<%BANNER%>

Sex and Race Differences in Rating Others' Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help

Permanent Link: http://ufdc.ufl.edu/UFE0021122/00001

Material Information

Title: Sex and Race Differences in Rating Others' Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help
Physical Description: 1 online resource (62 p.)
Language: english
Creator: Alqudah, Ashraf F
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: african, americans, assessment, caucasians, coping, differences, females, help, human, males, medical, mood, pain, race, recommending, sex, virtual
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Sex and race influence pain ratings. We studied these influences in ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help. Seventy-five undergraduates viewed virtual human virtual humans expressing pain, and provided computerized ratings via VASs. A series of Mixed ANOVAs was performed. Male and female participants rated female virtual humans higher than male virtual humans on pain intensity, (p < 0.05), pain unpleasantness, (p < 0.01), pain-related negative mood, (p < 0.05), poor pain coping, (p < 0.05), and recommending medical help, (p < 0.05). Male and female virtual humans need for medical help was rated higher by male participants compared to female participants, (p < 0.05). Males also rated African American and Caucasian virtual humans need for medical help higher than females' ratings, (p < 0.05). African Americans and Caucasians rated female virtual humans higher on pain intensity, (p < 0.05) and pain unpleasantness, (p < 0.05). Caucasians and African Americans viewed Caucasian virtual humans pain-related negative mood as higher than African Americans, (p < 0.05). Caucasians' ratings of male and female virtual humans pain-related negative mood were higher than African Americans' ratings, (p < 0.05). Caucasians rated females' pain-related negative mood higher than males', (p < 0.05). Caucasians' and African Americans' ratings for poor coping were higher for Caucasian virtual humans compared to African American virtual humans, (p < 0.05). African Americans' ratings for African American virtual humans' pain intensity were higher than for Caucasian virtual humans. In summary, both sexes and races had higher ratings for females' pain. Both races rated female virtual humans higher on each variable. Both races rated Caucasians as having more negative mood and poorer coping than African Americans. Females' higher negative mood and poorer coping might be explained the relationship between pain, mood, and coping. Results show that races may differ in sensitivity to pain expressions. Males' tendency to seek more pain medications may explain their high levels of recommending virtual humans to seek medical help. Technology used in this study (virtual humans) is discussed along with its possible future use and applicability.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Ashraf F Alqudah.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Robinson, Michael E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021122:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021122/00001

Material Information

Title: Sex and Race Differences in Rating Others' Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help
Physical Description: 1 online resource (62 p.)
Language: english
Creator: Alqudah, Ashraf F
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: african, americans, assessment, caucasians, coping, differences, females, help, human, males, medical, mood, pain, race, recommending, sex, virtual
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Sex and race influence pain ratings. We studied these influences in ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help. Seventy-five undergraduates viewed virtual human virtual humans expressing pain, and provided computerized ratings via VASs. A series of Mixed ANOVAs was performed. Male and female participants rated female virtual humans higher than male virtual humans on pain intensity, (p < 0.05), pain unpleasantness, (p < 0.01), pain-related negative mood, (p < 0.05), poor pain coping, (p < 0.05), and recommending medical help, (p < 0.05). Male and female virtual humans need for medical help was rated higher by male participants compared to female participants, (p < 0.05). Males also rated African American and Caucasian virtual humans need for medical help higher than females' ratings, (p < 0.05). African Americans and Caucasians rated female virtual humans higher on pain intensity, (p < 0.05) and pain unpleasantness, (p < 0.05). Caucasians and African Americans viewed Caucasian virtual humans pain-related negative mood as higher than African Americans, (p < 0.05). Caucasians' ratings of male and female virtual humans pain-related negative mood were higher than African Americans' ratings, (p < 0.05). Caucasians rated females' pain-related negative mood higher than males', (p < 0.05). Caucasians' and African Americans' ratings for poor coping were higher for Caucasian virtual humans compared to African American virtual humans, (p < 0.05). African Americans' ratings for African American virtual humans' pain intensity were higher than for Caucasian virtual humans. In summary, both sexes and races had higher ratings for females' pain. Both races rated female virtual humans higher on each variable. Both races rated Caucasians as having more negative mood and poorer coping than African Americans. Females' higher negative mood and poorer coping might be explained the relationship between pain, mood, and coping. Results show that races may differ in sensitivity to pain expressions. Males' tendency to seek more pain medications may explain their high levels of recommending virtual humans to seek medical help. Technology used in this study (virtual humans) is discussed along with its possible future use and applicability.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Ashraf F Alqudah.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Robinson, Michael E.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021122:00001


This item has the following downloads:


Full Text





SEX AND RACE DIFFERENCES IN RATING OTHERS' PAIN, PAIN-RELATED
NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP

















By

ASHRAF FARIS ALQUDAH


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE
UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007

































O 2007 Ashraf Faris Alqudah



































To my parents who provided me with endless love. To my brothers Abdulghafour and
Mohammad who planted gardens in the deserted land of my dreams. To my daughter Sarah who
is the candle of my life and the meaning of my smile.









ACKNOWLEDGMENTS

I thank my supervisory committee chair (Michael E. Robinson) and committee members

for their mentoring. I thank my department for its genuine and continuous guidance and

generosity. I thank the members of the Center for Pain Research and Behavioral Health for their

help and support.












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES ................. ...............7..____ .....


AB S TRAC T ......_ ................. ............_........9


CHAPTER


1. INTTRODUCTION ................. ...............11.......... ......


Sex Differences in Pain Perception and Rating ................. ...............11........... ..
Sex Differences in Pain-Related Negative Mood ................. ...............13...............
Sex Differences in Coping with Pain............... ...............17..
Racial Differences in Coping with Pain .............. .. ...............20...
Racial Differences in Pain-Related Negative Mood ................. ...............22...............
Facial Expression of Emotions ................. .......... .. .......... ..... ........2
Sex differences in recognition of facial expressions and facial pain expressions ................. .25
Vi gnettes Research .............. ...............26....
Study Rationale............... ...............2
Study Aim s .............. ...............29....
Hypotheses............... ...............2

2. METHOD S ................ ...............31........... ....


Participants .............. ...............3 1....
Recruitm ent ................... .......... ...............3.. 1....
Inclusion/Exclusion Criteria............... ...............3
Procedure ................. ...............3.. 1..............

A analysis .............. ...............33....

3. RE SULT S .............. ...............3 5....


Analysis of Pain Intensity Ratings ................. ...............35........... ...
Sex Effects ................. ...............35.................
Race Effects ............... ... ............ ...............36.......

Analysis of Pain Unpleasantness Ratings ................. ...............36........... ...
Sex Effects ................. ...............36.................
Race Effects .................. .... ...... ... ....... ...............36...

Analysi s of Pain-Related Negative Mood Ratings ................ ...............36........... ..
Sex Effects ................. ...............36.................
Race Effects ................... ...............37.......... ......

Analysis of Pain-Coping Ratings ................. ...............37................
Sex Effects ................. ...............37.................
Race Effects ................. ...............37.................













Analysis of Recommending Medical Help Ratings ................. ...............................38
Sex effects .............. ...............38....

Race effects .............. ...............38....


4. DI SCUS SSION ............. ...... .__ ...............47..


References............... ...............5


BIOGRAPHICAL SKETCH .............. ...............62....










LIST OF TABLES


Table page

3-1. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by male and female participants. .................. ..40

3-2. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by Caucasian and African American
participants. .............. ...............40....

3-3. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain intensity made by Caucasian and African American
participants. .............. ...............40....

3-4. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by male and female participants. ..........41

3-5. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by Caucasian and African American
participants. .............. ...............41....

3-6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual
humans on ratings of pain unpleasantness made by male, female, Caucasian, and
African American participants. .............. ...............42....

3-7. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain-related negative mood made by male and female
participants. .............. ...............42....

3-8. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants. .............. ...............43....

3-9. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by male and female
participants. .............. ...............43....

3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants. .............. ...............43....

3-11i. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by male and female participants. ................... ....44

3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by Caucasian and African American
participants. .............. ...............44....










3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain coping made by Caucasian and African American
participants ................. ...............44.................

3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain coping made by male and female participants ................... .....45

3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by male and female
participants ................. ...............45.................

3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants .............. ...............45....

3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of recommending medical help made by male and female
participants ................. ...............46.................

3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants .............. ...............46....

3-19. Correlations between the dependent variables .............. ...............46....











Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

SEX AND RACE DIFFERENCES IN RATING OTHERS' PAIN, PAIN-RELATED
NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP

By

Ashraf F ari s Al qudah

August 2007

Chair: Michael E. Robinson
Major: Psychology

Sex and race influence pain ratings. We studied these influences in ratings of pain

intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending

medical help. Seventy-five undergraduates viewed virtual human virtual humans expressing

pain, and provided computerized ratings via VASs. A series of Mixed ANOVAs was performed.

Male and female participants rated female virtual humans higher than male virtual humans on

pain intensity, (p < 0.05), pain unpleasantness, (p < 0.01), pain-related negative mood, (p <

0.05), poor pain coping, (p < 0.05), and recommending medical help, (p < 0.05). Male and

female virtual humans' need for medical help was rated higher by male participants compared to

female participants, (p < 0.05). Males also rated African American and Caucasian virtual

humans' need for medical help higher than females' ratings, (p < 0.05). African Americans and

Caucasians rated female virtual humans higher on pain intensity, (p < 0.05) and pain

unpleasantness, (p < 0.05). Caucasians and African Americans viewed Caucasian virtual

humans' pain-related negative mood as higher than African Americans', (p < 0.05). Caucasians'

ratings of male and female virtual humans' pain-related negative mood were higher than African

Americans' ratings, (p < 0.05). Caucasians rated females' pain-related negative mood higher









than males', (p < 0.05). Caucasians' and African Americans' ratings for poor coping were higher

for Caucasian virtual humans compared to African American virtual humans, (p < 0.05). African

Americans' ratings for African American virtual humans' pain intensity were higher than for

Caucasian virtual humans. In summary, both sexes and races had higher ratings for females'

pain. Both races rated female virtual humans higher on each variable. Both races rated

Caucasians as having more negative mood and poorer coping than African Americans. Females'

higher negative mood and poorer coping might be explained the relationship between pain,

mood, and coping. Results show that races may differ in sensitivity to pain expressions. Males'

tendency to seek more pain medications may explain their high levels of recommending virtual

humans to seek medical help. Technology used in this study (virtual humans) is discussed along

with its possible future use and applicability.









CHAPTER 1
INTTRODUCTION

Pain is an individual subj ective experience that is known to have psychological

components. Almost a fifth of American adults experience chronic pain (a total of 50 million).

Persistent pain is experienced by 17% of patients in the United States seen by primary care

physicians. And people who seek treatment for chronic pain each year are estimated to be about

4.9 million. Significant pain accompanies the maj ority of more than 23 million surgical

procedures that are performed each year in the United States. Direct and indirect costs for the

treatment of pain and the pain-related losses are estimated to be more than $125 billion per year

(Turk & Melzack, 2001).

Sex Differences in Pain Perception and Rating

Empirical investigations support the presence of sex differences in pain (Robinson, Riley,

Myers, Papas, Wise, Waxenberg, & Fillingim, 2001; Frot, Feine, & Bushnell, 2004; Robinson &

Wise, 2003; Ellermeier & Westphal, 1995; Vallerand & Polomano, 2000; Hawthorn &

Redmond, 1998; Unruh, 1996; Dao & LeResche, 2000; Robinson & Wise, 2004). However, the

degree to which sex influences pain perception is not completely clear. Although a number of

studies have shown that females perceive and express higher levels of pain than males, other

studies have found no differences between the sexes (Hawthorn & Redmond 1998). A number of

researches have shown that females are more likely to experience pain in a range of medical

conditions compared to males. For example, females report more frequent tension and migraine

headaches than males (Unruh, 1996), and have higher prevalence rates for orofacial (Dao et al,

2000) and musculoskeletal pain (Unruh, 1996). Sex-related differences in pain perception have

also been found in experimental pain settings (Frot et al. 2004).










The presence of sex differences in the appraisal of pain might arise for two reasons. First,

males and females have differences in their pain experience over the lifespan, suggesting the

presence of meaning constructs of pain and related coping styles. Second, sex-based social role

expectations are different for males and females. Subsequently, the interference of the pain

experience differs with the roles and responsibilities for females and males. Pain-related

emotional and affective responses might also be affected by differences in social role

expectations (Unruh, 1996).

It is relatively well established that differences do exist between the sexes. However, the

underlying mechanisms are not clear yet. It has been suggested that sex differences in pain

perception are driven by both biological and socially learned factors, and also by the possible

interaction between them. Different expectations were found between males and females in

terms of the typical male' s and female' s pain responding. Males are viewed as less willing to

report their pain and more able to endure it. A manipulation of sex- related pain expectancy in

experimental setting eliminated the sex differences in cold pressor pain (Robinson et al., 2004).

Males and females endorse different predispositions to willingness to report their pain

significantly (Robinson et al. 2001). That is, males are less willing to report pain. Robinson,

Riley, & Myers (2000) have argued that the differences reported in many laboratory

investigations could largely be explained by the sex-related expectations of pain. Robinson,

Gagnon, Riley, & Price (2003) attempted to explicitly manipulate the sex role stereotypes for

males and females to further determine the effects of these stereotypes and related expectations

on different psychophysical responses to experimental pain. One of their hypotheses was that

manipulating the expected performance for males and females would influence their subsequent

pain report and reduce or eliminate the documented sex differences in pain. They hypothesized









that in standard instructional sets, pain report would differ between males and females. And these

differences would decrease when females and males were given similar sex role expectations for

pain tolerance. Their work was the first to show that sex differences in pain report decrease when

sex role is experimentally manipulated. Results also supported the notion that assessments of sex

differences in pain responding, in laboratory settings, are influenced by sex role-related

expectations of pain. That is, pain tolerance can be manipulated by altering sex role-based

expectations for pain.

There are few studies examining how individuals view others in pain, either

experimentally or clinically. Robinson et al. (2001) have found that males and females differ

significantly in their pain expectations for self and others. Investigators examined how both

sexes observe experimentally induced pain in male and female participants. They found that,

regarding virtual humans' sex, viewers rated male virtual humans as having less pain than female

virtual humans. Regarding sex of the observer, however, female viewers rated observed pain

intensity significantly higher than did male viewers. In a more recent study, Robinson & Wise

(2004) found that participants rated female subj ects as experiencing greater pain intensity when

undergoing a cold pressor task compared to males. Parental observation, sociocultural norms,

acuity in observing overt behaviors, and beliefs regarding roles were suggested by the

investigators to play a part in the explanation of how one perceives another in pain.

Sex Differences in Pain-Related Negative Mood

The current definition of pain by the International Association for the Study of Pain as "an

unpleasant sensory and emotional experience associated with actual or potential tissue damage,

or described in terms of such damage." reflects the subj ective, multidimensional nature of pain.

A better understanding of the experience of clinical pain highlights the importance of









understanding the negative emotional experiences that accompany and contribute to the overall

pain experience (Robinson & Riley, 1998).

Previous research shows that pain is associated with negative mood (Gaskin, Green,

Robinson, & Geisser, 1992). Chronic pain patients show high psychological distress, including

depressed mood, anxiety, and anger (Feldman, Downey, & Schaffer-Neitz, 1999). Wade,

Dougherty, Hart, Rafli, & Price (1992); Wade, Dougherty, Archer, & Price (1996); and Price

(1999) proposed a sequential stage model of pain processing. The Perceived intensity of the pain

sensation was suggested to be the first stage. The second stage is the immediate pain

unpleasantness, which reflects an individual's immediate affective response to the pain sensation

and to the context of its occurrence. The immediate pain unpleasantness dimension involves

limited cognitive processing and is often linked to the physical sensation of pain. The third stage

involves long-term reflective or cognitive processing related to the meanings and implications of

pain on the individual's life (Price, 1999). Therefore, negative emotions such as depression,

anxiety, and anger, are thought to be characteristics of this third stage. The fourth and final stage

of the model is the apparent behavioral expression of pain.

Gaskin et al (1992) analyzed the ability of anxiety, anger, and depression to predict self-

report of clinical pain as indicated by the McGill Pain Questionnaire (MPQ). Researchers found

support for the hypothesis that chronic pain has a predisposing factor in the development of

negative mood. Feldman et al. (1999) investigated the relationship between daily pain, negative

mood, and social support in 109 participants with reflex sympathetic dystrophy syndrome and

found that pain led to increased depressed, anxiety, and anger. Slocumb, Kellner, Rosenfeld and

Pathak (1989) matched gynecologic patients with the abdominal pelvic pain syndrome with other

gynecologic patients. They administered to both groups self-rating scales of anxiety, depression,









and anger-hostility, and found that pain patients rated themselves significantly more anxious,

depressed, and hostile. Another study investigated the associations between a chronic pain

condition and common mood and anxiety disorders in a sample representative of the general US

civilian population utilizing the National Comorbidity Survey. Researchers found significant

positive associations between chronic pain and individual 12-month mood and anxiety disorders

(McWilliams, Cox, & Enns, 2003).

Individuals experiencing chronic pain have higher incidences of depression, lower levels of

physical functioning, and a poorer response to treatment (Geisser, Robinson, Keefe, & Weiner,

1994). Depression is a significant issue among pain patients. Prevalence rates for depression of

30% to 60% in clinic-based chronic pain samples highlight the significance of depression among

pain patients (Robinson & Riley, 1998). Romano & Turner (1985) reviewed the literature on the

relationship between pain and depression and concluded that research support can be found for

almost all hypotheses about the nature of the relationship between the two constructs:

"depression leads to pain by increasing pain sensitivity and decreasing pain threshold; pain

becomes a virtual equivalent of depression among patients with certain dispositions; pain serves

as a stressor that leads to subsequent depression; and that pain and depression occur

simultaneously, but are related only due to coincidentally similar psychological and/or biological

mechanisms". This highlights the importance of further investigation of the relationship between

pain and depression, and to include factors that are expected to have variant contributions to that

relationship such as the person's sex, how well the person is coping with his/her pain, the level

of pain the person is reporting, and sex differences in perceiving the person's mood, coping, pain

level, and his/her expected sex role.









Several studies indicate that patients with a variety of chronic pain conditions report

anxiety levels significantly greater than published norms and that a significant amount of the

variance in pain report can be explained by anxiety (Gaskin, Greene, Robinson, & Geisser, 1992;

Brown, Robinson, Riley, & Gremillion, 1996; Holzberg, Robinson, Geisser, & Gremillion,

1996). Gaskin et al. (1992) used regression methodology to ascertain relationships between

clinical pain measured by the McGill Pain Questionnaire and measures of depression, anxiety,

and anger and found that 33% of the McGill affective dimension of pain was associated with

state anger and state anxiety, and 19% of the McGill sensory dimension was associated with state

anxiety. Anger is considered as an affective state that may be related to pain and styles of

inhibiting anger have been found to be the strongest predictor of pain intensity (Kerns,

Rosenberg, & Jacob, 1994). The development of depression in general has been linked to the

suppression of anger in general, as well as specifically among pain patients (Beutler, Engle,

Oro'-Beutler, Daldrup, & Meredith, 1986).

Sex-specific relationships between pain and negative affect have been evidenced in both

community and clinical samples (Riley, Robinson, Wade, Myers, & Price, 2001). In the National

Health and Nutrition Examination Survey, pain and depressive symptoms tended to be more

evident in females than in males (Magni, Caldieron, Rigatti-Luchini, & Merksey, 1990). In pain

clinic patient samples, prevalence of depression and anxiety is typically higher for females

(Unruh, 1996), although at least one study reported more depression and anxiety in males

(Buckelew, Shutty, Hewitt, Landon, Morrow, & Frank, 1990). In within-day assessments of pain,

pain coping, and mood in males and females having Osteoarthritis, a study aimed to analyze sex

differences in dynamic relations between pain, mood, and pain coping. Participants rated their

pain, pain coping, and mood two times each day for 30 days using a booklet format. One Einding









was that males were more likely than females to experience an increase in negative mood and a

decrease in positive mood in the morning after an evening of increased pain (Keefe, Affleck,

Emery, Waters, Caldwell, Stainbrook, Hackshaw, Fox, & Wilson, 2004). Riley et al. (2001)

proposed a sequential model of pain processing with pain intensity as stage 1, pain

unpleasantness as stage 2, pain-related emotions (depression, anxiety, frustration, anger, fear) as

stage 3, and overt behavioral expression of pain as stage 4. Investigators tested hypotheses about

relationships between sex and the first 3 stages of pain processing in both sexes participants with

chronic pain and one of the findings was that pain-related emotions were more strongly related to

pain for males. Anxiety was one of the emotions most highly related to pain. Recent research

results highlight sex differences in the experience of pain and the importance of assessing pain-

related negative mood and sex differences.

Sex Differences in Coping with Pain

Lazarus & Folkman (1984) define coping as "constantly changing cognitive and behavioral

efforts to manage specific external and/or internal demands that are appraised as taxing or

exceeding the resources of the person". They also identified the person' s health status and energy

as one of the most pervasive coping resources in that they are relevant to coping in many, if not

all, stressful encounters. They suggest that a person who is weak, ill, tired or otherwise

debilitated has less energy to apply to coping than a healthy person and that it is easier to cope

when one is feeling well than when one is not. This notion implies that people who are in pain

will cope differently than people who are not and that pain would only be considered as a

stressor when, and if, a person believes or appraises the pain as taxing or exceeding his/her

recourses and abilities to manage it. Coping is a construct that many of the variables that

influence pain and disability fall under, and many models of pain and illness give coping










responses an important, if not central, role in understanding and predicting adjustment to pain

and illness (Boothby, Thorn, Stroud, & Jensen, 1999).

Given that individuals develop their own strategies for coping with painful experiences,

and since males and females differ in the experience of pain, it is likely that males and females

will develop different coping styles (Jensen, Turner, Romano, & Lawler, 1994; Weir, Browne,

Tunks, Gafni, & Roberts, 1996; Robinson et al, 2000). Unfortunately, little research has

investigated whether sex moderates or mediates the effectiveness of pain coping strategies

(Sullivan, Tripp, & Santor, 2000; Keefe, Lefebvre, Egert, Affleck, Sullivan, & Caldwell, 2000).

Unruh, Ritchie, & Merskey (1999), for example, presented results from a community based

telephone survey of people who reported pain in the two weeks before the interview. Researchers

found that females reported significantly more intense pain, as well as used a greater range of

coping strategies, i.e. greater social support seeking, problem-solving, positive self-statements

and palliative behaviors compared to males.

Another study aimed to determine whether sex differences would be found in the effect

that sensory-focused and emotion-focused coping instructions have on cold pressor pain

experiences. In this study, participants consisted of healthy adults, all of whom reported no

current pain. Compared to females, males showed less negative pain responses when focusing on

the sensory component of the pain experience, and compared to sensory focusing, emotional

focusing was found to increase the affective pain experience of females (Keogh & Herdenfeldt,

2002). Keefe et al. (2004) found that females used more problem focused coping than males, and

females who catastrophized were less likely than males to report negative mood. They also found

that males were more likely than females to use emotion-focused coping when their mood was

more negative.









Affleck, Tennen, Keefe, Lefebvre, Kashikar-Zuck, Wright, Starr, & Caldwell (1999) found

that females reported more problem solving, social support, positive self-statements, and

palliative behaviors than males. When the effects of disease and sex on daily pain, mood, and

coping were compared in 71 patients with Osteoarthritis and 76 patients with rheumatoid

arthritis, females had daily pain levels of 72% higher than the daily pain levels of males. Females

used more problem-focused and emotion-focused strategies every day than males. This suggests

the female participants endorsed more coping strategies than males.

The perceived seriousness of the pain experience may increase by the anticipated and

actual interference of pain on one's perceived responsibilities. Multiple primary role

responsibilities of females such as childcare or care for elderly parents, household management,

and paid employment may contribute to the appraisal of pain as threatening. They may attend to

pain earlier in an effort to minimize its' intrusiveness. Females may also be more worried and

irritated about pain. Role interference and perceived effectiveness or ineffectiveness of coping

strategies may contribute to the emotional response to pain. Normal biological processes that

result in troublesome pain experiences, recurrent pains with little or no pathological significance,

and pain experiences that are symptomatic of pathological, increase the complexity of female' s

pain experience and may lead to some frustration with self-management and assessment of pain.

Risks of depression and disability associated with pain may be increased due to irritability and

worry. Paid work remains the dominant occupational role for males although their involvement

in childcare and household responsibilities is slowly increasing. Risk of work disability may be

partially reduced by the greater opportunity to recover from pain if responsibilities for childcare,

household management and relationships are considered secondary and possibly assumed by a

partner. For males, unless the pain experience is interfering with work, they may perceive that










experience as having limited importance. While females may be more irritated and worried about

pain, males may be more embarrassed by pain. Embarrassment may cause males to minimize

pain unless pain increases in severity or interferes with work. Social and cultural norms that

accept insensitivity to pain and pain endurance as measures of virility may minimize the pain

expression or reporting (Unruh, 1996). Klonoff, Landrine, & Brown (1993) found that male

undergraduate students were significantly more likely than females to rate their emotional

response to common pain problems as embarrassment regardless of the location of the pain.

Participants of both sexes identified the greatest threats to be the overall interference of pain and

the emotional distress when asked about their appraisal of pain (Unruh et al., 1999).

