (eg, undertreatment of younger person's pain), which prompted observers to display a heightened sensitivity to all persons' pain. More research is needed to explore the indirect influence of valence on pain estimates.
4.5. The influence of patient sex
Observers rated males higher than females on pain, sympathy, and help. This sex effect was strong across all indicators, except for valence ratings. In general, these results contribute to the mixed body of literature regarding the impact of patient sex on observers' interpretations of their pain.4,34,66,68,71,78 The discrepancies in the literature are currently not well understood and could be due to methodological differences across studies, including study-specific features. For instance, observers in the present investigation were primarily young women, which was not the case in other studies. More research is needed to clarify patient sex effects.
4.6. Findings based on narrative data
Analysis of narrative data supported quantitative findings and the influence of contextual features on observers' interpretations of pain. Observers most frequently indicated that patients' demographic characteristics influenced their ratings. This is consistent with findings of the quantitative analyses, showing that observers' ratings differed as a function of patients' sex and age. In addition, observers documented various other contextual features that influenced their ratings, including their own beliefs. General trends suggest that some influences had a more widespread impact than others. For instance, observers reported that “pain expressed” and “patient demographics” influenced their observed pain, sympathy, and help ratings. By contrast, other characteristics (eg, “bracing”) were mentioned less frequently and more exclusively in the context of pain ratings. This may suggest that some contextual factors (eg, patient age) have a more pervasive influence on observers' judgement than other factors.
4.7. Theoretical contributions
Findings from this study add specificity to the communications model of pain by clarifying the influence of specific contextual factors on decoding nonverbal pain expressions. The consideration of multiple variables and interactions across variables allows for a more comprehensive description of the factors that influence pain communication. For instance, the combination of observer type and patient age moderated observers' ratings of sympathy and help. These results emphasize the intricate relationships across contextual factors and the influence of combinations of variables on pain decoding.
Moreover, results identified unique factors that impact the decoding of older and younger persons' pain experience. Observers primed with information about the misuse of the health care system attributed lower pain to younger patients, whereas priming information about the undertreatment of pain in older persons had a positive influence on observers' ratings of older persons' pain. In general, these findings suggest that specific contextual variables influence pain decoding differently depending on the age of the person expressing pain.
Because our observers were predominantly young females in university, future research should test the impact of these contextual factors in a more diverse sample of observers. This is particularly relevant, as observer and patient characteristics are known to influence pain decoding.19,25 Researchers may also evaluate the influence of additional contextual features, such as observers' ethnicity and sex.3,69 There would also be value in using manipulation checks in future research to ensure that experimental primes are perceived as intended. An additional limitation was the lack of information yielded regarding the relationship between pain judgements and clinical decisions. Clinical research evaluating health care professionals' behaviour is needed to examine the ecological validity of the present findings.
This investigation expanded our current understanding of the influence of contextual factors in decoding pain. Unique conceptual and methodological features of this study provide greater meaning to the results and allow for increased specificity in the communications model of pain.31,61 Results suggest that informational primes, observer-level factors, and patient characteristics all interact to influence observers' interpretations of pain expressions. Moreover, likeability of patients was found to indirectly influence observers' willingness to attribute pain, sympathy, and help. These results highlight the complexity of pain decoding and identify unique combinations of variables that influence perceptions of others' pain.
Conflict of interest statement
The authors have no conflicts of interest to declare.
This research was supported through grants from the AGE WELL Network of National Centres of Excellence (#WP6.3), the Canadian Institutes of Health Research (#201403), and the Saskatchewan Health Research Foundation (#2908). Amy Hampton was supported by a Health Professional Student Research Award and a Graduate Scholarship awarded by the University of Regina Faculty of Graduate Studies and Research.
The authors thank Reihaneh Ahmadi, Delaine Ammaturo-Shackleton, Erin Browne, and Natasha Gallant for her help with the coding of facial expressions.
Supplemental digital content
Supplemental digital content associated with this article can be found online at http://links.lww.com/PAIN/A631.
Supplemental video content
Video content associated with this article can be found online at http://links.lww.com/PAIN/A632.
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Observer judgements; Priming; Social deception; Aging; Older adults; Elderly; Stereotypes; Social influences
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