Racial Differences in Coping with Pain

The literature concerning chronic pain has shown that active coping, such as problem-

focused coping, tends to be associated with better physical and psychological functioning. And

passive coping, such as emotion-focused coping, tends to be associated with poorer physical and

psychological functioning (Jensen, Turner, Romano, & Karoly, 1991; Boothby et al., 1999).

Furthermore, patients who used problem-focused coping were better in adapting to chronic

disease than those who used emotion-focused strategies (Bombardier, D'Amico, & Jordan, 1990;

Maes, Leventhal, & de Ridder, 1996).

Little is known about racial differences in coping with pain as well as racial differences in

perceiving others' coping strategies when experiencing pain. It is possible that different coping

styles used by African Americans and Caucasians may impact the pain experience. For example,

in a study of pain coping among patients with rheumatoid arthritis, racial differences were

present in the use of pain coping strategies although no racial differences in pain were noted.

African Americans with rheumatoid arthritis reported significantly higher use of distraction and









praying/hoping as coping strategies, whereas, Caucasians reported greater use of ignoring pain

and coping statements (Jordan, Lumley, & Leisen, 1998).

Many researchers concluded that race is an important predictor of pain-related

symptomatology and pain coping (Edwards & Fillingim, 1999; Greenwald, 1991; Novy, Nelson,

Hetzel, Squitieru, & Kennington, 1998; Sheffield, Biles, Orom, Maixne, & Sheps, 2000; Zatzick

& Dimsdale, 1990). Others such as Edwards, Doleys, Fillingim, & Lowery (2001) highlighted

that future investigations may benefit from assessment of coping strategies as a potential

mediator or moderator of relationships between race and pain responses. Previous research has

suggested that coping, social learning, and attitudes might play an important role that is yet

unstudied in racial differences in health conditions, particularly pain (Folkman & Moskowitz,

2000; Moore & Brodsgaard I, 1999). Jordan et al (1998) compared racial groups on pain coping

strategies and control beliefs and the relationships of these variables to health status among

women with rheumatoid arthritis. They found that Racial groups did not differ in pain severity or

negative affect, but African-Americans used more coping techniques involving diverting

attention and praying/hoping. And that Caucasians used more coping techniques involving

ignoring pain. The relationships of praying/hoping and reinterpreting pain to RA adjustment

differed by racial group. Whereas, ignoring pain, coping statements, and stronger control beliefs

predicted better health status, diverting attention predicted more pain for all patients. These

findings suggest that there are racial differences in the use of coping strategies that should be

acknowledged when helping patients cope with their pain.

Campbell, Edwards, & Fillingim (2005), Examined racial differences in responses to

multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain and

found that African Americans reported greater use of passive pain coping strategies.









Racial differences in pain related coping were also found between African Americans and

Whites on every Coping Strategies Questionnaire-Revised scale dimensions after including sex

and age as covariates in the model (Hastie, Riley, & Fillingim, 2004).

Pain coping strategies generally vary widely between cultures. Cultural differences in pain

coping strategies might be as important as the differences in the prevalence pain or its reported

severity (Brodsgaard, 1999). Racial differences in pain coping within clinical samples might not

be the result of a long chronic pain experience, but might be present even in the absence of

chronic pain. So, racial differences in pain coping might indicate an exacerbation of stress

management styles that are inherited, such as pain. Coping is not individualistic but is folded in

the influences of the person' s ethno-cultural environment and sub-cultural context (Hastie et al.,

2004).

Racial Differences in Pain-Related Negative Mood

Race may have a maj or influence on the emotional and behavioral responses to pain and

pain appraisal (Edwards, Fillingim & Keefe, 2001). Socio-cultural factors related to racial

background may influence the meaning of the pain experience (Bates, 1996). Consequently, pain

appraisals can have a maj or influence on pain-related emotional responses such as depression

and anxiety, as well as behavioral responses such as the decision to seek treatment, adherence to

treatment regimens (Edwards et al., 2001).

Associations have also been reported between depression and emotion-focused coping

strategies in chronic pain (Weickgenant, Slater, Patterson, Atkinson, Grant, & Garfin, 1993; de

Ridder, & Schreurs, 2001; Endler, Corace, Summerfeldt, Johnson, & Rothbart, 2003). Studies on

patients coming to pain centers for initial assessment found that higher pain intensity and

depression were associated with being African American, younger, and having a pain duration of

more than 30 months (Anderson, Palos, Gning, Mendoza, Sanchez, Valero, Richman, Nazaria,










Hurley, Payne, & Cleeland, 2003; Green, Anderson, Baker, Campbell, Decker, Fillingim,

Kaloukalani, Lasch, Myers, Tait, Todd, & Vallerand, 2003; Green, Baker, Sato, Washington, &

Smith, 2003; and Green, Baker, Sato, Washington, & Smith, 2003). One study aimed to explore

relationships between chronic pain and race. The researchers asked the participants to rate the

degree to which their chronic pain interferes with their lives, and found that African Americans

had significantly higher rating than Caucasians on irritability, disturbed sleep, inability to

participate in pleasurable activities, and loss of appetite due to their pain condition (Portenoy,

Ugarte, Fuller, & Haas, 2004). Research on pain related mood has shown that African Americans

with chronic pain had higher pain severity, depression, and disability when compared to whites

with chronic pain (Carmen, Green, Ndao-Brumblay, Nagrant, Baker, & Rothman, 2004).

Riley, Wade, Myers, Sheffield, Papas, & Price (2002) found that African Americans

experience greater emotional suffering compared to white participants on similar levels of pain

intensity. The researchers identified depression, anxiety, frustration, anger, and fear as the

components of the emotional factor in their study. Researchers used VASs to assess for the

components of the emotional factor. In a retrospective analysis of persons younger than 50 years

of age presenting for chronic pain management in a multidisciplinary pain center, Green et al.

(2003) found that African American participants were more depressed, anxious, and irritable

compared to white participants.

Facial Expression of Emotions

Charles Darwin was one of the first who talked about facial expressions of emotion. In his

1872 book, Expression of the Emotions in Man and Animals, he suggested that humans'

expressive movements are remnants of earlier ones. Taking the expression of grief in adult as an

example, it is a toned down version of crying in the infants (Woodworth, 193 8). The wide-open

mouth of crying involves muscles of the corner of the mouth, and the slight movement of these










stays as a sign of grief after vocal crying has decreased as a response. Darwin described the

facial expression of disgust as a combination of closing off the nose to keep out unpleasant odor

and opening the mouth as if to spit out the contents (Woodworth & Schlosberg, 1954).

Having people judge facial expressions of emotions from photographs was introduced by

Darwin. Because the muscles and skin of the face are very mobile, the face was a logical choice.

In addition, the face is visible to others and is an important source of information in both verbal

and nonverbal social communications (Woodworth & Schlosberg, 1954).

Piderit also talked about the facial expressions of emotions in the 19th century. He argued

that mental images of obj ects should produce the same facial response as when the obj ect was

actually viewed. Therefore, when unpleasant thoughts exist, the mouth moves as if to avoid a

bitter taste, the eye region as if to avoid an unpleasant sight, the nose as to react to an unpleasant

odor. Piderit mentioned also the open mouth of attention and the appraising mouth, with lips

protruding. Piderit illustrated his arguments with simple line drawings. Boring and Titchener in

the 1920s used his drawings in studying judgments of emotional expressions by participants

(Woodworth & Schlosberg, 1954).

One way facial expressions were viewed is that it represents a psychobiological

phenomenon influenced by the humans' evolutionary heritage along with current circumstances.

This helped developing an evolutionary perspective on emotions. A perspective that would

suggest that emotion-specific changes in autonomic physiology have evolved to help that

adaptation processes that are presented as emotions, such as anger and fear. Ekman (1992)

proposed that each emotion state (emotion family) constitutes a family of affective states that

share commonalities in the way they are expressed. These commonalities between emotion

families are characteristic of that specific family and distinguishes it from other emotion









families. Research on facial expressions yielded the possibility of separate discrete emotional

states such as fear and anger. Contraction of specific facial muscles provides the information as

to whether the expression represents anger, fear, sadness, disgust, enjoyment, or surprise

(Ekman, 1993).

Some research has argued that the dynamic facial expressions are necessary for complete

emotional information extraction derived from faces (Caron, Caron, & Myers, 1985). The

dynamics of expression is a factor that facilitates recognition of expressions. Researchers used

different stimuli such as computer generated schematic movies (Wehrle, Kaiser, Schmidt, &

Scherer, 2000), Natural movies (Harwood, Hall, & Shinkfield, 1999), subtle displays of emotion

(Ambadar, Schooler, & Cohn, 2005), and point-light displays (Bassili, J, 1979) argued for the

importance of dynamics in the perception of facial expressions of emotions.


Sex differences in recognition of facial expressions and facial pain expressions

Males and females show differences in perception of facial expressions. The maj ority of

the literature shows that females are better in identifying different affects expressed through face

(Hall, 1978., Kirrouac & Dore, 1985., Nowicki & Hartigan, 1988., and Tylor & Johnsen, 2000).

However, some research suggest that sex differences depend on the type of facial expression

being observed. Nowicki et al. 1988 found that females are better in recognizing expressions

such as fear and sadness. Whereas, Wagner, McDonald, Manstead, 2986., Mandal &

Palchoudhury, 1985., and Rotter & Rotter, 1988, found that males are better in identifying

displays of anger. The sex differences in recognizing facial expressions seem to hold true even at

an early age. Boyatzis, Cazan, & Ting, 1993, found that 3.5 year-old girls accuracy in

recognizing facial expression matched 5-year-old boys' accuracy.









The most prominent nonverbal pain behavior has been considered to be the facial

expressions of pain (Craig & Patrick, 1985). In general, sex differences in facial expressions

have hardly been studied. And sex was rarely included as a factor in facial pain expressions

limited research (Kunz, Gruber, & Lautenbacher, 2006). Some research found no differences

between males and females in pain facial expressions (Craig, Hyde, & Patrick, 1991., and

Prkachin, 1992). However, Guinsburg, Peres, de Almeida, Balda, Bereguel, Tonelotto,

&Kopelman (2000) found increased facial pain responses in female neonates compared to male

neonates. Robinson et al. (2001) have found that males and females differ significantly in their

pain expectations for self and others. Viewers rated male virtual humans as having less pain than

female virtual humans and female viewers rated observed pain intensity significantly higher than

did male viewers. Robinson et al. (2004) found that participants rated female subj ects as

experiencing greater pain intensity when undergoing a cold pressor task compared to males.

Vignettes Research

This study used vignettes and virtual humans of virtual humans experiencing pain.

Vignettes, pioneered by Peter Rossi (Leahey, 2004) combine forms of survey research and

experimental designs. The vignette technique is applied to studies of problems in which

participants make evaluations regarding complicated objects. Desirable features included an

avoidance of real world multi-collinearity and the ability to isolate the independent variable of

interest. The vignette format is particularly appropriate for studying norms, attitudes, and beliefs

(Leahey, 2004). Jasso & Webster (1997); Jasso & Opp (1997); and Morrill, Snyderman, &

Dawson (1997) used the vignette format to explore normative judgments, sexed double

standards, and moral gaps in business settings.

Other researchers also used vignette formats in medical and health settings. Green,

Wheeler, & LaPorte (2003) used nine clinical vignettes to examine potential differences in the










physician' s pain management based on the type of pain and patient demographic characteristics,

and found that that the preparation of adequate pain management may be influenced by patient

characteristics and physician variability. In another study, Hassenbusch & Portenoy (2000)

investigated practice patterns via an internet-based survey distributed to physicians who manage

implantable infusion pumps for pain management. The survey used a standard questionnaire

format and two clinical vignettes to assess decision-making practices and found evidence of wide

variations in clinical practice among physicians. Goubert, Crombez, & Danneels (2004)

investigated whether pain catastrophizing and pain-related fear is related to a reluctance to

generalize an experience of lesser pain than expected to other similar situations. Researchers

used a series of vignettes to assess catastrophizing, overgeneralization, personalization and

selective abstraction related to general life experiences and to low back pain (LBP) experiences.

They also used three vignettes to assess the lack of generalization of corrective experiences

related to LBP. Researchers found that dysfunctional cognitions related to general life

experiences were the strongest predictor of the self-denigration subscale of the Beck Depression

Inventory (BDI). However only dysfunctional cognitions related to LBP accounted for a unique

contribution in predicting the somatic and physical function subscale of the BDI. Moreover,

dysfunctional cognitions related to LBP were significantly correlated with interference with daily

life due to pain.

In a study aimed to determine what factors influence emergency physicians' decisions to

prescribe an opioid analgesic for three common painful conditions, Tamayo-Sarver, Dawson,

Cydulka, Wigton, & Baker (2004) developed a baseline vignette, and items expected to influence

the decision for each of the three pain conditions: migraine, back pain, and ankle fracture, and

found that Physicians' likelihood of prescribing an opioid showed marked variability. Many









other studies have used vignette format in medical and health settings (Mitchell and Owens,

2004; Weisse, Sorum, & Dominguez, 2003; Adamson, Ben-Shlomo, Chaturvedi, & Donovan,

2003; Hazelett, Powell, & Androulakakis, 2002; Hamer, van den Hout, Halfens, Abu-Saad, &

Heijltjes, 1997; Tait & Chibnall, 1997; Carey, Hadler, Gillings, Stinnett, & Wallsten, 1988; and

Cohen, 1980).

In terms of medication practices, research using vignettes that were identical, except for

the sex of the patient indicates that different amounts of analgesic medication were chosen based

on the patients' sex, with nurses' choosing less pain medication for female patients experiencing

pain than when compared to males (Cohen, 1980; McDonald & bridge, 1991). Campbell (2002)

found that in prospective vignette studies, some nurses have indicated the intention to spend less

time engaged in pharmacological pain management of female patients, and to select less pain

medication for female patients. She also found, using lens model and vignette format, that patient

pain report appears to play an early predispositional role in the clinical decision making process.

She also found that patient sex, age, and race play smaller predispositional roles in the clinical

decision making process (Campbell, 2002).

Study Rationale

Relatively little is known about how males and females of different races vary in respect to

perceiving and rating pain, pain-related negative mood, pain coping, and the extent to which

each would recommend seeking medical help for males, females, Caucasians, and African

Americans when experiencing pain. Some research has been done on sex differences in rating

other individual's pain. Previous research has shown that differences in perceiving and rating

other' s pain lead to differences in judgments and decisions relative to pain management, drug

prescriptions and health care providing (Tamayo-Sarver et al, 2004; Campbell, 2002; Cohen,

1980; McDonald et al, 1991; Holm, Cohen, Dudas, Medema, & Allen 1989; Green et al, 2003; &










Hassenbusch et al, 2000). Since research has shown that sex and race differences in pain-related

negative mood and pain coping exist, the importance of investigating how males and females of

different races differ in perceiving other's pain-related negative mood and pain coping may in

turn lead to better understanding of the differences in the way males and females of different

races perceive, rate and respond to others' pain coping, pain-related negative mood, and better

pain management strategies.

This study adds to the determination of whether differences between males and females,

and differences between races exist in terms of perceiving and rating other peoples' pain. In

addition, this study contributes to the investigation of whether sex differences and/ or race

differences exist in perceiving and rating other's pain-related negative mood, pain coping, and

the extent of recommending seeking pain-related medical help.

Study Aims

The initial aim of this study is to determine whether sex and/or racial differences exist in

regard to rating other people's pain, pain-related negative mood, pain coping, and the extent of

recommending medical help for pain. Second, in this study, the sex role expectations of pain are

investigated as a possible mediator to the relationship between sex and the perceived others'

pain.

Hypotheses

There will be significant differences in participants' ratings for male and female virtual
humans' pain intensity, pain unpleasantness, pain-related negative mood, coping with
pain, and the extent in which virtual humans will be recommended to seek medical help
for their pain. Ratings made by male, female, Caucasian, and African American
participants for female virtual humans will be higher than their ratings for male virtual
humans.

There will be significant differences in participants' ratings for Caucasian and African
American virtual humans' pain intensity, pain uncleanness, pain-related negative mood,
coping with pain, and the extent in which the virtual humans will be recommended to










seek medical help for their pain. Male, female, Caucasian, and African American
participants will rate African American virtual humans higher.

There will be significant differences between male and female participants' ratings of
virtual humans' pain intensity, pain unpleasantness, pain-related negative mood, coping
with pain, and the extent in which the virtual humans will be recommended to seek
medical help for their pain. Female participants' ratings for male, female, Caucasian, and
African American Virtual humans will be higher than the ratings made by male
parti cipants.

There will be significant differences between Caucasian and African American
participants' ratings for virtual humans' pain intensity, pain unpleasantness, pain-related
negative mood, coping with pain, and the extent in which the virtual humans will be
recommended to seek medical help for their pain. Caucasian participants' ratings for
male, female, Caucasian, and African American virtual humans will be higher than the
ratings made by African American Participants.

Sex and race differences on rating others' pain, pain-related negative mood, pain coping,

and the extent of recommending medical help experiencing pain provides a broader range of

variables that may affect the way males and females of both races perceive and rate others' pain,

mood, and coping. This study provides baseline information regarding the role of the person's

pain, mood, and coping taken together on decisions and judgments regarding people who are

experiencing pain. It also provides initial data to explore sex and race differences on dealing with

other people's pain from both sexes and races, and its expected effects on a wider range of

behaviors including expected sex and race effects on health care behaviors toward pain patients.









CHAPTER 2
IVETHOD S

Participants

Recruitment

75 University of Florida undergraduate students of both sexes (53 females, 22 males) and

races (62 Caucasians, 13 African Americans) were recruited through flyers and posters

requesting volunteers to participate in this study.

Inclusion/Exclusion Criteria

Eligibility for participation required being at least 18 years old and English speaking. Only

males and females of African American or Caucasian background were included. Participation

was also contingent upon ability to give consent.

Procedure

Each participant was asked to read a description of the study including the time required to

complete the study and a reminder that the study is voluntary. After reading the study

description, all participants read and sign a computerized consent form acknowledging that the

study procedures were explained and that they could withdraw, without prejudice, from the study

at any time. Next, the participants filled out a demographic questionnaire. The following

demographic information was collected: sex, race, and age. After that, participants read a set of

instructions that provided information on how to approach the task and how to use Visual

Analogue Scales (VASs) to give ratings. Then, participants viewed the vignettes and the virtual

humans of both sexes and races. The virtual humans participants observed expressed pain

through facial expressions. These facial expressions of pain were digitally coded based on the

Facial Action Coding System (FACS). The FACS is based on anatomic analysis of facial muscle

movements and distinguishes 44 different action units (AUs). However, an abbreviated version









of FACS was used in this study focusing on 4 action units: brow lowering, tightening of the

orbital muscles surrounding the eye, nose wrinkling/upper lip raising, and eye closure.

Each virtual human the participants observed consisted of a vignette and a virtual reality

virtual human of the observed patient of each sex and race. Each virtual human contained three

cues: sex (two levels: male or female), race (two levels: Caucasian or African American), and

pain (two levels, and were manipulated only in the observed virtual human and was inferred by

the participants based on the virtual humans' facial pain expressions). Pain-related negative

mood, pain coping, and the virtual humans need to be recommended to seek medical help was

also inferred by the participants based on and related to the pain facial expressions of the

observed virtual human of both sexes and races.

In order to minimize the impact of social desirability on participants' ratings, participants

were instructed to completely respond to virtual humans in the order presented, complete one

virtual human before going to the next, and not to revisit a previously completed virtual human.

For each virtual human (of both sexes and races), participants (of both sexes and races) used

computerized VASs to (1) rate the level of pain intensity they think the observed virtual human

is experiencing, (2) rate the level of pain unpleasantness they think the observed virtual human is

experiencing, (3) rate the level of pain-related negative mood the observed virtual human is

experiencing due to his/her observed pain, (4) rate how well they think that the observed virtual

human is coping with the pain experience, and (5) rate the extent to which they would

recommend the observed virtual human to seek pain-related medical help. Participants also

completed a computerized version of the Sex Role Expectations of Pain questionnaire (GREP)

(appendix A) using computerized VASs to assess for the degree to which sex role expectations

of pain may contribute to their ratings.









The Gender Role Expectations of Pain questionnaire (GREP) consists of visual analog

scales to assess for participants' view of the typical male and female regarding pain sensitivity,

pain endurance, and willingness to report pain. It also assesses the participants' personal

attribution of his/her pain sensitivity, pain endurance, and willingness to report pain relative to

the typical male and female. The psychometric properties of the GREP factor structure are close

to the theoretical formulation of the scales, accounting for 76% of the variance in scores. The

questionnaire has good test-retest reliability with individual item correlations ranging from 0.53

to 0.93. The sex differences in the endorsement of items on the GREP were large, with the

largest differences (46% of variance) shown for willingness to report pain items. (Robinson et al,

2001). Wise et al (2002) found that the GREP was a significant predictor of experimental pain

ratings in undergraduate males and females, and that a significant proportion of sex differences

in pain report was accounted for.

Task duration was approximately 1 hour. Following completion of the task, participants

were asked to respond, in writing, to a task validity probe, in which they were asked to guess

what the study hypotheses were. Then, participants were briefed regarding the variables of

interest and the study hypotheses.

Analysis

All data analyses were performed using SPSS for windows (Version 15). Mixed model

ANOVA analyses were performed where sex and race, of participants and virtual humans,

served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related

negative mood, pain coping, and the extent to which the virtual humans were recommended to

seek medical help for their pain as dependent variables.

The 2 X 2 Mixed model ANOVAs were conducted as follows: ratings of pain intensity

served as a dependent variable, and sex of virtual humans (male and female) and sex of










participants (male and female) served as independent variables. The same process was repeated

for ratings of pain unpleasantness, pain-related negative mood, pain coping, and recommending

medical help. Then, ratings of pain intensity served as a dependent variable, and race of virtual

humans (Caucasian and African American), and sex of participants (male and female) served as

independent variables. The same process was repeated for ratings of pain unpleasantness, pain-

related negative mood, pain coping, and recommending medical help. After that, ratings of pain

intensity served as a dependent variable, and race of virtual humans (Caucasian and African

American), and race of participants (Caucasian and African American) served as independent

variables. The same process was repeated for ratings of pain unpleasantness, pain-related

negative mood, pain coping, and recommending medical help. Finally, ratings of pain intensity

served as a dependent variable, and sex of virtual humans (male and female), and race of

participants (Caucasian and African American) served as independent variables. The same

process was repeated for ratings of pain unpleasantness, pain-related negative mood, pain

coping, and recommending medical help.

Willingness to report pain and pain endurance (taken from the GREP), were investigated to

determine whether they meet the criteria to serve as covariates in the analyses of sex of virtual

humans and participants main effects on ratings of pain intensity and pain unpleasantness.









CHAPTER 3
RESULTS

A series of mixed model ANOVA models was performed where sex and race of

participants and virtual humans served as independent variables, and ratings of pain intensity,

pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the

[virtual humans] are recommended to seek medical help for their pain as dependent variables.

The willingness to report pain, and pain endurance are two factors of the GREP that are

being considered to be included in the model as covariates. However, correlation analysis was

conducted on these two factors as well as male and female participants' ratings of pain intensity

and pain unpleasantness for male and female virtual humans. Results showed that correlations

are not significant. Therefore, willingness to report pain, and pain endurance were dropped from

the model because the assumptions of covariance analysis were not met.

Analysis of Pain Intensity Ratings

Sex Effects

Both male and female participants rated pain intensity for female virtual humans

significantly higher than that for male virtual humans, F (1, 73) = 4.92, p < 0.05. Between

participants main effects, and sex of virtual human by sex of participant interactions were non-

signifieant (see table 3-1). Both Caucasian and African American participants rated pain

intensity for female virtual humans significantly higher than that for male virtual humans, F (1,

73) = 6.93, p < 0.05. Between participants' main effects or the sex of virtual human by race of

participant interaction effects were non-signifieant, (see table 3-2).










Race Effects

There was no main effect of race of virtual human on ratings of pain intensity. However,

African American participants rated African American virtual humans significantly higher than

Caucasian virtual humans, F (1, 73) = 4.73, p < 0.05, (see table 3-3).

Analysis of Pain Unpleasantness Ratings

Sex Effects

Both male and female participants rated pain unpleasantness for female virtual humans

significantly higher than that for male virtual humans, F (1, 73) = 7.61, p < 0.01. Main effect of

sex of viewer, and main effect and sex of virtual human by sex of viewer interaction were non-

signifieant, (see table 3-4). Both Caucasian and African American participants rated pain

unpleasantness for female virtual humans significantly higher than that for male virtual humans,

F (1, 73) = 4. 17, p < 0.05. Between participants' main effect and sex of virtual human by race of

participants' interaction were non- significant, (see table 3-5). These results mirrored the

intensity effects.

Race Effects

Race of virtual human did not have an effect on ratings of pain unpleasantness. Sex of

participant and race of participant did not have an effect on ratings of pain unpleasantness (see

table 3-6).

Analysis of Pain-Related Negative Mood Ratings

Sex Effects

Both male and female participants rated pain-related negative mood for female virtual

humans significantly higher than that for male virtual humans, F (1, 73) = 6.76, p < 0.05. No

significant interactions or between participants' effects were found, (see table 3-7). However, a

between participants main effect was found for race of participants; Caucasian participants'










ratings for both male and female virtual humans pain-related negative mood were significantly

higher than African American participants' ratings, F (1, 73) = 3.99, p = 0.05. An interaction of

sex of virtual human by race of participants was also found; Caucasian participants ratings for

female virtual humans were significantly higher than African American participants ratings for

female virtual humans, F (1, 73) = 4. 11, p < 0.05, (see table 3-8).

Race Effects

Race of virtual human did not have an effect on ratings of pain-related negative mood

made by male and female participants. (see table 3-9). However, both Caucasian and African

American participants viewed Caucasian virtual humans as having significantly higher levels of

pain-related negative mood, F (1, 73) = 5.34, p < 0.05. (see table 3-10).

Analysis of Pain-Coping Ratings

Sex Effects

Both male and female participants viewed female virtual humans as coping poorer than

male virtual humans, F (1, 73) = 6.37, p < 0.05. No significant between participants effect, and

sex of virtual human by sex of participant interactions were found, (see table 3-11). No

significant main effect for sex of virtual human on race of participants was found. Also, no

interaction or between race of participants effects were found (see table 3-12).

Race Effects

Both Caucasian and African American participants viewed Caucasian virtual humans as

coping poorer with their pain than African American virtual humans, F (1, 73) = 6.86, p < 0.05.

Race of participant did not have an effect on ratings of pain coping. (see table 3-13). Sex of

participant did not have an effect on ratings of pain coping (see table 3-14).










Analysis of Recommending Medical Help Ratings


Sex effects

A main effect for sex of virtual humans on sex of participants was found; both male and

female participants' ratings were significantly higher for female virtual humans than that for

male virtual humans, F (1, 73) = 5.98, p < 0.05. A sex of participants' main effect was also found

indicating that male participants' ratings were significantly higher than female participants'

ratings, F (1, 73) = 4.02, p < 0.05, (see table 3-15). Race of participant did not have an effect on

ratings of recommending medical help (See table 3-16).

Race effects

Sex of participant did not have an effect on ratings of recommending medical help.

However, male participants' ratings for both Caucasian and African American virtual humans

were significantly higher than that of female participants, F (1, 73) = 4.06, p < 0.05 (see table 3-

17). Sex of participant did not have an effect on ratings of recommending medical help (see table

3-18).

In summary, male and female participants rated female virtual humans' pain intensity, pain

unpleasantness, pain-related negative mood, poorer pain coping, and the need to seek medical

help as higher than male virtual humans. However, Caucasian and African American

participants' ratings for female virtual humans were higher than that for male virtual humans

only on pain intensity and pain unpleasantness. Caucasian virtual humans were viewed as having

higher pain-related negative mood and cope poorer with their pain than African American virtual

humans. African American virtual humans' pain intensity was rated higher only by African

American participants. Ratings made by male participants tended to be higher than ratings made

by female participants.









A correlation analysis was conducted between dependent variables. All dependent

variables in this study (ratings of pain intensity, pain unpleasantness, pain-related negative mood,

pain coping, and recommending medical help) were intercorrelated. Correlations ranged between

0.35 (pain coping and recommending medical help) to 0.87 (pain intensity and pain

unpleasantness (see table 3-19).










Table 3-1. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by male and female participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Male 40.6 15.8 4.92 0.063 0.03
Female 37.8 14

Female Male 41.6 14.7
Female 40.9 13.6
Pain Intensity Ratings for sex of 1.23 0.017 0.27
virtual human sex of participants

Between Participants Effect 0.24 0.003 0.62

Table 3-2. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain intensity made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 38.7 14.4 6.93 0.087 0.01
African American 38.6 15.9

Female Caucasian 40.9 14.2
African American 42.3 12.8
Pain Intensity Ratings for sex of 0.41 0.006 0.52
virtual human race of participants

Between Participants Effect 0.03 0.000 0.88

Table 3 -3. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain intensity made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Caucasian 39.4 13.7 2.62 0.035 0.11
African American 42.6 15.6

African American Caucasian 40 14.8
African American 38.3 12.9
Pain Intensity Ratings for race of 4.73 0.061 0.033
virtual human race of participants

Between Participants Effect 0.03 0.000 0.86










Table 3-4. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by male and female participants.
Virtual humans Participants M~ SD F (1, 73) rl 2 P
Male Male 43.2 16.8 7.61 0.095 0.007
Female 42 14.6

Female Male 46.9 16.9
Female 44 13.5
Pain unpleasantness ratings for sex of 0.57 0.008 0.454
virtual human sex of participants

Between Participants Effect 0.32 0.004 0.575

Table 3-5. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain unpleasantness made by Caucasian and African American
part cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 42.7 14.6 4.17 0.054 0.045
African American 40.4 18.1

Female Caucasian 45.3 14.7
African American 43 14.2
Pain unpleasantness ratings for sex 0.00 0.00 0.99
of virtual human race of
participant

Between Participants Effect 0.267 0.00 0.61










Table 3 -6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual
humans on ratings of pain unpleasantness made by male, female, Caucasian, and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Males 45.15 16.7 1.17 0.02 0.28
Females 44 13.3

African American Males 45 16.8
Females 42 14.7
Pain unpleasantness ratings for race of 0.77 0.01 0.38
virtual human sex of participant

Between Participants Effect 0.32 0.00 0.58

Caucasian Caucasian 44.58 14 2.55 0.03 0.11
African 43 16
American

African American Caucasian 43.4 15.4
African 40.4 14.9
American
Pain unpleasantness ratings for race of 0.38 0.01 0.54
virtual human race of participant

Between Participants Effect 0.268 0.00 0.61

Table 3-7. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain-related negative mood made by male and female
parti cipants.
Virtual humans Participants M~ SD F (1, 73) r 2 P
Male Male 41.2 15.9 6.76 0.085 0.011
Female 36.5 15.2

Female Male 44.2 15.3
Female 38.6 14.9
Pain-related negative mood ratings for 0.19 0.00 0.67
sex of virtual human sex of participants

Between Participants Effect 1.89 0.03 0.17










Table 3-8. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 39 15.2 0.55 0.01 0.46
African American 32.5 16.2

Female Caucasian 42.2 14.3
African American 31 16.2
Pain-related negative mood ratings 4.11 0.05 0.05
for virtual humans' sex *
participants' race

Between Participants Effect 4 0.52 0.05

Table 3 -9. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual
humans on ratings of pain pain-related negative mood made by male and female
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Male 42.8 15.8 1.29 0.02 0.26
Female 38.6 14.6

African American Male 42.6 15.8
Female 36.3 15.9
Pain-related negative mood ratings for 0.9 0.01 0.35
virtual humans' race participants' sex

Between Participants Effect 1.95 0.03 0.17

Table 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain pain-related negative mood made by Caucasian and
African American participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian African American 41 14.3 5.34 0.068 0.024
Female 34.4 17.5

African American Caucasian 40 15.4
African American 29.2 16.6
Pain-related negative mood ratings 2.47 0.03 0.12
for virtual humans' race *
participants' race

Between Participants Effect 3.87 0.05 0.053










Table 3-11i. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by male and female participants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Male 34.1 14.6 6.37 0.08 0.014
Female 31.8 13.3

Female Male 36 15
Female 34.2 13.4
Pain-coping ratings for virtual 0.08 0.00 0.78
humans' sex participants' sex

Between Participants Effect 0.35 0.01 0.56

Table 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of pain coping made by Caucasian and African American
parti cipants.
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 32.7 13.8 2.84 0.04 0.096
African American 31.6 13.4

Female Caucasian 35.2 13.5
African American 32.5 15.5
Pain-coping ratings for virtual 0.63 0.01 0.43
humans' sex participants' race

Between Participants Effect 0.21 0.00 0.65

Table 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain coping made by Caucasian and African American
participants
Virtual humans Participants' MSD F (1, 73) rl 2 P
Caucasian Caucasian 34.5 13.3 6.86 0.086 0.011
African American 34.5 15.3

African American Caucasian 33.6 14
African American 28.9 14.5
Pain-coping ratings for virtual 3.7 0.05 0.058
humans' race participants' race

Between Participants Effect 0.34 0.01 0.56










Table 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of pain coping made by male and female participants
Virtual humans Participants' MSD F (1, 73) rl 2 P
Caucasian Male 34.6 14.6 0.79 0.01 0.38
Female 34.4 13.3

African American Male 35.5 15
Female 31.7 13.8
Pain-coping ratings for virtual 3.27 0.04 0.08
humans' race participants' sex

Between Participants Effect 0.35 0.01 0.56

Table 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by male and female
participants
Virtual humans Participants M~ SD F (1, 73) rl 2 P
Male Male 51.9 25.1 5.98 0.076 0.017
Female 40.8 18.6

Female Male 53.8 24.2
Female 44.4 19
Recommending medical help ratings for 0.64 0.01 0.43
sex of virtual human sex of participants

Between Participants Effect 4.02 0.052 0.049

Table 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual
humans on ratings of recommending medical help made by Caucasian and African
American participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Male Caucasian 43.7 21.6 3.63 0.05 0.06
African American 45.8 20

Female Caucasian 47.1 21.7
African American 47.6 17.5
Recommending medical help ratings 0.37 0.01 0.54
for virtual humans' sex *
participants' race

Between Participants Effect 0.04 0.00 0.84










Table 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of recommending medical help made by male and female
participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Male 52.8 24.8 0.11 0.00 0.74
Female 42.9 19.3

African American Male 52.9 24.2
Female 42.1 18.4
Recommending medical help ratings for 0.21 0.00 0.65
virtual humans' race participants' sex

Between Participants Effect 4.06 0.53 0.048

Table 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of
virtual humans on ratings of recommending medical help made by Caucasian and
African American participants
Virtual humans Participants MSD F (1, 73) rl 2 P
Caucasian Caucasian 45.3 21.7 1.44 0.02 0.24
African American 48.1 20.1

African American Caucasian 45.3 21.5
African American 45.3 17.2
Recommending medical help ratings 1.36 0.02 0.25
for virtual humans' race *
participants' race

Between Participants Effect 0.05 0.00 0.85

Table 3-19. Correlations between the dependent variables
Pain Pain Pain-related Pain Recommending
Intensity Unpleasantness negative coping medical help
mood
Pain Intensity 1 0.87 0.72 0.68 0.53
Pain Unpleasantness 0.87 1 0.82 0.75 0.51
Pain-related negative 0.72 0.82 1 0.71 0.42
mood
Pain coping 0.68 0.75 0.71 1 0.35
Recommending medical 0.53 0.51 0.42 0.35 1
help









CHAPTER 4
DISCUSSION

Although pain levels were digitally controlled to be equal among male, female, Caucasian,

and African American virtual humans, these data indicate that participants of both sexes and

races still view females' pain, with both of its components, sensory (intensity) and affective

(unpleasantness), as significantly higher than that for male virtual humans. This is consistent

with other research findings. Robinson et al. (2001) found differences in participants' pain

ratings for observed males and females experiencing experimentally induced pain. They found

that viewers rated female virtual humans as having more pain than observed male virtual

humans. One possible explanation for why female virtual humans were viewed as having higher

pain levels than male virtual humans is the difference in pain expectations, that is, females are

expected to report higher levels of pain than males in general. Although willingness to report

pain, and pain endurance did not correlate significantly with pain ratings in this study, a sizable

literature shows that both males and females expect females to experience higher levels of pain

compared to males (Unrah, 1996, and Robinson et al, 2001). This study also suggests that

differences in expecting females to experience higher levels of pain are also true across races

(Caucasians and African Americans). Although between races rating did not differ, they both

rated female virtual humans to have higher pain levels.

African American participants viewed African American virtual humans' pain intensity as

significantly higher than Caucasian virtual humans' pain intensity. The ratings of African

Americans as having higher pain intensity than Caucasians is consistent with previous studies;

Walsh, Schoenfield, Ramamurthy, & Hoffman (1989) investigated pain tolerance to the cold

pressor test in Anglo-Saxons, Hispanics, and African Americans and found that African

Americans and Hispanics had lower pain tolerance. Sheffield, Biles, Orom, Maixner, & Sheps










(2000) Found that African Americans rated the thermal stimuli as more unpleasant and more

intense than Caucasians. Edwards et al (1999) found that African Americans had a lower thermal

pain tolerance and greater pain severity than Caucasians. Edwards et al (2001) also found that

African Americans report significantly greater pain severity and pain-related disability than

Caucasians. These studies investigated participants' ratings of their own pain conditions. The

current study, however, investigated participants' ratings of others' pain. Since Caucasians did

not rate African Americans' pain as high as African Americans did, results may indicate

differences between race-related cultures in terms of sensitivity to facial pain expressions, that' s

is, African Americans might be more sensitive to African Americans' facial expressions of pain

than Caucasians. Rahim-Williams, Riley III, Herrera, Campbell, Hastie & Fillingim (2007)

studied ethnic identity to determine whether it associates with experimental pain intensity in

three groups including African Americans. They found that African Americans scored the

highest on the ethnic identity measure. Researchers suggested that higher scores on the ethnic

identity measure would mean higher ethnic-specific socio-cultural influence on the pain

experience. Since African Americans scored higher on the ethnic identity measure, and that

means higher influence of their culture on pain experience, it is possible that they have rated

African American virtual humans' pain intensity as higher than that for Caucasian virtual

humans because they (the African American participants) are more sensitive to pain behaviors,

including facial pain expressions, exhibited by individuals of the same race-related culture. In the

Study mentioned above, Non-Hispanic Whites scored the lowest on the ethnic identity measure,

suggesting that it is possible that Caucasians are not as influenced by their racial culture. This

might suggest that Caucasians are less sensitive to pain behaviors, including facial pain

expressions, exhibited by individuals of the same race. However, further investigation of this









finding is needed to further understand and explain the existence and the implications of between

races differences in sensitivity to facial pain expressions.

The International Association for the Study of Pain defines pain in a way that highlights

the importance of understanding of the negative emotional experiences of pain. Part of that

emotional experience is the negative mood that accompanies pain experience. Although all facial

expressions of pain were digitally controlled to be similar for males and females in this study,

female virtual humans' pain-related negative mood was rated significantly higher than that for

male virtual humans' by both male and female participants. These results might be explained by

the positive relationship between pain and negative mood found and is consistent with the

findings of the National Health and Nutrition Examination Survey, where pain and depressive

symptoms tended to be more evident in females than in males (Magni et al, 1990). Turk &

Okifuji (1999) also found that females were viewed as more depressed than males when in pain.

These results also highlight the role of the expectations males have regarding the effects of

females' high levels of pain on their moods. Current data also indicate that Caucasians and

African Americans differ in their ratings of pain-related negative mood. Although Caucasian

participants' ratings of pain-related negative mood for male and female virtual humans were

significantly higher than African Americans' ratings, they even rated females' pain-related

negative mood as significantly higher than males' pain-related negative mood. This highlights

the role that culture might play in perceiving pain effects on the mood of females and males.

Caucasian virtual humans were rated by both African American and Caucasian participants

as having higher pain-related negative mood. However, this is not consistent with the positive

relationship between pain level and negative mood experiences. These results indicate that race

might moderate the relationship between pain and pain-related negative mood.









Consistent with the pain-related negative mood results, male and female participants rated

female virtual humans as coping poorer with their pain, and Caucasian virtual humans were rated

by both Caucasian and African America participants as coping poorer with their pain. These

results mirror the pain-related negative mood ratings. These results suggest that when females

and Caucasians are viewed as having higher levels of pain than males and African Americans,

they are more likely to be viewed as experiencing higher levels of pain-related negative mood

and higher levels of poorer pain-related coping strategies.

When someone's pain level, pain-related negative mood, and pain-maladaptive coping is

rated high, it is expected that he/she is more likely to be recommended to seek medical help for

his/her pain. In this study, female virtual humans were rated higher on all of those variables than

male virtual humans, they also were recommended to seek medical help for their pain

significantly more than male virtual humans. However, it was not expected for male participants'

recommendations to be higher than female participants'. Males recommended female virtual

humans to seek medical help for their pain significantly more than the recommendation made by

female participants. Male participants also recommended Caucasian and African American

virtual humans to seek medical help for their pain significantly more than the recommendations

made by female participants. One possible explanation to why males' recommendations are

higher than females' recommendations is the difference between males and females in pain-

related medication seeking behaviors. Males have been shown to request more drugs than

females after surgery when given access to patient controlled analgesia (Macintyre & Jarvis,

1995. Burns, Hodsman, McLintock, Gillies, Kenny, & McArdle (1989) and Stinshoff, Lang,

Berbaum, Lutgendorf, Logan & Berbaum (2004) also found that males tend to seek more

medications for their pain compared to females.









The ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain

coping, and recommending medical help showed significant intercorrelations. Relationships

between these dependent variables have a pattern that might add to the explanation of some of

the current results. For example, the high correlation between pain intensity, pain unpleasantness,

pain-related negative mood, and pain coping might add to the explanation as to why female

virtual videos were rated high on all of them, if pain rating influenced the other ratings.

The results of this study have exciting implications, however, this study has some

advantages and disadvantages worth noting. One limitation of this study is that only one African

American male participated in it. Efforts to recruit more African Americans through study

announcements to specifically target African American undergraduates were not successful.

The use of computerized virtual humans with digitally controlled facial expressions of pain

based on the FACS, and digitally controlled pain levels across sexes and races of virtual humans,

is innovative. This enables greater control over unifying facial pain expressions and levels of

pain than if we had used human virtual humans. This technique, by the high control it provides

over the ecology, also enables greater confidence in focusing on biases and variance brought to

the ratings by participants.

Furthermore, the virtual human technology used in this study, has the potential to develop

to be an educational assessment and intervention tool. Students, health care providers, and other

individuals can use this technology to assess for their own biases regarding pain expressed by

others and regarding specific variables of interest assigned to the observed virtual humans. This

technology is also accessible from almost everywhere in the world via the Internet. One

advantage of the easy access to this technology is that it makes, for example, cross-cultural

studies much easier to conduct if same stimuli were to be used. Such an example provides wider










scope of races to be easily studied, as well as other cultures. Although the virtual human

technology used in this study focused only on facial pain expressions without sound, future

considerations might add other pain expressions to this technology, such as, verbal pain

expressions, body gestures that are pain related, and adding background environments that

determine context in which the pain is being experienced.

One other advantage of using virtual humans in this study is that it eliminates the biases in

the making of the stimuli. These stimuli are basically made digitally identical except for the

variables at interest in this study. One other advantage to this study is the focus on how others

perceive and rate others' pain and other dependent variables in this study. Most research

investigating pain perception focused on self-reports. Although self-reports of pain experience

are an important component in the quest of understanding the nature of pain, it is also important

to investigate how others perceive and view the experience of pain communicated to them by

other individuals. This contributes significantly to the overall understanding of the nature of pain

including how others appraise and respond to others' experiences of pain.










REFERENCES


Adamson, J., Ben-Shlomo, Y., Chaturvedi, N., & Donovan, J. (2003). Race, socio-economic
position and sex-do they affect reported health-care seeking behaviour? Social Science &
Medicine, 57 (5), 895-904.

Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., Starr, K., &
Caldwell, D. S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis:
Independent effects of disease and sex on daily pain, mood, and coping. Pain, 83, 601-
609.

Ambadar, Z., Schooler, J., & Cohn, J (2005). Deciphering the enigmatic face: the importance of
facial dynamics in interpreting subtle facial expressions. Psychological Science. 16, 403-
410.

Anderson, K., Palos, G., Gning, I., Mendoza, T., Sanchez, M., Valero, V., Richman, S., Nazaria,
A., Hurley, J., Payne, R. & Cleeland, C. (2003). Multi-site randomized trial of pain
management education for minority outpatients with cancer pain. Pain 4, 95.

Bassili, J (1979). Emotion recognition: the role of facial movement and the relative importance
of upper and lower areas of the face. Journal of Personality and Social Psychology. 37,
2049-258.

Bates, M. S. (1996). Biocultural dimensions of chronic pain: implications for treatment of
multiracialpopulations. Albany, NY: State University of New York Press.

Beutler, L.E., Engle, D., Oro'-Beutler, M.E., Daldrup, R. & Meredith, K. (1986). Inability to
express intense affect: a common link between depression and pain? Journal of
Consulting and Clinical Psychology, 54 (6), 752-759.

Bombardier, C.H., D'Amico, C., & Jordan, J. S. (1990). The relationship of appraisal and coping
to chronic illness adjustment. Behavior Research and 7herapy 28, 297-304.

Boothby, J. L., Thorn, B. E., Stroud, M. W., & Jensen, M. P. (1999). Coping with Pain. In
Gatchel, R. G., & Turk, D. C. (Eds.), Psychosocial Factors in Pain. New York: Guilford
Press.

Boyatzis, C., Cazan, E., & Ting, C (1993). Preschool children' s decoding of facial emotions.
Journal of General Psychology. 1 54, 3 75-3 82.

Brodsgaard, M. R. (1999). Cross-cultural investigations of pain. In: Crombie IK, editor.
Epidemiology of pain. Seattle: IASP Press.

Brown, F. F., Robinson, M. E., Riley, J. L. & Gremillion, H. A. (1996). Pain severity, negative
affect, and microstressors as predictors of life interference in TMD patients. CRANIO,
14:63-70.










Buckelew, S. P., Shutty, M. S., Hewitt, J., Landon, T., Morrow, K. & Frank, R. G. (1990).
Health locus of control, sex differences and adjustment to persistent pain. Pain, 42: 287-
295.

Burns, J., Hodsman, N., McLintock, T., Gillies, G., Kenny, G., & McArdle, C. (1989). The
influence of patient characteristics on the requirements for postoperative analgesia.


Campbell, L. (2002). Predispositions Towards Pharmacological Pain Management: A policy
capturing study. University of Florida.

Carey, T. S., Hadler, N. M., Gillings, D., Stinnett, S., & Wallsten, T. (1988). Medical disability
assessment of the back pain patient for the social security administration: The weighting
of presenting clinical features. Journal of Clinical Epidemiology. 41 (7), 69 1-697.

Carmen, R., Green, S., Ndao-Brumblay, K., Nagrant, A. M., Baker, T. A. & Rothman, E. (2004).
Race, age, and sex influences among clusters of african american and white patients with
chronic pain. The Journal ofPain, 5 (3), 171-182.

Caron, R. F., Caron, A. J., & Myers, R. S (1985). Do infants see emotional expression in static
faces? ChildDevelopment. 56, 1552-1560.

Campbell, C. M., Edwards, R. R. & Fillingim, R. B. (2005). Racial differences in responses to
multiple experimental pain stimuli. Pain, 113 (1-2), 20-26.

Cohen F. (1980). Post-surgical pain relief: patient's status and nurse's medication choice. Pain,
9, 265-74.

Cooksey, R. W. (1996). Judgment Analysis: Theory, methods, and applications. San Diego, CA:
Academic Press.

Craig, K., Hyde, S., & Patrick, C (1991). Genuine, suppressed and faked facial behavior during
exacerbation of chronic low back pain. Pain. 46, 161-171.

Craig, K., & Patrick, C (1985). Facial expression during induced pain. Journal ofPersonality
and Social Psychology. 48, 1080-1091.

Dao, T. T. & LeResche, L. (2000). Sex differences in pain. Journal of Orofacial Pain, 14, 169-
84.

de Ridder, D. & Schreurs, K. (2001). Developing interventions for chronically ill patients: is
coping a helpful concept? Clinical Psychology Review, 21, 205-240.

Dennis, C. K. & Akiko O. (1999). Does sex make a difference in the prescription of treatments
and the adaptation to chronic pain by cancer and non-cancer patients? Pain, 82, 139-149.










Edwards, R. R., Doleys, D. M., Fillingim, R. B. & Lowery, D. (2001). Racial differences in pain
tolerance: clinical implications in a chronic pain population. Psychosomatic M~edicine 63:
316-323.

Edwards, R. R. & Fillingim, R. B. (1999). Racial differences in thermal pain responses.
Psychosomatic M~edicine 61 : 346-3 54.

Edwards, C. L., Fillingim, R. B. & Keefe, F. J. (2001). Race, race and pain. Pain, 94, 113-137.

Ekman, P (1993). Facial Expression of Emotion. American Psychologist. 48 (4), 384-392.

Ellermeier, W. & Westphal, W. (1995). Sex differences in pain ratings and pupil reactions to
painful pressure stimuli. Pain, 61 (3), 435-439.

Endler, N. S., Corace, K. M., Summerfeldt, L. J., Johnson, J. M. & Rothbart, P. (2003). Coping
with chronic pain. Personality and'Individ'ual Differences, 34, 323-346.

Feldman, S., Downey, G., & Schaffer-Neitz, R. (1999). Pain, Negative Mood, and Perceived
Support in Chronic Pain Patients: A Daily Diary Study of People With Reflex
Sympathetic Dystrophy Syndrome. Journal of Consulting and' Clinical Psychology, 67
(5), 776-785.

Folkman S, & Moskowitz, J. T. (2000). Positive affect and the other side of coping. American
Psychologist. 55 (6), 647-654.

Frot, M., Feine, J. S. & Bushnell, M. C. (2004). Sex differences in pain perception and anxiety.
A psychophysical study with topical capsaicin. Pain, 108 (3), 230-236.

Gaskin M. E., Greene A. F., Robinson M. E. Geisser & M. E. (1992). Negative affect and the
experience of chronic pain. Journal ofPsychosomatic Research, 36 (8), 707-713.

Geisser, M.E., Robinson, M. E., Keefe, F. J. & Weiner, M. L. (1994). Catastrophizing,
depression and the sensory, affective and evaluative aspects of chronic pain. Pain, 59 (1),
79-83.

Goubert, L., Crombez, G., & Danneels, L. (2004). The reluctance to generalize corrective
experiences in chronic low back pain patients: a questionnaire study of dysfunctional
cognitions. Behaviour Research and' Therapy, 43 (8), 105 5-1067.

Green, C. R, Anderson, K., Baker, T., Campbell, L., Decker, S., Fillingim, R., Kaloukalani, D.,
Lasch, K., Myers, C., Tait, R., Todd, K. & Vallerand, A. (2003). The unequal burden of
pain: Confronting racial and racial disparities in pain. Pain M~edicine, 4, 277-294.

Green, C. R., Baker, T. A., Sato, Y., Washington, T. L. & Smith, E. M. (2003). Race and chronic
Pain: A comparative study of young black and white Americans presenting for
management. Journal ofPain, 4, 176-183.











Green, C. R., Baker, T. A., Smith, E. M. & Sato, Y. (2003). The effect of race in older adults
presenting for chronic pain management: A comparative study of African and Caucasian
Americans. Journal ofPain, 4, 82-90.

Green, C. R., Wheeler, J. R. & LaPorte, F. (2003). Clinical Decision Making in Pain
Management: Contributions of Physician and Patient Characteristics to Variations in
Practice. The Journal of Pain, 4 (1), 29-39.

Greenwald, H. P. (1991). Interracial differences in pain perception. Pain. 44, 157-163.

Hall, J (1978). Gender effects in decoding nonverbal cues. Psychological Bulletin. 85, 845-857.

Hamers, J. P., van den Hout, M., Halfens, R. J., Abu-Saad, H. H., & Heijltjes, A. E. (1997).
Differences in pain assessment and decisions regarding the administration of analgesics
between novices, intermediates and experts in pediatric nursing. International Journal of
Nursing Studies. 34 (5), 325-334.

Harwood, N., Hall, L., & Shinkfield, A (1999). Recognition of facial emotional expressions from
moving and static displays by individuals with mental retardation. American Journal of
Mentally Retarded. 104 (3), 270-278.

Hastie, B. A., Riley, J. L. & Fillingim, R. B. (2004). Racial differences in pain coping: Factor
structure of the coping strategies questionnaire and coping strategies questionnaire-
revised. The Journal ofPain. 5 (6), 304-316.

Hassenbusch, S. J. & Portenoy, R. K. (2000). Current Practices in Intraspinal Therapy: A Survey
of Clinical Trends and Decision Making. Journal of Pain and Synapton; Management, 20
(2), S4-S 11.

Hawthorn, J. & Redmond, K. (1998). Pain : Causes and2anageenten. Maiden, Mass. Blackwell
Science.

Hazelett, S., Powell, C., & Androulakakis, V. (2002). Patients' behavior at the time of injury:
Effect on nurses' perception of pain level and subsequent treatment. Pain Management
Nursing, 3 (1), 28-35.

Holm, K., Cohen, F., Dudas, S., Medema, P. & Allen, B. (1989). Effect of personal pain
experience on pain assessment. Journal of Nursing Scholarship, 21, 72-5.

Holzberg, A. D., Robinson, M. E., Geisser, M. E. & Gremillion, H. A. (1996). The effects of
depression and chronic pain on psychosocial and physical functioning. Clinical Journal
ofPain 12, 118-125.

Jasso, G., & Opp, K. (1997). Probing the Character of Norms: A Factorial Survey Analysis of the
Norms of Political Action. American Sociological Review. 62 (6), 947-964.











Jasso, G. & Webster, M. (1997). Double standards in just earning for male and female workers.
Social Psychology Quarterly, 60 (1), 66-78.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: a
critical review of the literature. Pain. 47, 249-283.

Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994). Relationship of pain-
specific beliefs to chronic pain adjustment. Pain, 57, 301-309.

Jordan, M., Lumley, M., & Leisen, J. (1998). The relationships of cognitive coping and pain
control beliefs to pain and adjustment among African-American and Caucasian women
with rheumatoid arthritis. Arthritis Care and Research. 11, 80-8.

Keefe, F. G., Affleck, G., France, C. R., Emery, C. F., Waters, C., Caldwell, D. S., Stainbrook,
D., Hackshaw, K. V., Fox, L. C. & Wilson, K. (2004). Sex differences in pain, coping,
and mood in individuals having osteoarthritic knee pain: a within-day analysis. Pain, 110
(3), 571-577.

Keefe, F. J., Lefebvre, J. C., Egert, J. R., Affleck, G., Sullivan, M. J., & Caldwell, D. S. (2000).
The relationship of sex to pain, pain behavior, and disability in osteoarthritis patients: the
role of catastrophizing. Pain, 87, 325-334.

Keogh, E., & Herdenfeldt, M. (2002). Sex, coping and the perception of pain, Pain, 97 (3), 195-
201.

Kerns, R. D., Rosenberg, R. & Jacob, M. C. (1994). Anger expression and chronic pain. Journal
ofBehavioral M~edicine, 17 (1), 57-67.

Kirrouac, G & Dore, F (1985). Accuracy of the judgment of facial expressions as a function of
sex and level of education. Journal ofNonverbal Behavior. 9, 3-7.

Klonoff, E.A., Landrine, H. & Brown, M.A. (1993). Appraisal and response to pain may be a
function of its bodily function. Journal of psychosomatic research, 37, 661-670.

Kunz, M., Gruber, A., & Lautenbacher, S (2006). Sex differences in facial encoding of pain. The
Journal of Pain. 7 (12), 915-928.

Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and' Coping. New York: Springer
Publishing Company.

Leahey, E. (2004). The role of status in evaluating research: the case of data editing. Social
Science Research, 33 (3), 521-537.

Macintyre P, Jarvis D. (1995). Age is the best provider of postoperative morphine
requirements. Pain, 64, 357-364.











Maes, S., Leventhal, H., & de Ridder, D. T. (1996). Coping with chronic diseases. In: Zeidner,
M., Endler, N.S. (Eds.), Handbook of Coping. Theory, Research, Applications. Wiley,
New York.

Magni, G., Caldieron, C., Rigatti-Luchini, S. & Merksey, H. (1990). Chronic musculoskeletal
pain and depressive symptoms in the general population: An analysis of the 1 st National
Health and Nutrition Examination Survey data. Pain. 43, 299-307.

Mandal, M & Palchoudhury, S (1985). Perceptual skill in decoding facial affect. Perceptual and
Motor .\d// 60, 96-98.

McDonald, D. & Bridge, R. G. (1991). Sex stereotyping and nursing care. Research in Nursing
and Health. 14, 373-8.

McWilliams, L. A., Cox B. J. & Enns M. W. (2003). Mood and anxiety disorders associated with
chronic pain: an examination in a nationally representative sample. Pain, 106 (1-2), 127-
133.

Mitchell, K., & Owens, R. (2004). Judgments of laypersons and general practitioners on
justifiability and legality of providing assistance to die to a terminally ill patient: a view
from New Zealand. Patient Education and Counseling, 54 (1), 15-20.

Moore, R. & Brodsgaard, I. (1999). Cross-cultural investigations in pain. in Crombie IK (ed):
Epidemiology ofPain. Seattle, WA, IASP Press.

Morrill, C., Snyderman, E., & Dawson, E. J. (1997). It' s not what you do, but who you are:
informal social control, social status, and normative seriousness in organizations.
Sociological Forum, 12, 519-543.

Novy, D. M., Nelson, D. V., Hetzel, R. D, Squitieru, P. & Kennington, M. (1998). Coping with
chronic pain: sources of intrinsic and contextual variability. Journal of Behavioral
Medicine. 21 (1),19-34.

Nowicki, S & Hartigan, M (1988). Accuracy of facial affect recognition as a function of locus of
control orientation and anticipated interpersonal interaction. Journal of Social
Psychology. 128, 363-372.

Portenoy, R. K., Ugarte, C., Fuller, I. & Haas, G. (2004). Population-based survey of pain in the
United States: Differences among white, African American, and Hispanic subjects. The
Journal ofPain. 5 (6), 317-328.

Price, D. D. (1999). Psychological M~echanisms of Pain and Analgesia. Seattle, WA, IASP.

Prkachin, K (1992). The consistency of facial expression of pain: a comparison across
modalities. Pain. 51, 297-306.











Rahim-Williams, B., Riley III, J, L., Herrera, D., Campbell, C, M., Hastie, B, A., & Fillingim, R,
B. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans
and Hispanics. Pain, 129 (1-2), 177-184.

Riley, J. L., Wade, J. B., Myers, C. D., Sheffield, D., Papas, R. K. & Price, D. D. (2002).
Racial/racial differences in the experience of chronic pain. Pain. 100 (3), 291-298.

Riley, J. L., Robinson, M. E., Wade, J. B., Myers, C. D. & Price, D. D. (2001). Sex Differences
in Negative Emotional Responses to Chronic Pain. The Journal ofPain, 2 (6), 3 54-3 59.

Robinson, M. E., Gagnon, C. M., Riley, J. R. & Price, D. D. (2003). Altering sex role
expectations: effects on pain tolerance, pain threshold, and pain ratings. The Journal of
Pain, 4 (5), 284-288.

Robinson M. E. & Riley J. L. (1998). Role of negative emotions in pain, in Gatchel R. J. & Turk
D. C. (eds): Psychosocial Factors in Pain. New York, NY, Guilford Press, pp 74-88.

Robinson, M. E., Riley, J. L., & Myers, C. D. (2000). Psychosocial contributions to sex related
differences in pain responses. In: Fillingim, R. B. Sex, sex, and pain, Progress in pain
research and' management, 17. Seattle, WA: IASP Press, 41-68.

Robinson, M. E., Riley, J. L., Myers, C. D., Papas, R. K., Wise, E. A., Waxenberg, L. B. &
Fillingim, R. B. (2001). Sex role expectations of pain: Relationship to sex differences in
pain. Journal of Pain 2, 251-257.

Robinson, M. E. & Wise, E. A. (2004). Prior pain experience: influence on the observation of
experimental pain in men and women. The Journal ofPain, 5 (5), 264-269.

Robinson, M. E. & Wise, E. A. (2003). Sex bias in the observation of experimental pain. Pain,
104 (1-2), 259-264.

Robinson, M. E., Wise, E. A., Gagnon, C., Fillingim, R. B. & Price, D. D. (2004). Influences of
sex role and anxiety on sex differences in temporal summation of pain. The Journal of
Pain, 5 (2), 77-82.

Romano, J. M., & Turner, J. A. (1985). Chronic pain and depression: does the evidence support a
relationship? Psychological Bulletin, 97 (1), 18-34.

Rotter, N & Rotter, G (1988). Sex differences in encoding and decoding of negative facial
emotion. Journal ofNonverbal Behavior. 12, 139-148.

Sheffield, D., Biles, P. L., Orom, H., Maixne, W. & Sheps, D. S. (2000). Race and sex
differences in cutaneous pain perception. Psychosomatic M~edicine. 62 (4), 517-523.










Slocumb, J. C., Kellner, R., Rosenfeld, R. C. & Pathak, D. (1989). Anxiety and depression in
patients with the abdominal pelvic pain syndrome. General Hospital Psychiatry. 11 (1),
48-53.

Stinshoff, V. J., Lang, E. V., Berbaum, K. S., Lutgendorf, S., Logan, H. & Berbaum, M. (2004).
Effect of sex and gender on drug-seeking behavior during invasive medical procedures
Academic RadiRRR~~~~~RRRRR~~~~ology 11 (4), 390-397.

Sullivan, M. J., Tripp, D. A., & Santor, D. (2000). Sex differences in pain and pain behavior: the
role of catastrophizing. Cognitive 7herapy and'Research, 24, 121-134.

Tait, R. C., & Chibnall, J. T. (1997). Physician judgments of chronic pain patients. Social
Science & M~edicine. 45 (8), 1199-1205.

Tamayo-Sarver, J. H., Dawson, N. V., Cydulka, R. K., Wigton, R. S. & Baker, D. W. (2004).
Variability in Emergency Physician Decisionmaking About Prescribing Opioid
Anal gesics. Annals of Emergency M~edicine, 43 (4), 483-493.

Tayler, J & Johnsen, B (2000). Sex differences in judgment of facial affect: a multivariate
analysis of recognition errors. Scand'inavian Journal ofPsychology. 41, 243-246.

Turk, D. C. & Melzack, R. (2001). Handbook ofPain Assessment. New York: Guilford Press.

Unruh, A. M. (1996). Sex variations in clinical pain experience. Pain, 65 (2-3), 123-67.

Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does sex affect appraisal of pain and pain
coping strategies? ClinicalJournal ofPain, 15, 31-40.

Vallerand, A. H. & Polomano, R. C. (2000). The relationship of sex to pain. Pain Management
Nursing, 1 (3), 8-15.

Wade, J. B., Dougherty, L. M., Archer, C. R., & Price, D. D. (1996). Assessing the stages of pain
processing: A multivariate analytical approach. Pain. 68, 157-167.

Wade, J. B., Dougherty, L. M., Hart, R. P., Rafli, A. & Price, D. D. (1992). A canonical
correlation analysis of the influence of neuroticism and extraversion on chronic pain,
suffering, and pain behavior. Pain. 51, 67-73.

Wagner, H., McDonald, C., & Manstead, A (2986). Communication of individual emotions by
spontaneous facial expression. Journal ofPersonality and Social Psychology. 50, 737-
743.

Walsh N, Schoenfield L, Ramamurthy S, & Hoffman J. (1989). Normative model for cold
pressor test. American Journal ofPhysical M~edicine and Rehabilitation, 68, 6-11.










Wehrle, T., Kaiser, S., Schmidt, S., & Scherer, K (2000). Studying the dynamics of emotional
expression using synthesized facial muscle movements. Journal ofPersonality and'
Social Psychology. 78 (1), 105-119.

Weickgenant, A. L., Slater, M.A., Patterson, T. L., Atkinson, J. H., Grant, I. & Garfin, S. R.
(1993). Coping activities in chronic low back pain: relationship with depression. Pain,
53, 95-103.

Weir, R., Browne, G., Tunks, E., Gafni, A., & Roberts, J. (1996). Sex differences in psychosocial
adjustment to chronic pain and expenditures for health care services used. Clinical
Journal of Pain, 12, 277-290.

Weisse, C. S., Sorum, P. C., & Dominguez, R. E. (2003). The influence of sex and race on
physicians' pain management decisions. The Journal ofPain, 4 (9), 505-510.

Woodworth, R. S. (1939). Experimental Psychology. New York: Holt.

Woodworth, R. S., & Schlosberg, H. (1954). Experimental Psychology. New York: Holt.

Zatzick, D. F. & Dimsdale, J. E. (1990). Cultural variations in response to painful stimuli.
Psychosomatic M~edicine. 52, 544-557









BIOGRAPHICAL SKETCH

Ashraf Faris Alqudah was born on November 11, 1975 in Ajloun, Jordan. He grew up in

Ajloun until he graduated from Aj ouln High School in 1993. He moved to Amman, the capital

city of Jordan, to study at the University of Jordan (JU). He earned his B. A. and M. A. in

Psychology in 1997 and 2000, respectively. He worked as a teaching assistant for 1 year at JU

upon receiving a scholarship to pursue his Ph. D. degree in Clinical Psychology.

Upon finishing the teaching assistant year at JU, he was admitted to the Graduate School at

the University of Florida (UF) to work on his Ph. D. in Clinical Psychology at the UF Health

Science Center, College of Public Health and Health Professions, Department of Clinical and

Health Psychology. Upon completion of his Ph. D. program, Ashraf will j oin the faculty of the

Department of Psychology at JU. He has a 4-year-old daughter whose name is Sarah.





PAGE 1

SEX AND RACE DIFFERENCES IN RA TING OTHERS PAIN, PAIN-RELATED NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP By ASHRAF FARIS ALQUDAH A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007 1

PAGE 2

2007 Ashraf Faris Alqudah 2

PAGE 3

To my parents who provided me with endle ss love. To my brothers Abdulghafour and Mohammad who planted gardens in the deserted land of my dreams. To my daughter Sarah who is the candle of my life a nd the meaning of my smile. 3

PAGE 4

ACKNOWLEDGMENTS I thank my supervisory committee chair (Mic hael E. Robinson) and committee members for their mentoring. I thank my department for its genuine and c ontinuous guidance and generosity. I thank the members of the Center for Pain Research and Behavioral Health for their help and support. 4

PAGE 5

TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT.....................................................................................................................................9 CHAPTER 1. INTRODUCTION................................................................................................................ ..11 Sex Differences in Pain Perception and Rating......................................................................11 Sex Differences in Pain-Related Negative Mood...................................................................13 Sex Differences in Coping with Pain......................................................................................17 Racial Differences in Coping with Pain.................................................................................20 Racial Differences in Pain-Related Negative Mood...............................................................22 Facial Expression of Emotions...............................................................................................23 Sex differences in recognition of facial expressions and facial pain expressions..................25 Vignettes Research.................................................................................................................26 Study Rationale.......................................................................................................................28 Study Aims.............................................................................................................................29 Hypotheses..............................................................................................................................29 2. METHODS..................................................................................................................... ........31 Participants.............................................................................................................................31 Recruitment.................................................................................................................... .31 Inclusion/Exclusion Criteria............................................................................................31 Procedure................................................................................................................................31 Analysis....................................................................................................................... ...........33 3. RESULTS..................................................................................................................... ..........35 Analysis of Pain Intensity Ratings..........................................................................................35 Sex Effects.......................................................................................................................35 Race Effects.....................................................................................................................36 Analysis of Pain Unpleasantness Ratings...............................................................................36 Sex Effects.......................................................................................................................36 Race Effects.....................................................................................................................36 Analysis of Pain-Related Negative Mood Ratings.................................................................36 Sex Effects.......................................................................................................................36 Race Effects.....................................................................................................................37 Analysis of Pain-Coping Ratings............................................................................................37 Sex Effects.......................................................................................................................37 Race Effects.....................................................................................................................37 5

PAGE 6

6 Analysis of Recommending Medical Help Ratings................................................................38 Sex effects.......................................................................................................................38 Race effects.....................................................................................................................38 4. DISCUSSION.................................................................................................................. .......47 References......................................................................................................................................53 BIOGRAPHICAL SKETCH.........................................................................................................62

PAGE 7

LIST OF TABLES Table page 3-1. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain intensity ma de by male and female participants.....................40 3-2. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants.........................................................................................................................40 3-3. Descriptive statistics and mixed model ANO VA results of the effect of race of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants.........................................................................................................................40 3-4. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by male and female participants...........41 3-5. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by Caucasian and African American participants.........................................................................................................................41 3-6. Descriptive statistics and mixed model ANOVA results the effect of race of virtual humans on ratings of pain unpleasantness made by male, female, Caucasian, and African American participants...........................................................................................42 3-7. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain-related negative mood made by male and female participants.........................................................................................................................42 3-8. Descriptive statistics and mixed model ANO VA results of the effect of sex of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants...........................................................................................43 3-9. Descriptive statistics and mixed model ANO VA results of the effect of race of virtual humans on ratings of pain pain-related negative mood made by male and female participants.........................................................................................................................43 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants...........................................................................................43 3-11. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by male and female participants........................44 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by Caucasian and African American participants.........................................................................................................................44 7

PAGE 8

8 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by Caucasian and African American participants................................................................................................................... ......44 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by male and female participants........................45 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medi cal help made by male and female participants................................................................................................................... ......45 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medical help made by Caucasian and African American participants........................................................................................................45 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medi cal help made by male and female participants................................................................................................................... ......46 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medical help made by Caucasian and African American participants........................................................................................................46 3-19. Correlations between the dependent variables.....................................................................46

PAGE 9

Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy SEX AND RACE DIFFERENCES IN RA TING OTHERS PAIN, PAIN-RELATED NEGATIVE MOOD, PAIN COPING, AND RECOMMENDING MEDICAL HELP By Ashraf Faris Alqudah August 2007 Chair: Michael E. Robinson Major: Psychology Sex and race influence pain ratings. We studied these influences in ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help. Seventy-five undergraduates view ed virtual human virtual humans expressing pain, and provided computerized ratings via VAS s. A series of Mixe d ANOVAs was performed. Male and female participants rated female virtual humans higher than male virtual humans on pain intensity, ( p < 0.05), pain unpleasantness, ( p < 0.01), pain-related negative mood, ( p < 0.05), poor pain coping, ( p < 0.05), and recommending medical help, (p < 0.05). Male and female virtual humans need for medical help was rated higher by male participants compared to female participants, ( p < 0.05). Males also rated African American and Caucasian virtual humans need for medical help higher than females ratings, ( p < 0.05). African Americans and Caucasians rated female virtual humans higher on pain intensity, ( p < 0.05) and pain unpleasantness, ( p < 0.05). Caucasians and African Americans viewed Caucasian virtual humans pain-related negative mood as higher than African Americans, ( p < 0.05). Caucasians ratings of male and female virtual humans pain -related negative mood were higher than African Americans ratings, ( p < 0.05). Caucasians rated females pain-related negative mood higher 9

PAGE 10

10 than males, ( p < 0.05). Caucasians and African Americans ratings for poor coping were higher for Caucasian virtual humans compared to African American virtual humans, ( p < 0.05). African Americans ratings for African American virtua l humans pain intensity were higher than for Caucasian virtual humans. In summary, both sexe s and races had higher ratings for females pain. Both races rated female virtual huma ns higher on each variable. Both races rated Caucasians as having more negative mood and poorer coping than African Americans. Females higher negative mood and poorer coping might be explained the relationship between pain, mood, and coping. Results show that races may diffe r in sensitivity to pain expressions. Males tendency to seek more pain medications may expl ain their high levels of recommending virtual humans to seek medical help. Technology used in this study (virtual humans) is discussed along with its possible future use and applicability.

PAGE 11

CHAPTER 1 INTRODUCTION Pain is an individual subj ective experience that is known to have psychological components. Almost a fifth of American adults experience chronic pain (a total of 50 million). Persistent pain is experienced by 17% of patie nts in the United States seen by primary care physicians. And people who seek treatment for chr onic pain each year are estimated to be about 4.9 million. Significant pain accompanies the majo rity of more than 23 million surgical procedures that are performed each year in the United States. Direct and indirect costs for the treatment of pain and the pain-r elated losses are estimated to be more than $125 billion per year (Turk & Melzack, 2001). Sex Differences in Pain Perception and Rating Empirical investigations suppor t the presence of sex differe nces in pain (Robinson, Riley, Myers, Papas, Wise, Waxenberg, & Fillingim, 2001; Frot, Feine, & Bushnell, 2004; Robinson & Wise, 2003; Ellermeier & Westphal, 1995; Vallerand & Polomano, 2000; Hawthorn & Redmond, 1998; Unruh, 1996; Dao & LeResche, 2000; Robinson & Wise, 2004). However, the degree to which sex influences pain perception is not completely clear. Although a number of studies have shown that females perceive and express higher levels of pain than males, other studies have found no differences between the sexes (Hawthorn & Redmond 1998). A number of researches have shown that females are more lik ely to experience pain in a range of medical conditions compared to males. For example, females report more frequent tension and migraine headaches than males (Unruh, 1996), and have highe r prevalence rates for or ofacial (Dao et al, 2000) and musculoskeletal pain (Unruh, 1996). Sex-re lated differences in pain perception have also been found in experimental pa in settings (Frot et al. 2004). 11

PAGE 12

The presence of sex differences in the appraisa l of pain might arise for two reasons. First, males and females have differences in their pa in experience over the lifespan, suggesting the presence of meaning constructs of pain and rela ted coping styles. Second, sex-based social role expectations are different for males and female s. Subsequently, the in terference of the pain experience differs with the roles and responsib ilities for females and males. Pain-related emotional and affective responses might also be affected by differences in social role expectations (Unruh, 1996). It is relatively well established that differe nces do exist between the sexes. However, the underlying mechanisms are not clear yet. It has been suggested that sex differences in pain perception are driven by both biological and socially learned f actors, and also by the possible interaction between them. Different expectati ons were found between males and females in terms of the typical males and females pain responding. Males are viewed as less willing to report their pain and more able to endure it. A ma nipulation of sexrelate d pain expectancy in experimental setting eliminated the sex differen ces in cold pressor pain (Robinson et al., 2004). Males and females endorse different predisposi tions to willingness to report their pain significantly (Robinson et al. 2001). That is, males are less willing to report pain. Robinson, Riley, & Myers (2000) have argued that th e differences reported in many laboratory investigations could largely be explained by th e sex-related expectati ons of pain. Robinson, Gagnon, Riley, & Price (2003) attempted to explicit ly manipulate the sex role stereotypes for males and females to further determine the effect s of these stereotypes a nd related expectations on different psychophysical respons es to experimental pain. On e of their hypotheses was that manipulating the expected performance for males and females would influence their subsequent pain report and reduce or eliminate the documen ted sex differences in pain. They hypothesized 12

PAGE 13

that in standard instructional sets, pain report would differ between males and females. And these differences would decrease when females and male s were given similar sex role expectations for pain tolerance. Their work was the first to show that sex differences in pain report decrease when sex role is experimentally manipulated. Results also supported the notion th at assessments of sex differences in pain responding, in laboratory settings, are influenced by sex rolerelated expectations of pain. That is, pain tolerance can be manipulat ed by altering sex rolebased expectations for pain. There are few studies examining how indi viduals view others in pain, either experimentally or clinically. R obinson et al. (2001) have f ound that males and females differ significantly in their pain expectations for se lf and others. Investig ators examined how both sexes observe experimentally induced pain in male and female participants. They found that, regarding virtual humans sex, view ers rated male virtual humans as having less pain than female virtual humans. Regarding sex of the observer, however, female viewers rated observed pain intensity significantly higher than did male viewers. In a more recent study, Robinson & Wise (2004) found that participants rated female subject s as experiencing greater pain intensity when undergoing a cold pressor task compared to male s. Parental observation, sociocultural norms, acuity in observing overt behavi ors, and beliefs regarding roles were suggested by the investigators to play a part in the explan ation of how one perceives another in pain. Sex Differences in Pain-Related Negative Mood The current definition of pain by the Internati onal Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or po tential tissue damage, or described in terms of such damage. reflects the subjective, multidimensional nature of pain. A better understanding of the experience of c linical pain highlights the importance of 13

PAGE 14

understanding the negative emotional experience s that accompany and contribute to the overall pain experience (Robinson & Riley, 1998). Previous research shows that pain is a ssociated with negative mood (Gaskin, Green, Robinson, & Geisser, 1992). Chronic pain patien ts show high psychological distress, including depressed mood, anxiety, and anger (Feldm an, Downey, & Schaffer-Neitz, 1999). Wade, Dougherty, Hart, Rafii, & Price (1992); Wade, Dougherty, Archer, & Price (1996); and Price (1999) proposed a sequential stage model of pain processing. The Pe rceived intensity of the pain sensation was suggested to be the first stag e. The second stage is the immediate pain unpleasantness, which reflects an individuals immediate affective re sponse to the pain sensation and to the context of its occu rrence. The immediate pain unp leasantness dimension involves limited cognitive processing and is often linked to the physical sensation of pain. The third stage involves long-term reflective or cognitive processing related to the meanings and implications of pain on the individuals life (P rice, 1999). Therefore, negative emotions such as depression, anxiety, and anger, are thought to be characteristics of this third stage. The fourth and final stage of the model is the apparent be havioral expression of pain. Gaskin et al (1992) analyzed th e ability of anxiety, anger, and depression to predict selfreport of clinical pain as indicated by the Mc Gill Pain Questionnaire (MPQ). Researchers found support for the hypothesis that chronic pain has a predisposing factor in the development of negative mood. Feldman et al. (1999) investigated the re lationship between daily pain, negative mood, and social support in 109 pa rticipants with reflex sympathetic dystrophy syndrome and found that pain led to increased depressed, anxiety, and anger. Slocumb, Kellner, Rosenfeld and Pathak (1989) matched gynecologic patients with the abdominal pelvic pain syndrome with other gynecologic patients. They administered to both groups self-rating scales of anxiety, depression, 14

PAGE 15

and anger-hostility, and found that pain patients rated themselves significantly more anxious, depressed, and hostile. Another study investigated the associat ions between a chronic pain condition and common mood and anxiet y disorders in a sample repres entative of the general US civilian population utilizing the National Como rbidity Survey. Researchers found significant positive associations between chronic pain and individual 12-month mood and anxiety disorders (McWilliams, Cox, & Enns, 2003). Individuals experiencing chronic pain have higher incidences of depression, lower levels of physical functioning, and a poorer response to tr eatment (Geisser, Robinson, Keefe, & Weiner, 1994). Depression is a significant issue among pain patients. Prevalence rates for depression of 30% to 60% in clinic-based chronic pain samp les highlight the significance of depression among pain patients (Robinson & Riley, 1998). Romano & Turner (1985) reviewed the literature on the relationship between pain and depression and conc luded that research support can be found for almost all hypotheses about the nature of the relationship between the two constructs: depression leads to pain by increasing pain se nsitivity and decreasing pain threshold; pain becomes a virtual equivalent of depression among patients with certain dispositions; pain serves as a stressor that leads to subsequent depr ession; and that pain and depression occur simultaneously, but are related only due to coincidentally similar psychol ogical and/or biological mechanisms. This highlights the importance of further investigat ion of the relationship between pain and depression, and to include factors that are expected to have variant contributions to that relationship such as the persons sex, how well th e person is coping with his/her pain, the level of pain the person is reporting, and sex differences in perceiving the persons mood, coping, pain level, and his/her expected sex role. 15

PAGE 16

Several studies indicate that patients with a variety of chronic pain conditions report anxiety levels signifi cantly greater than published norms and that a significant amount of the variance in pain report can be explained by a nxiety (Gaskin, Greene, Robinson, & Geisser, 1992; Brown, Robinson, Riley, & Gremillion, 1996; Holzberg, Robinson, Geisser, & Gremillion, 1996). Gaskin et al. (1992) used regression methodology to ascertain relationships between clinical pain measured by th e McGill Pain Questionnaire and measures of depression, anxiety, and anger and found that 33% of the McGill affective dimension of pain was associated with state anger and state anxiety, and 19% of the McG ill sensory dimension was associated with state anxiety. Anger is considered as an affective state that may be related to pain and styles of inhibiting anger have been found to be the st rongest predicto r of pain intensity (Kerns, Rosenberg, & Jacob, 1994). The development of de pression in general has been linked to the suppression of anger in general, as well as spec ifically among pain patients (Beutler, Engle, Oro-Beutler, Daldrup, & Meredith, 1986). Sex-specific relationships between pain and ne gative affect have been evidenced in both community and clinical samples (Riley, Robins on, Wade, Myers, & Price, 2001). In the National Health and Nutrition Examination Survey, pain and depressive symptoms tended to be more evident in females than in males (Magni, Caldie ron, Rigatti-Luchini, & Me rksey, 1990). In pain clinic patient samples, prevalence of depres sion and anxiety is typically higher for females (Unruh, 1996), although at least one study reported more depre ssion and anxiety in males (Buckelew, Shutty, Hewitt, Landon, Morrow, & Fra nk, 1990). In within-day assessments of pain, pain coping, and mood in males and females having Osteoarthritis, a study aimed to analyze sex differences in dynamic relations between pain, mood, and pain coping. Participants rated their pain, pain coping, and mood two times each day fo r 30 days using a booklet format. One finding 16

PAGE 17

was that males were more likely than females to experience an increase in negative mood and a decrease in positive mood in the morning after an evening of increased pain (Keefe, Affleck, Emery, Waters, Caldwell, Stainbrook, Hacksh aw, Fox, & Wilson, 2004). Riley et al. (2001) proposed a sequential model of pain processi ng with pain intensity as stage 1, pain unpleasantness as stage 2, pain-relat ed emotions (depression, anxiet y, frustration, anger, fear) as stage 3, and overt behavioral expr ession of pain as stage 4. Inves tigators tested hypotheses about relationships between sex and the fi rst 3 stages of pain processing in both sexes participants with chronic pain and one of the findings was that pain-related emotions were more strongly related to pain for males. Anxiety was one of the emotions most highly related to pain. Recent research results highlight sex differences in the experience of pain and the importance of assessing painrelated negative mood and sex differences. Sex Differences in Coping with Pain Lazarus & Folkman (1984) define coping as co nstantly changing cognitive and behavioral efforts to manage specific exte rnal and/or internal demands th at are appraised as taxing or exceeding the resources of the person. They also identified the persons health status and energy as one of the most pervasive copi ng resources in that they are re levant to coping in many, if not all, stressful encounters. They suggest that a person who is weak, ill, tired or otherwise debilitated has less energy to apply to coping than a heal thy person and that it is easier to cope when one is feeling well than when one is not. This notion implies that people who are in pain will cope differently than people who are not a nd that pain would only be considered as a stressor when, and if, a person believes or appr aises the pain as taxing or exceeding his/her recourses and abilities to mana ge it. Coping is a construct th at many of the variables that influence pain and disability fall under, and many models of pain and illness give coping 17

PAGE 18

responses an important, if not cen tral, role in understanding and predicting adjustment to pain and illness (Boothby, Thorn, Stroud, & Jensen, 1999). Given that individuals develop their own strategies for coping with painful experiences, and since males and females differ in the experien ce of pain, it is likely that males and females will develop different coping styles (Jensen, Tu rner, Romano, & Lawler, 1994; Weir, Browne, Tunks, Gafni, & Roberts, 1996; Robinson et al 2000). Unfortunately, little research has investigated whether sex moderates or mediates the effectiveness of pain coping strategies (Sullivan, Tripp, & Santor, 2000; Keefe, Lefebvre, Egert, Affleck, Sullivan, & Caldwell, 2000). Unruh, Ritchie, & Merskey (1999), for example, presented results from a community based telephone survey of people who repor ted pain in the two weeks befo re the interview. Researchers found that females reported significantly more inte nse pain, as well as used a greater range of coping strategies, i.e. greater social support seeking, problem-solving, positive self-statements and palliative behaviors compared to males. Another study aimed to determine whether se x differences would be found in the effect that sensory-focused and emotion-focused copi ng instructions have on cold pressor pain experiences. In this study, participants consis ted of healthy adults, all of whom reported no current pain. Compared to females, males showed less negative pain responses when focusing on the sensory component of the pa in experience, and compared to sensory focusing, emotional focusing was found to increase the affective pain experience of females (Keogh & Herdenfeldt, 2002). Keefe et al. (2004) found that females used more problem focused coping than males, and females who catastrophized were less likely than males to repo rt negative mood. They also found that males were more likely than females to use emotion-focused coping when their mood was more negative. 18

PAGE 19

Affleck, Tennen, Keefe, Lefebvre, Kashikar-Z uck, Wright, Starr, & Caldwell (1999) found that females reported more problem solving, social support, positive self-statements, and palliative behaviors than male s. When the effects of disease and sex on daily pain, mood, and coping were compared in 71 patients with Oste oarthritis and 76 patients with rheumatoid arthritis, females had daily pain levels of 72% hi gher than the daily pain levels of males. Females used more problem-focused and emotion-focused st rategies every day than males. This suggests the female participants endorsed mo re coping strategies than males. The perceived seriousness of the pain expe rience may increase by the anticipated and actual interference of pain on one's perceive d responsibilities. Multiple primary role responsibilities of females such as childcare or care for elderly parents, household management, and paid employment may contribute to the appraisa l of pain as threaten ing. They may attend to pain earlier in an effort to minimize its' intrus iveness. Females may also be more worried and irritated about pain. Role interference and perc eived effectiveness or in effectiveness of coping strategies may contribute to the emotional response to pain. No rmal biological processes that result in troublesome pain experiences, recurren t pains with little or no pathological significance, and pain experiences that are symptomatic of pathological, increase the complexity of females pain experience and may lead to some frustrati on with self-management and assessment of pain. Risks of depression and disability associated with pain may be in creased due to i rritability and worry. Paid work remains the dominant occupatio nal role for males although their involvement in childcare and household responsib ilities is slowly increasing. Risk of work disability may be partially reduced by the greater opport unity to recover from pain if responsibilities for childcare, household management and relationships are co nsidered secondary a nd possibly assumed by a partner. For males, unless the pa in experience is interfering with work, they may perceive that 19

PAGE 20

experience as having limited importance. While fe males may be more irri tated and worried about pain, males may be more embarrassed by pain. Embarrassment may cause males to minimize pain unless pain increases in severity or interf eres with work. Social and cultural norms that accept insensitivity to pain and pain endurance as measures of virility may minimize the pain expression or reporting (Unruh, 1996). Klonoff, Landrine, & Br own (1993) found that male undergraduate students were significantly more likely than females to rate their emotional response to common pain problems as embarrassme nt regardless of the location of the pain. Participants of both sexes identifi ed the greatest threats to be th e overall interference of pain and the emotional distress when asked about th eir appraisal of pain (Unruh et al., 1999). Racial Differences in Coping with Pain The literature concerning chronic pain has shown that active coping, such as problemfocused coping, tends to be associated with be tter physical and psychol ogical functioning. And passive coping, such as emotion-focused coping, tends to be associated with poorer physical and psychological functioning (Jensen, Turner, Romano, & Karoly, 1991; Boothby et al., 1999). Furthermore, patients who used problem-focused coping were better in adapting to chronic disease than those who used emotion-focused st rategies (Bombardier, DAmico, & Jordan, 1990; Maes, Leventhal, & de Ridder, 1996). Little is known about racial differences in copi ng with pain as well as racial differences in perceiving others coping strategi es when experiencing pain. It is possible that different coping styles used by African Americans and Caucasians may impact the pain experience. For example, in a study of pain coping among patients with rh eumatoid arthritis, r acial differences were present in the use of pain copi ng strategies although no racial di fferences in pain were noted. African Americans with rh eumatoid arthritis reported signifi cantly higher use of distraction and 20

PAGE 21

praying/hoping as coping strategi es, whereas, Caucasians reported greater use of ignoring pain and coping statements (Jordan, Lumley, & Leisen, 1998). Many researchers concluded that race is an important predic tor of pain-related symptomatology and pain coping (Edwards & Fillingim, 1999; Greenwald, 1991; Novy, Nelson, Hetzel, Squitieru, & Kennington, 1998; Sheffield, Biles, Orom, Maixne, & Sheps, 2000; Zatzick & Dimsdale, 1990). Others such as Edwards, Doleys, Fillingim, & Lowery (2001) highlighted that future investigations may benefit from assessment of coping strategies as a potential mediator or moderator of relationships between race and pain responses. Previous research has suggested that coping, social lear ning, and attitudes might play an important role that is yet unstudied in racial differences in health cond itions, particularly pain (Folkman & Moskowitz, 2000; Moore & Brodsgaard I, 1999). Jordan et al (1998) compared racial groups on pain coping strategies and control be liefs and the relationships of thes e variables to health status among women with rheumatoid arthritis. They found that R acial groups did not diffe r in pain severity or negative affect, but African-Americans used more coping techniques involving diverting attention and praying/hoping. And that Caucas ians used more coping techniques involving ignoring pain. The relationships of praying/hoping and reinterpreting pain to RA adjustment differed by racial group. Whereas, ignoring pain, coping statements, and stronger control beliefs predicted better health status, di verting attention predicted more pain for all patients. These findings suggest that there are racial differences in the use of coping strategies that should be acknowledged when helping pati ents cope with their pain. Campbell, Edwards, & Fillingim (2005), Examin ed racial differences in responses to multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain and found that African Americans reported greater use of passive pain coping strategies. 21

PAGE 22

Racial differences in pain related coping we re also found between African Americans and Whites on every Coping Strategies Questionnaire-Revised scale dimensions after including sex and age as covariates in the mode l (Hastie, Riley, & Fillingim, 2004). Pain coping strategies generall y vary widely between cultures. Cultural differences in pain coping strategies might be as important as the di fferences in the prevalen ce pain or its reported severity (Brodsgaard, 1999). Racial differences in pain coping w ithin clinical samples might not be the result of a long chronic pain experience, but might be present ev en in the absence of chronic pain. So, racial differences in pain c oping might indicate an exacerbation of stress management styles that are inherited, such as pain Coping is not individuali stic but is folded in the influences of the persons ethno-cultural envi ronment and sub-cultural context (Hastie et al., 2004). Racial Differences in Pa in-Related Negative Mood Race may have a major influence on the emotional and behavioral responses to pain and pain appraisal (Edwards, Fillingim & Keefe, 2001). Socio-cultural factor s related to racial background may influence the meaning of the pain experience (Bates, 1996) Consequently, pain appraisals can have a major influence on pain-related emotional responses such as depression and anxiety, as well as behavioral responses such as the decision to seek treatment, adherence to treatment regimens (Edwards et al., 2001). Associations have also been reported between depression and emotion-focused coping strategies in chronic pain (Weickgenant, Slat er, Patterson, Atkinson, Grant, & Garfin, 1993; de Ridder, & Schreurs, 2001; Endler, Corace, Summ erfeldt, Johnson, & Rothbart, 2003). Studies on patients coming to pain centers for initial a ssessment found that highe r pain intensity and depression were associated with being African American, younger, and having a pain duration of more than 30 months (Anderson, Palos, Gni ng, Mendoza, Sanchez, Valero, Richman, Nazaria, 22

PAGE 23

Hurley, Payne, & Cleeland, 2003; Green, Anderson, Baker, Campbell, Decker, Fillingim, Kaloukalani, Lasch, Myers, Tait, Todd, & Valle rand, 2003; Green, Baker, Sato, Washington, & Smith, 2003; and Green, Baker, Sato, Washingt on, & Smith, 2003). One study aimed to explore relationships between chronic pain and race. The researchers asked the participants to rate the degree to which their chronic pain interferes with th eir lives, and found that African Americans had significantly higher rating th an Caucasians on irritability, disturbed sleep, inability to participate in pleasurable activit ies, and loss of appetite due to their pain condition (Portenoy, Ugarte, Fuller, & Haas, 2004). Research on pain re lated mood has shown that African Americans with chronic pain had higher pain severity, depr ession, and disability when compared to whites with chronic pain (Carmen, Green, Ndao-Brumblay, Nagrant, Baker, & Rothman, 2004). Riley, Wade, Myers, Sheffield, Papas, & Price (2002) found that African Americans experience greater emotional suffering compared to white participants on similar levels of pain intensity. The researchers identified depression, anxiet y, frustration, anger, and fear as the components of the emotional factor in their st udy. Researchers used VASs to assess for the components of the emotional factor. In a retros pective analysis of persons younger than 50 years of age presenting for chronic pain management in a multidisciplinary pain center, Green et al. (2003) found that African American participants were more de pressed, anxious, and irritable compared to white participants. Facial Expression of Emotions Charles Darwin was one of the first who talked about facial expressi ons of emotion. In his 1872 book, Expression of the Emotions in Man a nd Animals, he suggested that humans expressive movements are remnants of earlier ones Taking the expression of grief in adult as an example, it is a toned down version of cryi ng in the infants (Woodwor th, 1938). The wide-open mouth of crying involves muscles of the corner of the mouth, and the slight movement of these 23

PAGE 24

stays as a sign of grief after vocal crying has decreased as a response. Darwin described the facial expression of disgust as a combination of closing off the nose to keep out unpleasant odor and opening the mouth as if to spit out the contents (Woodworth & Schlosberg, 1954). Having people judge facial expr essions of emotions from photographs was introduced by Darwin. Because the muscles and skin of the face are very mobile, the face was a logical choice. In addition, the face is visible to others and is an important sour ce of information in both verbal and nonverbal social communications (Woodworth & Schlosberg, 1954). Piderit also talked about the facial expression s of emotions in the 19th century. He argued that mental images of objects should produce th e same facial response as when the object was actually viewed. Therefore, when unpleasant thoughts exis t, the mouth moves as if to avoid a bitter taste, the eye region as if to avoid an unpleasant sight, the nose as to react to an unpleasant odor. Piderit mentioned also the open mouth of attention and th e appraising mouth, with lips protruding. Piderit illustrated hi s arguments with simple line dr awings. Boring and Titchener in the 1920s used his drawings in studying judgmen ts of emotional expressions by participants (Woodworth & Schlosberg, 1954). One way facial expressions were viewed is that it represents a psychobiological phenomenon influenced by the humans evolutionary heritage along with current circumstances. This helped developing an evolutionary pers pective on emotions. A perspective that would suggest that emotion-specific changes in aut onomic physiology have evolved to help that adaptation processes that are presented as em otions, such as anger and fear. Ekman (1992) proposed that each emotion state (emotion family) c onstitutes a family of affective states that share commonalities in the way they are ex pressed. These commonalities between emotion families are characteristic of that specific family and distinguishes it from other emotion 24

PAGE 25

families. Research on facial expressions yielded the possibility of separate discrete emotional states such as fear and anger. Contraction of specific facial mu scles provides the information as to whether the expression repres ents anger, fear, sadness, disgust, enjoyment, or surprise (Ekman, 1993). Some research has argued that the dynamic f acial expressions are necessary for complete emotional information extraction derived fr om faces (Caron, Caron, & Myers, 1985). The dynamics of expression is a factor that facilitates recognition of expressions. Researchers used different stimuli such as computer generated sc hematic movies (Wehrle, Kaiser, Schmidt, & Scherer, 2000), Natural movies (Harwood, Hall, & Shinkfield, 1999), subtle displays of emotion (Ambadar, Schooler, & Cohn, 2005), a nd point-light displays (Ba ssili, J, 1979) argued for the importance of dynamics in the perception of facial expressions of emotions. Sex differences in recognition of facial ex pressions and facial pain expressions Males and females show differences in percep tion of facial expressions. The majority of the literature shows that female s are better in identifying different affects expressed through face (Hall, 1978., Kirrouac & Dore, 1985., Nowicki & Hartigan, 1988., and Tylor & Johnsen, 2000). However, some research suggest that sex differences depend on the type of facial expression being observed. Nowicki et al. 1988 found that females are better in recognizing expressions such as fear and sadness. Whereas, Wa gner, McDonald, Mans tead, 2986., Mandal & Palchoudhury, 1985., and Rotter & Rotter, 1988, found that males are bette r in identifying displays of anger. The sex differences in recogniz ing facial expressions seem to hold true even at an early age. Boyatzis, Cazan, & Ting, 1993, found that 3.5 year-old girls accuracy in recognizing facial expression matc hed 5-year-old boys accuracy. 25

PAGE 26

The most prominent nonverbal pain behavior has been considered to be the facial expressions of pain (Craig & Patrick, 1985). In ge neral, sex differences in facial expressions have hardly been studied. And sex was rarely in cluded as a factor in f acial pain expressions limited research (Kunz, Gruber, & Lautenbach er, 2006). Some research found no differences between males and females in pain facial expressions (Craig, Hyde, & Patrick, 1991., and Prkachin, 1992). However, Guinsburg, Peres, de Almeida, Balda, Bereguel, Tonelotto, &Kopelman (2000) found increased f acial pain responses in female neonates compared to male neonates. Robinson et al. (2001) have found that males and female s differ significantly in their pain expectations for self and others. Viewers ra ted male virtual humans as having less pain than female virtual humans and female viewers rated observed pain intensity significantly higher than did male viewers. Robinson et al. (2004) found that participants rated female subjects as experiencing greater pain intensity when undergoing a cold pressor task compared to males. Vignettes Research This study used vignettes and virtual humans of virtual humans experiencing pain. Vignettes, pioneered by Peter Rossi (Leahey, 200 4) combine forms of survey research and experimental designs. The vignett e technique is applied to st udies of problems in which participants make evaluations regarding complicated objects. De sirable features included an avoidance of real world multi-collinearity and the ability to isolate the independent variable of interest. The vignette format is particularly appr opriate for studying norms, attitudes, and beliefs (Leahey, 2004). Jasso & Webster (1997); Jass o & Opp (1997); and Morrill, Snyderman, & Dawson (1997) used the vignette format to explore normative judgments, sexed double standards, and moral gaps in business settings. Other researchers also used vignette format s in medical and health settings. Green, Wheeler, & LaPorte (2003) used nine clinical vignettes to examine potential differences in the 26

PAGE 27

physicians pain management based on the type of pain and patient demogr aphic characteristics, and found that that the preparation of adequate pain management may be influenced by patient characteristics and physician variability. In another study, Hassenbusch & Portenoy (2000) investigated practice patt erns via an internet-based survey di stributed to physicians who manage implantable infusion pumps for pain management The survey used a standard questionnaire format and two clinical vignett es to assess decision-making pract ices and found evidence of wide variations in clinical pr actice among physicians. Goubert, Crombez, & Danneels (2004) investigated whether pain catas trophizing and pain-related fear is related to a reluctance to generalize an experience of lesse r pain than expected to other similar situations. Researchers used a series of vignettes to assess catast rophizing, overgeneralization, personalization and selective abstraction related to general life expe riences and to low back pain (LBP) experiences. They also used three vignettes to assess the l ack of generalization of corrective experiences related to LBP. Researchers found that dysf unctional cognitions re lated to general life experiences were the strongest predictor of the self-denigration subscale of the Beck Depression Inventory (BDI). However only dysfunctional c ognitions related to LBP accounted for a unique contribution in predicting the somatic and phys ical function subscale of the BDI. Moreover, dysfunctional cognitions related to LBP were significantly correlated with interference with daily life due to pain. In a study aimed to determine what factors influence emergency physicians decisions to prescribe an opioid analgesic for three comm on painful conditions, Tamayo-Sarver, Dawson, Cydulka, Wigton, & Baker (2004) developed a baselin e vignette, and items expected to influence the decision for each of the three pain conditions : migraine, back pain, and ankle fracture, and found that Physicians likelihood of prescribing an opioid show ed marked variability. Many 27

PAGE 28

other studies have used vignette format in me dical and health setti ngs (Mitchell and Owens, 2004; Weisse, Sorum, & Dominguez, 2003; Ad amson, Ben-Shlomo, Chaturvedi, & Donovan, 2003; Hazelett, Powell, & Androulakakis, 2002; Ha mer, van den Hout, Halfens, Abu-Saad, & Heijltjes, 1997; Tait & Chibnall, 1997; Carey, Hadler, Gillings, Stinnett, & Wallsten, 1988; and Cohen, 1980). In terms of medication practices, research us ing vignettes that were identical, except for the sex of the patient indicates that different am ounts of analgesic medication were chosen based on the patients sex, with nurses choosing less pain medication fo r female patients experiencing pain than when compared to males (Cohen, 1980; McDonald & bridge, 1991). Campbell (2002) found that in prospective vignette studies, some nurses have indicated the intention to spend less time engaged in pharmacological pain management of female patients, and to select less pain medication for female patients. She also found, usi ng lens model and vignette format, that patient pain report appears to play an early predispositio nal role in the clinical decision making process. She also found that patient sex, age, and race play smaller predispositional roles in the clinical decision making process (Campbell, 2002). Study Rationale Relatively little is known about how males and fema les of different races vary in respect to perceiving and rating pain, pain-related negative mood, pain coping, and the extent to which each would recommend seeking medical help fo r males, females, Caucasians, and African Americans when experiencing pain. Some resear ch has been done on sex differences in rating other individuals pain. Previous research has shown that diff erences in perceiving and rating others pain lead to differences in judgments and decisions re lative to pain management, drug prescriptions and health care providing (Tamay o-Sarver et al, 2004; Campbell, 2002; Cohen, 1980; McDonald et al, 1991; Holm, Cohen, Dudas, Medema, & Allen 1989; Green et al, 2003; & 28

PAGE 29

Hassenbusch et al, 2000). Since research has shown that sex and race differences in pain-related negative mood and pain coping exist, the importan ce of investigating how males and females of different races differ in perceiving others pain -related negative mood and pain coping may in turn lead to better understanding of the differenc es in the way males and females of different races perceive, rate and respond to others pa in coping, pain-related negative mood, and better pain management strategies. This study adds to the determination of whet her differences between males and females, and differences between races exist in terms of perceiving and rating other peoples pain. In addition, this study contributes to the investigation of whether sex differences and/ or race differences exist in perceiving and rating others pain-related negative mood, pain coping, and the extent of recommending seek ing pain-related medical help. Study Aims The initial aim of this study is to determine whether sex and/or racial differences exist in regard to rating other peoples pain, pain-related negative mood, pain coping, and the extent of recommending medical help for pain. Second, in this study, the sex role expectations of pain are investigated as a possible mediator to the re lationship between sex and the perceived others pain. Hypotheses There will be significant diffe rences in participants ratings for male and female virtual humans pain intensity, pain unpleasantne ss, pain-related negative mood, coping with pain, and the extent in which virtual humans will be recommended to seek medical help for their pain. Ratings made by male, fe male, Caucasian, and African American participants for female virtual humans will be higher than their ratings for male virtual humans. There will be significant diffe rences in participants rati ngs for Caucasian and African American virtual humans pain intensity, pa in uncleanness, pain-related negative mood, coping with pain, and the extent in which the virtual humans will be recommended to 29

PAGE 30

30 seek medical help for their pain. Male, female, Caucasian, and African American participants will rate African American virtual humans higher. There will be significant diffe rences between male and fema le participants ratings of virtual humans pain intensity, pain unpleas antness, pain-related negative mood, coping with pain, and the extent in which the virtual humans will be recommended to seek medical help for their pain. Female participan ts ratings for male, female, Caucasian, and African American Virtual humans will be higher than the ratings made by male participants. There will be significant differences between Caucas ian and African American participants ratings for virtual humans pain intensity, pain unpleasantness, pain-related negative mood, coping with pain, and the exte nt in which the virtual humans will be recommended to seek medical help for thei r pain. Caucasian part icipants ratings for male, female, Caucasian, and African American virtual humans will be higher than the ratings made by African American Participants. Sex and race differences on rating others pa in, pain-related negativ e mood, pain coping, and the extent of recommending medical help ex periencing pain provides a broader range of variables that may affect the way males and female s of both races perceive and rate others pain, mood, and coping. This study provide s baseline information regard ing the role of the persons pain, mood, and coping taken toge ther on decisions and judgme nts regarding people who are experiencing pain. It also provides initial data to explore sex and race differences on dealing with other peoples pain from both sexes and races, and its expect ed effects on a wider range of behaviors including expected sex and race effects on health care behaviors toward pain patients.

PAGE 31

CHAPTER 2 METHODS Participants Recruitment 75 University of Florida undergraduate students of both sexes (53 females, 22 males) and races (62 Caucasians, 13 African Americans) were recruite d through flyers and posters requesting volunteers to pa rticipate in this study. Inclusion/Exclusion Criteria Eligibility for particip ation required being at least 18 y ears old and English speaking. Only males and females of African American or Ca ucasian background were included. Participation was also contingent upon ability to give consent. Procedure Each participant was asked to read a descrip tion of the study includi ng the time required to complete the study and a reminder that the study is voluntary. After reading the study description, all particip ants read and sign a computerized consent form acknowledging that the study procedures were explained an d that they could withdraw, w ithout prejudice, from the study at any time. Next, the participants filled out a demographic questionnaire. The following demographic information was collected: sex, race, a nd age. After that, participants read a set of instructions that provided information on how to approach the task and how to use Visual Analogue Scales (VASs) to give ratings. Then, pa rticipants viewed the vignettes and the virtual humans of both sexes and races. The virtual humans participants observed expressed pain through facial expressions. These facial expressions of pain we re digitally coded based on the Facial Action Coding System (FACS). The FACS is based on anatomic analysis of facial muscle movements and distinguishes 44 di fferent action units (AUs). Howe ver, an abbreviated version 31

PAGE 32

of FACS was used in this study focusing on 4 action units: brow loweri ng, tightening of the orbital muscles surrounding the eye, nose wr inkling/upper lip raising, and eye closure. Each virtual human the participants observed consisted of a vignette and a virtual reality virtual human of the observed patient of each se x and race. Each virtual human contained three cues: sex (two levels: male or female), race (t wo levels: Caucasian or African American), and pain (two levels, and were manipulated only in the observed virtual human and was inferred by the participants based on the virtual humans facial pain expressions). Pain-related negative mood, pain coping, and the virtual humans need to be recommended to seek medical help was also inferred by the participants based on and re lated to the pain facial expressions of the observed virtual human of both sexes and races. In order to minimize the impact of social desi rability on participants ratings, participants were instructed to completely respond to virt ual humans in the order presented, complete one virtual human before going to the next, and not to revisit a previously completed virtual human. For each virtual human (of both sexes and races), participants (of both sexes and races) used computerized VASs to (1) rate the level of pain intensity they think the observed virtual human is experiencing, (2) rate the level of pain unplea santness they think the observed virtual human is experiencing, (3) rate the level of pain-related negative mood the obs erved virtual human is experiencing due to his/her observed pain, (4) rate how well they think that the observed virtual human is coping with the pain experience, a nd (5) rate the extent to which they would recommend the observed virtual human to seek pa in-related medical help. Participants also completed a computerized version of the Sex Role Expectations of Pain questionnaire (GREP) (appendix A) using computerized VASs to assess for the degree to which sex role expectations of pain may contribut e to their ratings. 32

PAGE 33

The Gender Role Expectations of Pain questi onnaire (GREP) consis ts of visual analog scales to assess for participants view of the t ypical male and female regarding pain sensitivity, pain endurance, and willingness to report pain. It also assesses the pa rticipants personal attribution of his/her pain sensitivity, pain e ndurance, and willingness to report pain relative to the typical male and female. The psychometric prope rties of the GREP fact or structure are close to the theoretical formulation of the scales, accounting for 76% of the variance in scores. The questionnaire has good testretest reliability wi th individual item correlations ranging from 0.53 to 0.93. The sex differences in the endorsement of items on the GREP were large, with the largest differences (46% of variance) shown for willingness to report pain items. (Robinson et al, 2001). Wise et al (2002) found that the GREP was a significant pr edictor of experimental pain ratings in undergraduate males and females, and that a significant proportion of sex differences in pain report was accounted for. Task duration was approximately 1 hour. Following completion of the task, participants were asked to respond, in writing, to a task valid ity probe, in which they were asked to guess what the study hypotheses were. Then, participan ts were briefed regarding the variables of interest and the study hypotheses. Analysis All data analyses were performed usi ng SPSS for windows (Version 15). Mixed model ANOVA analyses were performed where sex and race, of participants and virtual humans, served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the virtual humans were recommended to seek medical help for their pa in as dependent variables. The 2 X 2 Mixed model ANOVAs were conducted as follows: ratings of pain intensity served as a dependent variab le, and sex of virtual humans (male and female) and sex of 33

PAGE 34

34 participants (male and female) served as independent variables. The same process was repeated for ratings of pain unpleasantness, pain-relat ed negative mood, pain coping, and recommending medical help. Then, ratings of pain intensity serv ed as a dependent variable, and race of virtual humans (Caucasian and African Amer ican), and sex of participants (male and female) served as independent variables. The same process was rep eated for ratings of pain unpleasantness, painrelated negative mood, pain coping, and recommending medical help. After that, ratings of pain intensity served as a dependent variable, and race of virtual humans (Caucasian and African American), and race of participants (Caucasian and African American) served as independent variables. The same process was repeated for ratings of pain unpleas antness, pain-related negative mood, pain coping, and recommending medical help. Finally, ratings of pain intensity served as a dependent variable and sex of virtual humans (mal e and female), and race of participants (Caucasian and African American) served as independent variables. The same process was repeated for ratings of pain unpl easantness, pain-related negative mood, pain coping, and recommending medical help. Willingness to report pain and pain endurance (taken from the GREP), were investigated to determine whether they meet the criteria to serve as covariates in the analyses of sex of virtual humans and participants main effects on ratings of pain intensity a nd pain unpleasantness.

PAGE 35

CHAPTER 3 RESULTS A series of mixed model ANOVA models was performed where sex and race of participants and virtual humans served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the [virtual humans] are recommended to seek medical help for their pain as dependent variables. The willingness to report pain, and pain endur ance are two factors of the GREP that are being considered to be included in the model as covariates. Howe ver, correlation analysis was conducted on these two factors as well as male and female participants rati ngs of pain intensity and pain unpleasantness for male and female virt ual humans. Results showed that correlations are not significant. Therefore, willingness to report pain, and pain endurance were dropped from the model because the assumptions of covariance analysis were not met. Analysis of Pain Intensity Ratings Sex Effects Both male and female participants rated pain intensity for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 4.92, p < 0.05. Between participants main effects, and sex of virtual human by sex of pa rticipant interactions were nonsignificant (see table 3-1). Both Caucasian and African American participants rated pain intensity for female virtual humans significantl y higher than that for male virtual humans, F (1, 73) = 6.93, p < 0.05. Between participants main effects or the sex of virtual human by race of participant interaction effects were non-significant, (see table 3-2). 35

PAGE 36

Race Effects There was no main effect of race of virtual human on ratings of pain intensity. However, African American participants rated African American virtual humans significantly higher than Caucasian virtual humans, F (1, 73) = 4.73, p < 0.05, (see table 3-3). Analysis of Pain Unpleasantness Ratings Sex Effects Both male and female participants rated pa in unpleasantness for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 7.61, p < 0.01. Main effect of sex of viewer, and main effect and sex of virt ual human by sex of viewer interaction were nonsignificant, (see table 3-4). Both Caucasian a nd African American par ticipants rated pain unpleasantness for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 4.17, p < 0.05. Between participants main effect and sex of virtual human by race of participants interaction were nonsignificant, (see table 3-5) These results mirrored the intensity effects. Race Effects Race of virtual human did not have an effect on ratings of pain unpleasantness. Sex of participant and race of participant did not have an effect on ratings of pain unpleasantness (see table 3-6). Analysis of Pain-Related Negative Mood Ratings Sex Effects Both male and female participants rated pa in-related negative m ood for female virtual humans significantly higher than that for male virtual humans, F (1, 73) = 6.76, p < 0.05. No significant interactions or between participants effects were f ound, (see table 3-7). However, a between participants main effect was found for race of participants; Caucasian participants 36

PAGE 37

ratings for both male and female virtual humans pain-related negative mo od were significantly higher than African American participants ratings, F (1, 73) = 3.99, p = 0.05. An interaction of sex of virtual human by race of participants was also found; Caucasian participants ratings for female virtual humans were significantly higher than African American participants ratings for female virtual humans, F (1, 73) = 4.11, p < 0.05, (see table 3-8). Race Effects Race of virtual human did not have an eff ect on ratings of pain-related negative mood made by male and female participants. (see ta ble 3-9). However, both Caucasian and African American participants viewed Caucasian virtual hu mans as having significantly higher levels of pain-related negative mood, F (1, 73) = 5.34, p < 0.05. (see table 3-10). Analysis of Pain-Coping Ratings Sex Effects Both male and female participants viewed female virtual humans as coping poorer than male virtual humans, F (1, 73) = 6.37, p < 0.05. No significant between participants effect, and sex of virtual human by sex of participant interactions we re found, (see table 3-11). No significant main effect for sex of virtual hum an on race of participants was found. Also, no interaction or between race of participants effects were found (see table 3-12). Race Effects Both Caucasian and African American partic ipants viewed Caucasian virtual humans as coping poorer with their pain than African American virtual humans, F (1, 73) = 6.86, p < 0.05. Race of participant did not have an effect on ra tings of pain coping. (see table 3-13). Sex of participant did not have an effect on ratings of pain coping (see table 3-14). 37

PAGE 38

Analysis of Recommendin g Medical Help Ratings Sex effects A main effect for sex of virtual humans on sex of participants was found; both male and female participants ratings were significantly higher for female virtual humans than that for male virtual humans, F (1, 73) = 5.98, p < 0.05. A sex of participants main effect was also found indicating that male participants ratings were significantly higher than female participants ratings, F (1, 73) = 4.02, p < 0.05, (see table 3-15). Race of partic ipant did not have an effect on ratings of recommending medical help (See table 3-16). Race effects Sex of participant did not have an effect on ratings of recommending medical help. However, male participants ratings for both Caucasian and African Am erican virtual humans were significantly higher than that of female participants, F (1, 73) = 4.06, p < 0.05 (see table 317). Sex of participant did not have an effect on ratings of recommending medical help (see table 3-18). In summary, male and female participants rate d female virtual humans pain intensity, pain unpleasantness, pain-related nega tive mood, poorer pain coping, and the need to seek medical help as higher than male virtual humans. However, Caucasian and African American participants ratings for female virtual humans we re higher than that for male virtual humans only on pain intensity and pain unpleasantness. Ca ucasian virtual humans were viewed as having higher pain-related negative mood and cope poorer w ith their pain than Af rican American virtual humans. African American virtual humans pa in intensity was rated higher only by African American participants. Ratings made by male part icipants tended to be higher than ratings made by female participants. 38

PAGE 39

A correlation analysis was conducted between dependent variables. All dependent variables in this study (ratings of pain intensity, pain unpleasa ntness, pain-related negative mood, pain coping, and recommending medical help) were intercorrelated. Correla tions ranged between 0.35 (pain coping and recommending medical he lp) to 0.87 (pain intensity and pain unpleasantness (see table 3-19). 39

PAGE 40

Table 3-1. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain intensity ma de by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 40.6 15.8 4.92 0.063 0.03 Female 37.8 14 Female Male 41.6 14.7 Female 40.9 13.6 Pain Intensity Ratings for sex of virtual human sex of participants 1.23 0.017 0.27 Between Participants Effect 0.24 0.003 0.62 Table 3-2. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 38.7 14.4 6.93 0.087 0.01 African American 38.6 15.9 Female Caucasian 40.9 14.2 African American 42.3 12.8 Pain Intensity Ratings for sex of virtual human race of participants 0.41 0.006 0.52 Between Participants Effect 0.03 0.000 0.88 Table 3-3. Descriptive st atistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain intensity ma de by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 39.4 13.7 2.62 0.035 0.11 African American 42.6 15.6 African American Caucasian 40 14.8 African American 38.3 12.9 Pain Intensity Ratings for race of virtual human race of participants 4.73 0.061 0.033 Between Participants Effect 0.03 0.000 0.86 40

PAGE 41

Table 3-4. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 43.2 16.8 7.61 0.095 0.007 Female 42 14.6 Female Male 46.9 16.9 Female 44 13.5 Pain unpleasantness ratings for sex of virtual human sex of participants 0.57 0.008 0.454 Between Participants Effect 0.32 0.004 0.575 Table 3-5. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain unpleasantness made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 42.7 14.6 4.17 0.054 0.045 African American 40.4 18.1 Female Caucasian 45.3 14.7 African American 43 14.2 Pain unpleasantness ratings for sex of virtual human race of participant 0.00 0.00 0.99 Between Participants Effect 0.267 0.00 0.61 41

PAGE 42

Table 3-6. Descriptive st atistics and mixed model ANOVA results the effect of race of virtual humans on ratings of pain unpleasantness made by male, female, Caucasian, and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Males 45.15 16.7 1.17 0.02 0.28 Females 44 13.3 African American Males 45 16.8 Females 42 14.7 Pain unpleasantness ratings for race of virtual human sex of participant 0.77 0.01 0.38 Between Participants Effect 0.32 0.00 0.58 Caucasian Caucasian 44.58 14 2.55 0.03 0.11 African American 43 16 African American Caucasian 43.4 15.4 African American 40.4 14.9 Pain unpleasantness ratings for race of virtual human race of participant 0.38 0.01 0.54 Between Participants Effect 0.268 0.00 0.61 Table 3-7. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain-related negative mood made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 41.2 15.9 6.76 0.085 0.011 Female 36.5 15.2 Female Male 44.2 15.3 Female 38.6 14.9 Pain-related negative mood ratings for sex of virtual human sex of participants 0.19 0.00 0.67 Between Participants Effect 1.89 0.03 0.17 42

PAGE 43

Table 3-8. Descriptive st atistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain pain-relat ed negative mood made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 39 15.2 0.55 0.01 0.46 African American 32.5 16.2 Female Caucasian 42.2 14.3 African American 31 16.2 Pain-related negative mood ratings for virtual humans sex participants race 4.11 0.05 0.05 Between Participants Effect 4 0.52 0.05 Table 3-9. Descriptive st atistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-related negative mood made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 42.8 15.8 1.29 0.02 0.26 Female 38.6 14.6 African American Male 42.6 15.8 Female 36.3 15.9 Pain-related negative mood ratings for virtual humans race participants sex 0.9 0.01 0.35 Between Participants Effect 1.95 0.03 0.17 Table 3-10. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain pain-re lated negative mood made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Caucasian African American 41 14.3 5.34 0.068 0.024 Female 34.4 17.5 African American Caucasian 40 15.4 African American 29.2 16.6 Pain-related negative mood ratings for virtual humans race participants race 2.47 0.03 0.12 Between Participants Effect 3.87 0.05 0.053 43

PAGE 44

Table 3-11. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by male and female participants. Virtual humans Participants M SD F (1, 73) 2 P Male Male 34.1 14.6 6.37 0.08 0.014 Female 31.8 13.3 Female Male 36 15 Female 34.2 13.4 Pain-coping ratings for virtual humans sex participants sex 0.08 0.00 0.78 Between Participants Effect 0.35 0.01 0.56 Table 3-12. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of pain coping made by Caucasian and African American participants. Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 32.7 13.8 2.84 0.04 0.096 African American 31.6 13.4 Female Caucasian 35.2 13.5 African American 32.5 15.5 Pain-coping ratings for virtual humans sex participants race 0.63 0.01 0.43 Between Participants Effect 0.21 0.00 0.65 Table 3-13. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 34.5 13.3 6.86 0.086 0.011 African American 34.5 15.3 African American Caucasian 33.6 14 African American 28.9 14.5 Pain-coping ratings for virtual humans race participants race 3.7 0.05 0.058 Between Participants Effect 0.34 0.01 0.56 44

PAGE 45

Table 3-14. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of pain coping made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 34.6 14.6 0.79 0.01 0.38 Female 34.4 13.3 African American Male 35.5 15 Female 31.7 13.8 Pain-coping ratings for virtual humans race participants sex 3.27 0.04 0.08 Between Participants Effect 0.35 0.01 0.56 Table 3-15. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medi cal help made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Male Male 51.9 25.1 5.98 0.076 0.017 Female 40.8 18.6 Female Male 53.8 24.2 Female 44.4 19 Recommending medical help ratings for sex of virtual human sex of participants 0.64 0.01 0.43 Between Participants Effect 4.02 0.052 0.049 Table 3-16. Descriptive statistics and mixed model ANOVA results of the effect of sex of virtual humans on ratings of recommending medical help made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Male Caucasian 43.7 21.6 3.63 0.05 0.06 African American 45.8 20 Female Caucasian 47.1 21.7 African American 47.6 17.5 Recommending medical help ratings for virtual humans sex participants race 0.37 0.01 0.54 Between Participants Effect 0.04 0.00 0.84 45

PAGE 46

Table 3-17. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending me dical help made by male and female participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Male 52.8 24.8 0.11 0.00 0.74 Female 42.9 19.3 African American Male 52.9 24.2 Female 42.1 18.4 Recommending medical help ratings for virtual humans race participants sex 0.21 0.00 0.65 Between Participants Effect 4.06 0.53 0.048 Table 3-18. Descriptive statistics and mixed model ANOVA results of the effect of race of virtual humans on ratings of recommending medical help made by Caucasian and African American participants Virtual humans Participants M SD F (1, 73) 2 P Caucasian Caucasian 45.3 21.7 1.44 0.02 0.24 African American 48.1 20.1 African American Caucasian 45.3 21.5 African American 45.3 17.2 Recommending medical help ratings for virtual humans race participants race 1.36 0.02 0.25 Between Participants Effect 0.05 0.00 0.85 Table 3-19. Correlations between the dependent variables Pain Intensity Pain Unpleasantness Pain-related negative mood Pain coping Recommending medical help Pain Intensity 1 0.87 0.72 0.68 0.53 Pain Unpleasantness 0.87 1 0.82 0.75 0.51 Pain-related negative mood 0.72 0.82 1 0.71 0.42 Pain coping 0.68 0.75 0.71 1 0.35 Recommending medical help 0.53 0.51 0.42 0.35 1 46

PAGE 47

CHAPTER 4 DISCUSSION Although pain levels were digitally controlled to be equal among male, female, Caucasian, and African American virtual humans, these data indicate th at participants of both sexes and races still view females pain, with both of its components, sensory (intensity) and affective (unpleasantness), as significantly hi gher than that for male virtua l humans. This is consistent with other research findings. Robinson et al. (2001) found diffe rences in participants pain ratings for observed males and females experien cing experimentally induced pain. They found that viewers rated female virtual humans as ha ving more pain than observed male virtual humans. One possible explanation for why female virtual humans were vi ewed as having higher pain levels than male virtual humans is the diffe rence in pain expectati ons, that is, females are expected to report higher levels of pain than males in general. Although willingness to report pain, and pain endurance did not correlate significantly with pain ratings in this study, a sizable literature shows that both males and females expect females to experience higher levels of pain compared to males (Unrah, 1996, and Robinson et al, 2001). This study also suggests that differences in expecting females to experience highe r levels of pain are also true across races (Caucasians and African Americans). Although be tween races rating did not differ, they both rated female virtual humans to have higher pain levels. African American participants viewed African American virtual humans pain intensity as significantly higher than Caucas ian virtual humans pain inte nsity. The ratings of African Americans as having higher pain intensity than Ca ucasians is consistent with previous studies; Walsh, Schoenfield, Ramamurthy, & Hoffman (1989) investigated pain tolerance to the cold pressor test in Anglo-Saxons, Hispanics, a nd African Americans and found that African Americans and Hispanics had lower pain toleran ce. Sheffield, Biles, Orom, Maixner, & Sheps 47

PAGE 48

(2000) Found that African Americans rated the thermal stimuli as more unpleasant and more intense than Caucasians. Edwards et al (1999) found that African Americans had a lower thermal pain tolerance and greater pain severity than Caucasians. Edwards et al (2001) also found that African Americans report significantly greater pain se verity and pain-related disability than Caucasians. These studies invest igated participants ratings of their own pain conditions. The current study, however, investigated participants ratings of othe rs pain. Since Caucasians did not rate African Americans pain as high as African Americans did, results may indicate differences between race-related cultures in terms of sensitivity to facial pain expressions, thats is, African Americans might be mo re sensitive to African Americans facial expressions of pain than Caucasians. Rahim-Williams, Riley III, He rrera, Campbell, Hastie & Fillingim (2007) studied ethnic identity to determine whether it associates with experimental pain intensity in three groups including African Americans. Th ey found that African Americans scored the highest on the ethnic identity measure. Research ers suggested that higher scores on the ethnic identity measure would mean higher ethnic-spec ific socio-cultural influence on the pain experience. Since African Americans scored high er on the ethnic identity measure, and that means higher influence of their culture on pain ex perience, it is possible that they have rated African American virtual humans pain intensity as higher than that for Caucasian virtual humans because they (the African American participants) are more sensitive to pain behaviors, including facial pain expressions, exhibited by individuals of the sa me race-related culture. In the Study mentioned above, Non-Hispanic Whites scored the lowest on the ethni c identity measure, suggesting that it is possible that Caucasians are not as influen ced by their racial culture. This might suggest that Caucasians are less sensitiv e to pain behaviors, including facial pain expressions, exhibited by individuals of the same race. However, further investigation of this 48

PAGE 49

finding is needed to further understand and explai n the existence and the implications of between races differences in sensitivity to facial pain expressions. The International Association for the Study of Pain defines pain in a way that highlights the importance of understanding of the negative emotional experien ces of pain. Part of that emotional experience is the nega tive mood that accompanies pain experience. Although all facial expressions of pain were digita lly controlled to be similar for males and females in this study, female virtual humans pain-related negative mo od was rated significantly higher than that for male virtual humans by both male and female pa rticipants. These result s might be explained by the positive relationship between pain and nega tive mood found and is consistent with the findings of the National Health and Nutrition Examination Surve y, where pain and depressive symptoms tended to be more evident in female s than in males (Magni et al, 1990). Turk & Okifuji (1999) also found that females were view ed as more depressed than males when in pain. These results also highlight the role of the expectations males have regarding the effects of females high levels of pain on their moods. Cu rrent data also indicate that Caucasians and African Americans differ in th eir ratings of pain-related negative mood. Although Caucasian participants ratings of pain-related negative mood for male and female virtual humans were significantly higher than African Americans ratings, they even rated females pain-related negative mood as significantly higher than males pain-related negative mood. This highlights the role that culture might play in perceiving pain effects on the mood of females and males. Caucasian virtual humans were rated by both Af rican American and Caucasian participants as having higher pain-related negative mood. However, this is not consistent with the positive relationship between pain level a nd negative mood experiences. Thes e results indicate that race might moderate the relationship between pain and pain-related negative mood. 49

PAGE 50

Consistent with the pain-related negative mood re sults, male and female participants rated female virtual humans as coping poorer with thei r pain, and Caucasian virtual humans were rated by both Caucasian and African Am erica participants as coping poorer with their pain. These results mirror the pain-related negative mood rati ngs. These results suggest that when females and Caucasians are viewed as having higher leve ls of pain than males and African Americans, they are more likely to be viewed as experien cing higher levels of pain-related negative mood and higher levels of poorer pa in-related coping strategies. When someones pain level, pain-related ne gative mood, and pain-maladaptive coping is rated high, it is expected that he /she is more likely to be recommended to seek medical help for his/her pain. In this study, female virtual humans were rated higher on all of those variables than male virtual humans, they also were recommended to seek medical help for their pain significantly more than male virt ual humans. However, it was not e xpected for male participants recommendations to be higher than female par ticipants. Males recommended female virtual humans to seek medical help for their pain si gnificantly more than the recommendation made by female participants. Male participants also recommended Caucasian and African American virtual humans to seek medical help for their pa in significantly more than the recommendations made by female participants. One possible explanation to why males recommendations are higher than females recommendations is the di fference between males and females in painrelated medication seeking behaviors. Males ha ve been shown to request more drugs than females after surgery when given access to patie nt controlled analgesia (Macintyre & Jarvis, 1995. Burns, Hodsman, McLintock, Gillies, Ken ny, & McArdle (1989) and Stinshoff, Lang, Berbaum, Lutgendorf, Logan & Berbaum (2004) also found that males tend to seek more medications for their pain compared to females. 50

PAGE 51

The ratings of pain intensity, pain unpleas antness, pain-related negative mood, pain coping, and recommending medical help showed significant intercorrelations. Relationships between these dependent variables have a pattern that might add to the ex planation of some of the current results. For example, the high correlat ion between pain intensity, pain unpleasantness, pain-related negative mood, and pain coping might add to the explanation as to why female virtual videos were rated high on all of them, if pain rating influenced the other ratings. The results of this study have exciting implications, however, this study has some advantages and disadvantages worth noting. One lim itation of this study is that only one African American male participated in it. Efforts to recruit more African Americans through study announcements to specifically target African American undergra duates were not successful. The use of computerized virtual humans with di gitally controlled facial expressions of pain based on the FACS, and digitally controlled pain levels across sexes and races of virtual humans, is innovative. This enables greate r control over unifying facial pa in expressions and levels of pain than if we had used human virtual humans. This technique, by the high control it provides over the ecology, also enables gr eater confidence in focusing on biases and variance brought to the ratings by participants. Furthermore, the virtual human technology used in this study, has the potential to develop to be an educational assessment and intervention tool. Students, health care providers, and other individuals can use this technol ogy to assess for their own biases regarding pain expressed by others and regarding specific variables of interest assigned to the observed virtual humans. This technology is also accessible from almost ever ywhere in the world via the Internet. One advantage of the easy access to this technology is that it makes, for ex ample, cross-cultural studies much easier to conduct if same stimuli we re to be used. Such an example provides wider 51

PAGE 52

52 scope of races to be easily studied, as we ll as other cultures. Although the virtual human technology used in this study focused only on f acial pain expressions without sound, future considerations might add other pain expressions to this technology, such as, verbal pain expressions, body gestures that are pain rela ted, and adding background environments that determine context in which the pain is being experienced. One other advantage of using virt ual humans in this study is that it eliminates the biases in the making of the stimuli. These stimuli are basically made digitally identical except for the variables at interest in this study. One other advantage to this study is the focus on how others perceive and rate others pain and other dependent variables in this study. Most research investigating pain perception focused on self-repo rts. Although self-reports of pain experience are an important component in the quest of unders tanding the nature of pai n, it is also important to investigate how others perc eive and view the experience of pain communicated to them by other individuals. This contributes significantly to the overall understanding of the nature of pain including how others appraise and respond to others expe riences of pain.

PAGE 53

REFERENCES Adamson, J., Ben-Shlomo, Y., Chaturvedi, N ., & Donovan, J. (2003). Race, socio-economic position and sex-do they affect reported health-care seeking behaviour? Social Science & Medicine, 57 (5), 895-904. Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., Starr, K., & Caldwell, D. S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: Independent effects of disease a nd sex on daily pain, mood, and coping. Pain 83, 601609. Ambadar, Z., Schooler, J., & Cohn, J (2005). Deciphe ring the enigmatic face: the importance of facial dynamics in interpreting subtle facial expressions. Psychological Science 16, 403410. Anderson, K., Palos, G., Gning, I., Mendoza, T., Sanchez, M., Valero, V., Richman, S., Nazaria, A., Hurley, J., Payne, R. & Cleeland, C. (2003). Multi-site randomized trial of pain management education for minority outpatients with cancer pain. Pain 4, 95. Bassili, J (1979). Emotion recognition: the role of facial movement and the relative importance of upper and lower areas of the face. Journal of Personality and Social Psychology 37, 2049-258. Bates, M. S. (1996). Biocultural dimensions of chronic pai n: implications for treatment of multiracial populations Albany, NY: State University of New York Press. Beutler, L.E., Engle, D., Oro-Beutler, M.E., Daldrup, R. & Meredith, K. (1986). Inability to express intense affect: a common link between depression and pain? Journal of Consulting and Clinical Psychology 54 (6), 752. Bombardier, C.H., DAmico, C., & Jordan, J. S. (1990). The relationship of appraisal and coping to chronic illness adjustment. Behavior Research and Therapy 28, 297. Boothby, J. L., Thorn, B. E., Stroud, M. W., & Jensen, M. P. (1999). Coping with Pain. In Gatchel, R. G., & Turk, D. C. (Eds.), Psychosocial Factors in Pain New York: Guilford Press. Boyatzis, C., Cazan, E., & Ting, C (1993). Preschool childrens decoding of facial emotions. Journal of General Psychology 154, 375-382. Brodsgaard, M. R. (1999). Crosscultural investiga tions of pain. In: Crombie IK, editor. Epidemiology of pain Seattle: IASP Press. Brown, F. F., Robinson, M. E., Riley, J. L. & Gremillion, H. A. (1996). Pain severity, negative affect, and microstressors as predictors of life interference in TMD patients. CRANIO, 14:63-70. 53

PAGE 54

Buckelew, S. P., Shutty, M. S., Hewitt, J., Landon, T., Morrow, K. & Frank, R. G. (1990). Health locus of control, sex differences and adjustment to persistent pain. Pain, 42: 287295. Burns, J., Hodsman, N., McLint ock, T., Gillies, G., Kenny, G., & McArdle, C. (1989). The influence of patient characteristics on the requirements for postoperative analgesia. Anaesthesia 44, 2 6. Campbell, L. (2002). Predispositions Towards Pharmacol ogical Pain Management: A policy capturing study. University of Florida. Carey, T. S., Hadler, N. M., Gillings, D., Stinnett, S., & Wallsten, T. (1988). Medical disability assessment of the back pain patient for the so cial security administ ration: The weighting of presenting clinical features. Journal of Clinic al Epidemiology. 41 (7), 691-697. Carmen, R., Green, S., Ndao-Brumblay, K., Nagrant, A. M., Baker, T. A. & Rothman, E. (2004). Race, age, and sex influences among clusters of african american a nd white patients with chronic pain. The Journal of Pain 5 (3), 171-182. Caron, R. F., Caron, A. J., & Myers, R. S (1985). Do infants see emotional expression in static faces? Child Development 56, 1552-1560. Campbell, C. M., Edwards, R. R. & Fillingim, R. B. (2005). Racial differences in responses to multiple experimental pain stimuli. Pain, 113 (1-2), 20-26. Cohen F. (1980). Post-surgical pain relief: pa tients status and nurse s medication choice. Pain 9, 265. Cooksey, R. W. (1996). Judgment Analysis: Theory, methods, and applications San Diego, CA: Academic Press. Craig, K., Hyde, S., & Patrick, C (1991). Genuine suppressed and faked facial behavior during exacerbation of chronic low back pain. Pain 46, 161-171. Craig, K., & Patrick, C (1985). Facial expression during induced pain. Journal of Personality and Social Psychology 48, 1080-1091. Dao, T. T. & LeResche, L. ( 2000). Sex differences in pain. Journal of Orofacial Pain, 14, 169 84. de Ridder, D. & Schreurs, K. ( 2001). Developing interventions for chronically ill patients: is coping a helpful concept? Clinical Psychology Review, 21, 205. Dennis, C. K. & Akiko O. (1999). Does sex make a difference in the pr escription of treatments and the adaptation to chronic pain by cancer and non-cancer patients? Pain, 82, 139-149. 54

PAGE 55

Edwards, R. R., Doleys, D. M., Fillingim, R. B. & Lowery, D. (2001). Racial differences in pain tolerance: clinical implicati ons in a chronic pain population. Psychosomatic Medicine 63: 316-323. Edwards, R. R. & Fillingim, R. B. (1999). R acial differences in thermal pain responses. Psychosomatic Medicine 61: 346-354. Edwards, C. L., Fillingim, R. B. & Keefe, F. J. (2001). Race, race and pain. Pain 94, 113-137. Ekman, P (1993). Facial Expression of Emotion. American Psychologist. 48 (4), 384-392. Ellermeier, W. & Westphal, W. (1995). Sex differences in pain ratings and pupil reactions to painful pressure stimuli. Pain 61 (3), 435-439. Endler, N. S., Corace, K. M., Summerfeldt, L. J., Johnson, J. M. & Rothbart, P. (2003). Coping with chronic pain. Personality and Individual Differences 34, 323. Feldman, S., Downey, G., & Schaffer-Neitz, R. (1999). Pain, Negative Mood, and Perceived Support in Chronic Pain Patients: A Da ily Diary Study of People With Reflex Sympathetic Dystrophy Syndrome. Journal of Consulting and Clinical Psychology 67 (5), 776-785. Folkman S, & Moskowitz, J. T. (2000). Po sitive affect and the other side of coping. American Psychologist 55 (6), 647-654. Frot, M., Feine, J. S. & Bushnell, M. C. (2004) Sex differences in pain perception and anxiety. A psychophysical study with topical capsaicin. Pain, 108 (3), 230-236. Gaskin M. E., Greene A. F., Robinson M. E. Ge isser & M. E. (1992). Negative affect and the experience of chronic pain. Journal of Psychosomatic Research 36 (8), 707-713. Geisser, M.E., Robinson, M. E., Keefe, F. J. & Weiner, M. L. (1994). Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain. Pain 59 (1), 79-83. Goubert, L., Crombez, G., & Danneels, L. ( 2004). The reluctance to generalize corrective experiences in chronic low back pain patie nts: a questionnaire study of dysfunctional cognitions. Behaviour Research and Therapy, 43 (8), 1055-1067. Green, C. R Anderson, K., Baker, T., Campbell, L., Decker, S., Fillingim, R., Kaloukalani, D., Lasch, K., Myers, C., Tait, R., Todd, K. & Vallerand, A. (2003). The unequal burden of pain: Confronting racial and racial disparities in pain. Pain Medicine 4, 277-294. Green, C. R., Baker, T. A., Sato, Y., Washington T. L. & Smith, E. M. (2003). Race and chronic Pain: A comparative study of young black and white Americans presenting for management. Journal of Pain 4, 176-183. 55

PAGE 56

Green, C. R., Baker, T. A., Smith, E. M. & Sato, Y. (2003). The effect of race in older adults presenting for chronic pain management: A comparative study of African and Caucasian Americans. Journal of Pain 4, 82-90. Green, C. R., Wheeler, J. R. & LaPorte, F. (2003). Clinical Decision Making in Pain Management: Contributions of Physician and Patient Characteristics to Variations in Practice. The Journal of Pain, 4 (1), 29-39. Greenwald, H. P. (1991). Interracial differences in pain perception. Pain. 44, 157-163. Hall, J (1978). Gender effects in decoding nonverbal cues. Psychological Bulletin 85, 845-857. Hamers, J. P., van den Hout, M., Halfens, R. J., Abu-Saad, H. H., & Heijltjes, A. E. (1997). Differences in pain assessment and decisions regarding the administration of analgesics between novices, interm ediates and experts in pediatric nursing. International Journal of Nursing Studies. 34 (5), 325-334. Harwood, N., Hall, L., & Shinkfield, A (1999). Rec ognition of facial emotional expressions from moving and static displays by indi viduals with mental retardation. American Journal of Mentally Retarded. 104 (3), 270-278. Hastie, B. A., Riley, J. L. & Fillingim, R. B. (2 004). Racial differences in pain coping: Factor structure of the coping strategies questi onnaire and coping stra tegies questionnairerevised. The Journal of Pain. 5 (6), 304-316. Hassenbusch, S. J. & Portenoy, R. K. (2000). Current Practices in Intraspinal Therapy: A Survey of Clinical Trends and Decision Making. Journal of Pain and Symptom Management, 20 (2), S4-S11. Hawthorn, J. & Redmond, K. (1998). Pain : Causes and Management. Malden, Mass. Blackwell Science. Hazelett, S., Powell, C., & Androulakakis, V. (2 002). Patients' behavior at the time of injury: Effect on nurses' perception of pain level and subsequent treatment. Pain Management Nursing, 3 (1), 28-35. Holm, K., Cohen, F., Dudas, S., Medema, P. & Allen, B. (1989). Effect of personal pain experience on pain assessment. Journal of Nursing Scholarship 21, 72. Holzberg, A. D., Robinson, M. E., Geisser, M. E. & Gremillion, H. A. (1996). The effects of depression and chronic pain on psyc hosocial and physical functioning. Clinical Journal of Pain 12, 118-125. Jasso, G., & Opp, K. (1997). Probing the Character of Norms: A Factorial Survey Analysis of the Norms of Political Action. American Sociological Review. 62 (6), 947-964. 56

PAGE 57

Jasso, G. & Webster, M. (1997). Double standards in just earning for male and female workers. Social Psychology Quarterly, 60 (1), 66-78. Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: a critical review of the literature. Pain. 47, 249. Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994). Relationship of painspecific beliefs to chronic pain adjustment. Pain 57, 301. Jordan, M., Lumley, M., & Leisen, J. (1998). Th e relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis. Arthritis Care and Research. 11, 80. Keefe, F. G., Affleck, G., France, C. R., Emer y, C. F., Waters, C., Caldwell, D. S., Stainbrook, D., Hackshaw, K. V., Fox, L. C. & Wilson, K. (2004). Sex differences in pain, coping, and mood in individuals havi ng osteoarthritic knee pain : a within-day analysis. Pain 110 (3), 571-577. Keefe, F. J., Lefebvre, J. C., Egert, J. R., Af fleck, G., Sullivan, M. J., & Caldwell, D. S. (2000). The relationship of sex to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain, 87, 325. Keogh, E., & Herdenfeldt, M. (2002). Sex, coping and the perception of pain, Pain 97 (3), 195201. Kerns, R. D., Rosenberg, R. & Jacob, M. C. (1994). Anger expression and chronic pain. Journal of Behavioral Medicine 17 (1), 57. Kirrouac, G & Dore, F (1985). Accuracy of the judg ment of facial expressions as a function of sex and level of education. Journal of Nonverbal Behavior 9, 3-7. Klonoff, E.A., Landrine, H. & Brown, M.A. (1993) Appraisal and response to pain may be a function of its bodily function. Journal of psychosomatic research 37, 661-670. Kunz, M., Gruber, A., & Lautenbacher, S (2006). Sex differences in facial encoding of pain. The Journal of Pain 7 (12), 915-928. Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and Coping New York: Springer Publishing Company. Leahey, E. (2004). The role of status in ev aluating research: the case of data editing. Social Science Research 33 (3), 521-537. Macintyre P, Jarvis D. (1995). Age is th e best provider of postoperative morphine requirements. Pain 64, 357. 57

PAGE 58

Maes, S., Leventhal, H., & de Ridder, D. T. ( 1996). Coping with chronic diseases. In: Zeidner, M., Endler, N.S. (Eds.), Handbook of Coping Theory, Research, Applications. Wiley, New York. Magni, G., Caldieron, C., Rigatti-Luchini, S. & Merksey, H. (1990). Chronic musculoskeletal pain and depressive symptoms in the general population: An analysis of the 1st National Health and Nutrition Examination Survey data. Pain. 43, 299-307. Mandal, M & Palchoudhury, S ( 1985). Perceptual skill in decoding facial affect. Perceptual and Motor Skills 60, 96-98. McDonald, D. & Bridge, R. G. (1991) Sex stereotyping and nursing care. Research in Nursing and Health .14, 373. McWilliams, L. A., Cox B. J. & Enns M. W. ( 2003). Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain 106 (1-2), 127133. Mitchell, K., & Owens, R. (2004). Judgments of laypersons and gene ral practitioners on justifiability and legality of providing assistan ce to die to a termina lly ill patient: a view from New Zealand. Patient Education and Counseling 54 (1), 15-20. Moore, R. & Brodsgaard, I. (1999). Cross-cultural investigations in pai n. in Crombie IK (ed): Epidemiology of Pain Seattle, WA, IASP Press. Morrill, C., Snyderman, E., & Dawson, E. J. (1997). Its not what you do, but who you are: informal social control, social status, and normative seriousness in organizations. Sociological Forum, 12, 519. Novy, D. M., Nelson, D. V., Hetzel, R. D, S quitieru, P. & Kennington, M. (1998). Coping with chronic pain: sources of intrin sic and contextual variability. Journal of Behavioral Medicine. 21 (1),19-34. Nowicki, S & Hartigan, M (1988). Accuracy of facial affect recognition as a function of locus of control orientation a nd anticipated interp ersonal interaction. Journal of Social Psychology. 128, 363-372. Portenoy, R. K., Ugarte, C., Fuller, I. & Haas, G. (2004). Population-based survey of pain in the United States: Differences among white, Afri can American, and Hispanic subjects. The Journal of Pain. 5 (6), 317-328. Price, D. D. (1999). Psychological Mechanisms of Pain and Analgesia Seattle, WA, IASP. Prkachin, K (1992). The consistency of faci al expression of pain: a comparison across modalities. Pain 51, 297-306. 58

PAGE 59

Rahim-Williams, B., Riley III, J, L., Herrera, D., Ca mpbell, C, M., Hastie, B, A., & Fillingim, R, B. (2007). Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics. Pain 129 (1-2), 177-184. Riley, J. L., Wade, J. B., Myers, C. D., Sheffi eld, D., Papas, R. K. & Price, D. D. (2002). Racial/racial differences in th e experience of chronic pain. Pain. 100 (3), 291-298. Riley, J. L., Robinson, M. E., Wade, J. B., Myers, C. D. & Price, D. D. (2001). Sex Differences in Negative Emotional Responses to Chronic Pain. The Journal of Pain 2 (6), 354-359. Robinson, M. E., Gagnon, C. M., Riley, J. R. & Price, D. D. (2003). Altering sex role expectations: effects on pa in tolerance, pain thre shold, and pain ratings. The Journal of Pain 4 (5), 284-288. Robinson M. E. & Riley J. L. (1998). Role of nega tive emotions in pain, in Gatchel R. J. & Turk D. C. (eds): Psychosocial Factors in Pain New York, NY, Guilford Press, pp 74-88. Robinson, M. E., Riley, J. L., & Myers, C. D. (2000). Psychosocial contri butions to sex related differences in pain responses. In: Fillingim, R. B. Sex, sex, and pain, Progress in pain research and management 17. Seattle, WA: IASP Press, 41. Robinson, M. E., Riley, J. L., Myers, C. D., Pa pas, R. K., Wise, E. A., Waxenberg, L. B. & Fillingim, R. B. (2001). Sex role expectations of pain: Relationship to sex differences in pain. Journal of Pain 2, 251-257. Robinson, M. E. & Wise, E. A. (2004). Prior pa in experience: influence on the observation of experimental pain in men and women. The Journal of Pain 5 (5), 264-269. Robinson, M. E. & Wise, E. A. (2003). Sex bias in the observation of experimental pain. Pain 104 (1-2), 259-264. Robinson, M. E., Wise, E. A., Gagnon, C., Fillingim, R. B. & Price, D. D. (2004). Influences of sex role and anxiety on se x differences in temporal summation of pain. The Journal of Pain 5 (2), 77-82. Romano, J. M., & Turner, J. A. (1985). Chronic pain and depression: doe s the evidence support a relationship? Psychological Bulletin 97 (1), 18. Rotter, N & Rotter, G (1988). Sex differences in encoding and decoding of negative facial emotion. Journal of Nonverbal Behavior. 12, 139-148. Sheffield, D., Biles, P. L., Orom, H., Mai xne, W. & Sheps, D. S. (2000). Race and sex differences in cutaneous pain perception. Psychosomatic Medicine. 62 (4), 517-523. 59

PAGE 60

Slocumb, J. C., Kellner, R., Rosenfeld, R. C. & Pathak, D. (1989). Anxiety and depression in patients with the abdominal pelvic pain syndrome. General Hospital Psychiatry 11 (1), 48-53. Stinshoff, V. J., Lang, E. V., Berbaum, K. S., Lutgendorf, S., Logan, H. & Berbaum, M. (2004). Effect of sex and gender on drug-seeking beha vior during invasive medical procedures Academic Radiology 11 (4), 390-397. Sullivan, M. J., Tripp, D. A., & Santor, D. (2000). Sex differences in pain and pain behavior: the role of catastrophizing. Cognitive Therapy and Research 24,121. Tait, R. C., & Chibnall, J. T. (1997). Phys ician judgments of chronic pain patients. Social Science & Medicine 45 (8), 1199-1205. Tamayo-Sarver, J. H., Dawson, N. V., Cydulka, R. K., Wigton, R. S. & Baker, D. W. (2004). Variability in Emergency Physician D ecisionmaking About Prescribing Opioid Analgesics. Annals of Emergency Medicine, 43 (4), 483-493. Tayler, J & Johnsen, B (2000). Sex differences in judgment of facial affect: a multivariate analysis of recognition errors. Scandinavian Journal of Psychology. 41, 243-246. Turk, D. C. & Melzack, R. (2001). Handbook of Pain Assessment New York: Guilford Press. Unruh, A. M. (1996). Sex variations in clinical pain experience. Pain, 65 (2), 123. Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does sex affect appraisal of pain and pain coping strategies? Clinical Journal of Pain 15, 31. Vallerand, A. H. & Polomano, R. C. (2000) The relationship of sex to pain. Pain Management Nursing, 1 (3), 8-15. Wade, J. B., Dougherty, L. M., Archer, C. R., & Pr ice, D. D. (1996). Assessing the stages of pain processing: A multivariate analytical approach. Pain. 68, 157-167. Wade, J. B., Dougherty, L. M., Hart, R. P., Rafii, A. & Price, D. D. (1992). A canonical correlation analysis of the in fluence of neuroticism and extraversion on chronic pain, suffering, and pain behavior. Pain. 51, 67-73. Wagner, H., McDonald, C., & Manstead, A (2986) Communication of individual emotions by spontaneous facial expression. Journal of Personality and Social Psychology 50, 737743. Walsh N, Schoenfield L, Ramamurthy S, & Hoffman J. (1989). Normative model for cold pressor test. American Journal of Physical Medicine and Rehabilitation 68, 6. 60

PAGE 61

61 Wehrle, T., Kaiser, S., Schmidt, S., & Schere r, K (2000). Studying the dynamics of emotional expression using synthesized facial muscle movements. Journal of Personality and Social Psychology 78 (1), 105-119. Weickgenant, A. L., Slater, M.A., Patterson, T. L ., Atkinson, J. H., Grant, I. & Garfin, S. R. (1993). Coping activities in chronic low back pain: relationship with depression. Pain, 53, 95. Weir, R., Browne, G., Tunks, E., Gafni, A., & Robe rts, J. (1996). Sex differences in psychosocial adjustment to chronic pain and expend itures for health care services used. Clinical Journal of Pain 12, 277. Weisse, C. S., Sorum, P. C., & Dominguez, R. E. (2003). The influence of sex and race on physicians' pain management decisions. The Journal of Pain 4 (9), 505-510. Woodworth, R. S. (1939). Experimental Psychology New York: Holt. Woodworth, R. S., & Schlosberg, H. (1954). Experimental Psychology. New York: Holt. Zatzick, D. F. & Dimsdale, J. E. (1990). Cultu ral variations in res ponse to painful stimuli. Psychosomatic Medicine 52, 544-557

PAGE 62

BIOGRAPHICAL SKETCH Ashraf Faris Alqudah was born on November 11, 1975 in Ajloun, Jordan. He grew up in Ajloun until he graduated from Ajouln High School in 1993. He moved to Amman, the capital city of Jordan, to study at the University of Jordan (JU). He earned his B. A. and M. A. in Psychology in 1997 and 2000, respectively. He worked as a teaching assistant for 1 year at JU upon receiving a scholarship to pursue hi s Ph. D. degree in Clinical Psychology. Upon finishing the teaching assistant year at JU he was admitted to the Graduate School at the University of Florida (UF) to work on his P h. D. in Clinical Psychology at the UF Health Science Center, College of Public Health and Health Professions, Department of Clinical and Health Psychology. Upon completion of his Ph. D. program, Ashraf will join the faculty of the Department of Psychology at JU. He has a 4-year-old daughter whose name is Sarah. 62


xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20101113_AAAAFW INGEST_TIME 2010-11-13T07:17:16Z PACKAGE UFE0021122_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 54959 DFID F20101113_AAAMYS ORIGIN DEPOSITOR PATH alqudah_a_Page_62.jp2 GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
b772e29ec908b93610382f4e8c39684a
SHA-1
bc35080a1d4b55def44de7b6b9f968418c90e0b2
51938 F20101113_AAANAT alqudah_a_Page_15.pro
2999a701443b386ac8ffc79519134762
e2a4d4d435331213581a8e5830643962efa5c7e5
2035 F20101113_AAANKN alqudah_a_Page_06thm.jpg
9700a14432295325f726ec2fb4e889c4
294127f51544c72fe2ef328a3d594c75d20290da
58481 F20101113_AAANFQ alqudah_a_Page_10.jp2
8689261d5bc8121102ba1903f042f96e
5aaabfe800cb7854bc017d2c0cf2e8e4c0e4c442
130303 F20101113_AAAMYT alqudah_a_Page_58.jp2
59b639b225db950410a591d9022b1b32
276a2c2d13b004211239a67b3fabee88c4fdd886
84323 F20101113_AAANAU alqudah_a_Page_57.jpg
6a048acc68eb2456a42fb799ef0bf554
d9affcf3137b85d0ef873293b8da88fe5f45d7ab
22148 F20101113_AAANKO alqudah_a_Page_09.QC.jpg
4da45db390abc4ef99b1696cec255d1f
75d8c5988877ca58d0a347d1fc0dd46a0660887e
115699 F20101113_AAANFR alqudah_a_Page_13.jp2
2ad7568bd43c5ce9476177e0e6fe5a64
32b872077c1973621f2a6ab4b4e3e334e66f54d5
1053954 F20101113_AAAMYU alqudah_a_Page_23.tif
4abedb4b359d9c7a061b4a907c41fff3
3928481b76306c08a7b6e6df9fc66c6c84dfd7f9
7072 F20101113_AAANAV alqudah_a_Page_14thm.jpg
587f27bc26b938fb0fdc0abe205b3253
99a8be372abd976f5513dd135e9426729271ff57
6189 F20101113_AAANKP alqudah_a_Page_09thm.jpg
a562b6b32196692f75b8c9805191cfd2
70b156b3333c46f629771d0eca2a8eb760e405f8
121351 F20101113_AAANFS alqudah_a_Page_14.jp2
62b4479e4d32e4eccb6ae1301ecc3932
a4bfe003a9673b8a53936f2731d857bc91c0605c
F20101113_AAANAW alqudah_a_Page_55.tif
0e2401b9da81ed989c91cf67d7b9b71b
4dd144398480349e1bc85899a9a8ef292cbc864e
13910 F20101113_AAANKQ alqudah_a_Page_10.QC.jpg
1fdb1557c34a0df167e09f6ab2e0241e
a6fcf479505dc4367e5777820ebc114fed3d4164
121044 F20101113_AAANFT alqudah_a_Page_16.jp2
1d771e1e4d96c2e5a9c86c522f5f7ae8
032d1be04b7c48fab432cf7774d12b1d5c1efa8f
68969 F20101113_AAAMYV alqudah_a_Page_09.jpg
34149c87c9e9fa3f9ffc5a6581c7a5ce
60d7781f1a35053001fb51f9817c50f174349e2b
75237 F20101113_AAANAX alqudah_a_Page_33.jpg
348b22f59a2bad97647c904eae7665f0
8f91a038a4f1f349f613fad86fbe0dbdce6371b6
6480 F20101113_AAANKR alqudah_a_Page_11thm.jpg
acd86ba4745c1ed91b36a0669d69535c
bc7b5bddec8ac92c27c9a2f426497e3855e7dfda
117964 F20101113_AAANFU alqudah_a_Page_17.jp2
541fc39125dcf3d27b499e777a62cae7
ea5445f2082a4e068c2c564f809416b7f628034e
73140 F20101113_AAAMYW alqudah_a_Page_25.jpg
234ceb555de06d50b5b69b41089e4e4f
4f51f7c3fc99025136f38a84e7f3e33cc6f4ddec
5588 F20101113_AAANAY alqudah_a_Page_30thm.jpg
3231b5835b411caf3c3c04c70d14a548
a65f81ffeabf9e23b734405108f316ddf0017046
6717 F20101113_AAANKS alqudah_a_Page_12thm.jpg
5e290b1dbb712b16afc631dd2a7523c4
4e374ea8798ba2946d85b11d827919bc2d8d9377
115104 F20101113_AAANFV alqudah_a_Page_18.jp2
5436e2d1b4861a1e48092ee32236d27a
a66a266262ae93e97b428dee51e93fb8001a7b85
2174 F20101113_AAAMYX alqudah_a_Page_12.txt
d5f444656792df225ea06a576403d314
dba2f176be42513e946e844d300d0036906aeee5
24298 F20101113_AAANKT alqudah_a_Page_15.QC.jpg
1ed31130bfa196bf2ba7726db5428ce0
b3eeccd61e0a1bee7dcf59f4778e42f2ba6a07b3
122562 F20101113_AAANFW alqudah_a_Page_19.jp2
b4e308f57bd3703f4570973aa2c61c0d
0722f3ce936a6166cb1453d57614533a1f0865f4
54683 F20101113_AAAMWA alqudah_a_Page_17.pro
a8972e9b0ddfdacac42958bbdc816d5e
17f09bfeedaf7e322ca4063378c7e3a384bc065b
78867 F20101113_AAAMYY alqudah_a_Page_16.jpg
031deaabc4dbe93a7e1ab83c057544f5
367e14c9c8391bc7b8b3afdf12d535ce994d5604
F20101113_AAANAZ alqudah_a_Page_60.tif
84181f0226cb97136348f829451c28b7
7c74b08497adc33fc3f7618f9d68fab9f2e9f774
6934 F20101113_AAANKU alqudah_a_Page_16thm.jpg
38b68c2b9bf9ce1f8676f48e51aed48a
71758b5ba78deb881d0f9462adaf9296e384811c
119999 F20101113_AAANFX alqudah_a_Page_21.jp2
113aa8555a5e4b0b35359fe65d29a296
cf2fd184b1b5f7c988f92a2dc14ebb46aa2aa66f
19697 F20101113_AAAMWB alqudah_a_Page_35.QC.jpg
583a45e980965d4133ebed82a6a2cb5f
6abcb458dcfc2bb9d51a2a6ab5fd9cb75311511d
6697 F20101113_AAAMYZ alqudah_a_Page_15thm.jpg
63017c3d9727388b558b2b1977417078
12a49e0adce4e51a0b265fc4623e285d0ae7acaf
6893 F20101113_AAANKV alqudah_a_Page_17thm.jpg
17e80b6df0bb85ff0e70fef5025b1e51
60b6bd466dea498d670b331fc8be252982765132
121772 F20101113_AAANFY alqudah_a_Page_23.jp2
a2a862570a7966ef1f48d40cdb89ff12
7f9808edbd4669f9e1425905595752332efc115d
1170 F20101113_AAAMWC alqudah_a_Page_41.txt
5ed4017bae1d5d63740ac6218ef0eddf
0c2781142c3c7a1ea67b3812bc2a226a3a9ee977
26757 F20101113_AAANKW alqudah_a_Page_19.QC.jpg
00ce75c931bfc413f57a8220db40d0f8
c85ba7406810f8105dec68b8d27ca24473d4cac9
F20101113_AAANDA alqudah_a_Page_41.tif
1f5576392bfa9af281d34cd1259924df
1c5191d73b90c4f2d50faf2a937c322c8bdc7502
112781 F20101113_AAANFZ alqudah_a_Page_25.jp2
b4f1d7eb5e955957e194c3ed7e6548bd
a1d37e5eac73bf9f40699583310fc838d78c9154
F20101113_AAAMWD alqudah_a_Page_29.tif
b0a871561fd336c2e7677cddb2d42be2
c1104cf8985376c7577410b0078cf91043022d38
25157 F20101113_AAANKX alqudah_a_Page_20.QC.jpg
667feee25b8e56b65fc42ae7b584c8ef
90f271ab117a6261059139f225893e9bf862d216
F20101113_AAANDB alqudah_a_Page_40.tif
fa775a62f4ff6e44cd4ae42a5a43bf64
f9461d05cfa5f8164da2f925a8b276b5db057182
F20101113_AAAMWE alqudah_a_Page_04.tif
c7c074b9219ad3ca1ad4bdc812e2190d
8d5d8b43d800448f6986d3cf55d88d35b8528508
6975 F20101113_AAANKY alqudah_a_Page_20thm.jpg
7de5efeb9ad10ca78eb1fc7a41973527
f549e204002b6d9d19742ca67d9de2269c989115
7174 F20101113_AAANDC alqudah_a_Page_28thm.jpg
a53e4c50b84549a22fb2e20c31d57762
b93aa4025d96c954bd5736bc6fbb37bba68e8d19
5652 F20101113_AAAMWF alqudah_a_Page_02.jp2
e7be804c21585760e4fadc107d69643d
b30a1d8824f0cbe9eadf453af7253edf0de916bc
F20101113_AAANIA alqudah_a_Page_58.tif
9278f3602169a23958ba695ee61adc62
d54f01c49d5abded5337d3e7e08cb7fb7aa37307
25627 F20101113_AAANKZ alqudah_a_Page_21.QC.jpg
31bedcaaf0c611ef8018a28c1d28ca78
c217ebca54f2780b54ea9aca5d962636802b0cab
64848 F20101113_AAANDD alqudah_a_Page_45.jpg
d6ad48938daa37a568ae1da10d0c81aa
899e67f40b2e15d0c751086c418c1fcd01d9c127
2167 F20101113_AAAMWG alqudah_a_Page_16.txt
c162d0d75d4e16db30987cc36878aabd
538c3955a124ee04a6bd5bd8cef5b023e45baf1e
25714 F20101113_AAANDE alqudah_a_Page_14.QC.jpg
6b9bc078bbb2138bba70dc80e05dd975
5a25dffc1af95ea4a65101c974087d2b4b0863e0
25919 F20101113_AAAMWH alqudah_a_Page_27.QC.jpg
edddbfc4d2d8b2b300d72a19931ddc66
5b7dbce05951f6b0c95728ad95fa993e53ed5475
F20101113_AAANIB alqudah_a_Page_59.tif
a9097d8caecded0dcc8ff0f5d7e1c478
efd74b2c1322cbfff82bea201134c518b17cf426
1794 F20101113_AAANDF alqudah_a_Page_37.txt
94cc06c7fac3e7983c34820d34b7e606
316448e12ffdc65b18171fa17a240a5edcbc3ea8
28387 F20101113_AAAMWI alqudah_a_Page_01.jp2
29963899812c2b7b1443287a71b2d667
a881db4e1dba6ad3887cb54b3199e986cd1d81a8
F20101113_AAANIC alqudah_a_Page_61.tif
276f8bdb9e4f5a3abdc3049a706874b6
4d646b5104119483fa357497529fa5660eef4e34
48069 F20101113_AAANDG alqudah_a_Page_11.pro
1b170ecdf347c4c07083edd54149a076
03077f7475a14af8ff620a3e6c4cf770f895156d
2230 F20101113_AAAMWJ alqudah_a_Page_19.txt
77f39625e6468bf7cc224ea66ebd6c67
fefb0318a9af82b0a6cf47c1b95d7c5fcd5d7fd6
6112 F20101113_AAANID alqudah_a_Page_03.pro
83658a279e1a6de3e8b95a8320ea9e3d
6781b7960b0e935b1fb4d02fefc3266db7dc1a26
2168 F20101113_AAANDH alqudah_a_Page_28.txt
0018f9044304d8cb4683bf550fc3f524
ce7baa737c38467a7d09349e71f09ecb9d76aafc
26216 F20101113_AAAMWK alqudah_a_Page_23.QC.jpg
61af7bcdc620e14e652cc8473d93be57
342b8fee4eedfb11d2e5a621881d0a81729c1bd4
74855 F20101113_AAANIE alqudah_a_Page_05.pro
85417df971535713940b223709312758
8b60ce0efe2eb5de2a54bf7287e9aeb40d59a7fb
F20101113_AAANDI alqudah_a_Page_50.tif
232d9ec5cd40a390ca60ebcdf7ce8d86
8f23cccf623955acde057376b3936f2ebbc600f6
F20101113_AAAMWL alqudah_a_Page_15.tif
a547dbf2ff1174f130cd176d805fb26f
87458a43cc0883af02c5d8b0fc4fbe40ff882945
12559 F20101113_AAANIF alqudah_a_Page_06.pro
575a538dced506344cdf80f90ebe604f
77f68e5575737cfe5cda354931106f9cd4460e4c
1051904 F20101113_AAANDJ alqudah_a_Page_47.jp2
4f134a3950ac870f8159ffd20bcaa452
97ded19f1bf10af44ee86cdcd1403120ca08eb6b
2166 F20101113_AAAMWM alqudah_a_Page_22.txt
ea358e990f0ea757f18c1c0a92afa8f8
7b6b0336c0c1bfccb7900a7ace8db54841d8ae97
55161 F20101113_AAANIG alqudah_a_Page_12.pro
311a92e629c7fe5a19babd17f00d3bdb
35c5ae71936d18532fce24c70e75a5155c4f0201
25271604 F20101113_AAANDK alqudah_a_Page_07.tif
6abc1e745c344242b7d3f1bf13342f1d
ff1750ed76333928c4ec94df767bf4cee6a59d0e
77154 F20101113_AAAMWN alqudah_a_Page_17.jpg
cac47dd46fdf07e61908e9cc004ab55e
193e4b8c7a743f2735ad0557af9a24591e5fd0c8
53699 F20101113_AAANIH alqudah_a_Page_13.pro
bb6442c234b630dcd9350f98bd9adcb5
52175d0da3c58bace17096d697a1f06b2e160850
86108 F20101113_AAANDL alqudah_a_Page_47.jpg
50e0e53d748b40bce23c69f3b24a6a97
a8be5f8f371dfafaf10de3eeb14c43e6b97688ad
2140 F20101113_AAAMWO alqudah_a_Page_21.txt
a4bb174acc221ac57b606c23cf6417d1
8a4d155c29c08d85244bffa46cbd54ce0aa69435
55201 F20101113_AAANII alqudah_a_Page_16.pro
45ab386f76fea2d4d10db6b95bc6743b
bb98a75532ff342bcc4b2337be44521690ff711b
87877 F20101113_AAANDM alqudah_a_Page_45.jp2
f591a471942be95d0b07602d403cd38e
22918cc6236fa74d0bf7cc371f26189704f4ed3d
50381 F20101113_AAAMWP alqudah_a_Page_25.pro
ac1e314cd927850f3d3784fd3f2c1edf
1e7f7dc547a947a53a4e1555f1028574a83b73f3
52334 F20101113_AAANIJ alqudah_a_Page_18.pro
0cf1a915351378ecb73b2ed6bb198811
4f94844b74d4a387da7d860c13d87069b8a6a6f0
2364 F20101113_AAANDN alqudah_a_Page_39thm.jpg
8b3f200eda901d69c4a3d240cffd3723
e9ed68f06d34b5efb707cce2dd05424afde5b339
53883 F20101113_AAANIK alqudah_a_Page_20.pro
db12b946d5120fcf1da0eef011453ea4
2737deeabfc365a9ff4f84b260bbedeb54847767
F20101113_AAANDO alqudah_a_Page_62.tif
d34260cdf8beb522df789a3028a5263a
32df4704cd06d35a2e38b1abc6680b55df3af3fb
44348 F20101113_AAAMWQ alqudah_a_Page_37.pro
30c24f60b3700c94bf46deab6766c36a
e5f94a1031111cdfa0559e6d80cc5037bbecffc0
54409 F20101113_AAANIL alqudah_a_Page_21.pro
7e5ca6ade31a05d549320d26c0691253
dac279a1115445d0bb878da30979ad8ca45cac8b
F20101113_AAANDP alqudah_a_Page_11.tif
912edb8ce488cca478c575143ae23aa3
9fefe9b0196833b6689ed81ac6fa1c8d6a2819e9
6750 F20101113_AAAMWR alqudah_a_Page_18thm.jpg
11a5355e6bf7af0c67be8b58b358afdf
79d00a4df2486eb6828689b0584f26d962592754
54413 F20101113_AAANIM alqudah_a_Page_22.pro
72451ca12e9e8cc84ce158650554cb4b
9876fddff0c34feb6147998293f9bd399c49f1a2
46447 F20101113_AAANDQ alqudah_a_Page_38.pro
8aaa601c675b4f8d3218a3f17d25d694
2d37240b170cfd1f8e7a68e6414ca7b99d6eb63c
115474 F20101113_AAAMWS alqudah_a_Page_32.jp2
964e1b008f430f66dbcad39db300eba9
a0689c55a12b2f84fb85360224316a126431dc12
56037 F20101113_AAANIN alqudah_a_Page_23.pro
ba1d13c15d2c55a6982af2b7fb82bfd3
7b171c3af554df9e7a01e99a7dfaf8f27295aabd
25026 F20101113_AAANDR alqudah_a_Page_57.QC.jpg
c1c8c9daf24d239b8805467bb63aade9
33e2f2e541085be1eb84e41036cec88f580a4512
3982 F20101113_AAAMWT alqudah_a_Page_10thm.jpg
2c32a9ab8c6a1484b17f530d4eb53bb3
d92d28ccfc160a00c3224e7b11eff3011894253b
55179 F20101113_AAANIO alqudah_a_Page_27.pro
ae8a699103f25a226559e237606e03f5
82ec148c901a731d1a80c3af8224ff0adaafe988
46452 F20101113_AAANDS alqudah_a_Page_09.pro
60ac475e4706d27e34e7d0fb2a9e5e17
419535b052935fff6d9f0726d2fd99c183d77d39
22108 F20101113_AAAMWU alqudah_a_Page_38.QC.jpg
777e7d040eeaac521cec3e9e26e8d465
09cb7f69992df3927aed7381eb414397e010cdfa
54328 F20101113_AAANIP alqudah_a_Page_28.pro
d356ae0dd64118dcae23d4189c37fc06
8e4c84edce364fabe5e8c7270f47ef5328bf3cab
91766 F20101113_AAANDT alqudah_a_Page_43.jp2
44f199259f24e506d7d5a268caec55d3
4fcfbec22a694ad45d1983e5f7d50a2d59395f9a
6821 F20101113_AAAMWV alqudah_a_Page_33thm.jpg
cf464db19fb160456e0d17e1907f7d0f
002871bc409f8fb3c9c2ff15608384814c7cbcd2
44440 F20101113_AAANIQ alqudah_a_Page_31.pro
81be73abe8a83e1087775f3e665c4822
7f32bfad7bb718b05480878d21117017abf0a924
19995 F20101113_AAANDU alqudah_a_Page_04.jpg
4ec7319eb4ded6c91c7efd58a34caee0
1cb92ae6b7f603698ad3e992bee93753183087f5
F20101113_AAAMWW alqudah_a_Page_03.tif
bb19eca11da422525c31575566ab3b53
1164ce7258ea5d3886fb9f1ad3bdb75c63e5123e
54340 F20101113_AAANIR alqudah_a_Page_32.pro
3f89a2260bc470ab5238eaa045872d33
26e16afff033f911d66edfb4781d58847f5d31ce
130225 F20101113_AAANDV alqudah_a_Page_59.jp2
68b6357c02e231197d8019eb93406a36
c727ce473780394522df8534c38ca4866dc6e0ec
2117 F20101113_AAAMWX alqudah_a_Page_50.txt
b258a217aecda569159eb1ca54b745f9
3b489d2e52166f24c36f295c96ee119526209107
40042 F20101113_AAANIS alqudah_a_Page_34.pro
819655a4b9ca32f93622d3d21df5d6bf
6a9999f2186fe071ce69d5dc14d674895d921e1e
2065 F20101113_AAANDW alqudah_a_Page_18.txt
2d59f9602effcec63e334ea0f621d761
2df1ee50de382e97729c898879096bfe608c9f3d
79075 F20101113_AAAMWY alqudah_a_Page_27.jpg
64059efee1d6445543977c5698a525b9
d08fa1851f929fc52e9df36cebb190dd8c2313cb
41825 F20101113_AAANIT alqudah_a_Page_35.pro
5889bdfb2b24140cfdd8f41411c52755
da996b096185d44f837be0d3a43e95a56d7fe4f0
2500 F20101113_AAANDX alqudah_a_Page_58.txt
05204dcda10277f2a95ac397388693e4
de697043e95b9cf36a457d119f4def49cd912774
56847 F20101113_AAAMWZ alqudah_a_Page_19.pro
175dbe58011e8b41b9d77558673d7e6e
287b19c20c8e178962b4da13a559888f9d5f6df8
43898 F20101113_AAANIU alqudah_a_Page_36.pro
be31d6f8639a6fc3e9cdb19458339c18
081cbbdb02225ca851f723d0eb74893ccbedfbf5
113723 F20101113_AAANDY alqudah_a_Page_15.jp2
ef5807d595b26678c579f1b380f92b59
640fa1e6f8f581204b5521bafc6dc3d1ca6e0ffb
10458 F20101113_AAANIV alqudah_a_Page_39.pro
9e7a03e6e7fa39a166e2eba8361de0be
0452d6fec3ea2d9bab2c933ef6982fc0a8a60444
38266 F20101113_AAANIW alqudah_a_Page_40.pro
aa63cda3e102faff07ac8c4d23223a5d
cc82e76c272d58216e1c9abbf2d43c13b6219b27
117346 F20101113_AAAMZA alqudah_a_Page_20.jp2
0ad6d441ff79bbe6b9bf8431a606f2a8
9674fdae06503129e65b9ba3be05bf65e154ac0e
2188 F20101113_AAANBA alqudah_a_Page_49.txt
1973f55f52fa86d467d601afddac2a53
0a20f34660b445db8c7276b43fa80abf031ffe39
6355 F20101113_AAANDZ alqudah_a_Page_06.QC.jpg
beaa44414f6eb251a60112d7ca24f4ff
f18ebbff60e3ca58f19364fef2bf29fb76e321a3
32660 F20101113_AAANIX alqudah_a_Page_42.pro
f48045516398e5304c3c26c733eed065
1f0c181f4a6c85409edb0b5c131d5a3886102f05
37713 F20101113_AAAMZB alqudah_a_Page_45.pro
b64d6c8f93fa9ccdca26dea5705ff601
db031b3c9ba09b9086e4b25677003dc98745ba02
2141 F20101113_AAANBB alqudah_a_Page_04thm.jpg
17000355b66a9b1c4a9e3fb74fc86255
841b0436e40f847efd60633b62bcae6e4b8a25b5
53887 F20101113_AAANIY alqudah_a_Page_47.pro
d2d126d41c0bea7fa42f30721cfc2c6b
6a68cd4d84d9ddb7fddbfaf7573644e8aa5b0619
F20101113_AAAMZC alqudah_a_Page_20.tif
e549b6c0bf6d4de7f214cedd18a54cb4
8dd60380c11c6d12d6fe867a4aabcc54ef05ffcb
25263 F20101113_AAANBC alqudah_a_Page_33.QC.jpg
94335ea2b1c39bc0aa7bef1f0d8caae6
3e7431d30202f3420bf26c67fba0a3344d758c3c
121178 F20101113_AAANGA alqudah_a_Page_27.jp2
02a576df78a55a7599d4178cba1d3fee
88c80976b4b89e41c0a5c0d220f1b6cfce91788d
57307 F20101113_AAANIZ alqudah_a_Page_48.pro
9260e13b77a236b8e75d18579b3ce6cb
9a9c1c68fbde2372d3dbfd6b4b0baed053a1f587
36381 F20101113_AAAMZD alqudah_a_Page_46.pro
a3d923e0742f621b326f8beb39dcdd62
334ddb973c3daf52cb48de470c245f00378a5386
1161 F20101113_AAANBD alqudah_a_Page_61.txt
ea45e392e207491cec9f67db412e403a
6a32a6ec82da210408562092d4e47d6bd0b2d83f
119947 F20101113_AAANGB alqudah_a_Page_28.jp2
913a3ab68021cbae6277409d7a32b660
614e4eaab73e8863c246dbacfbf5779cfa5e5589
24508 F20101113_AAAMZE alqudah_a_Page_18.QC.jpg
558c37450acf20908404fa3d826f9785
76aec1c37778e0315475bc0218025f523d7d2e42
25227 F20101113_AAANBE alqudah_a_Page_13.QC.jpg
9afcd6ab8cf6c00c9c7e4eb7cc85d594
0d8d9afac7cbcacb52a59f2653e12fbc1dbd40bd
7010 F20101113_AAANLA alqudah_a_Page_22thm.jpg
7921699cc9df818a1451303493f6c9d0
98dc9fbdb1af3446c851cf0f71e7f71a603ed671
116068 F20101113_AAANGC alqudah_a_Page_29.jp2
70325b732f41e763ed149d8aa64ae127
f90e2d0461b3474c0e207778f0688ea0208c145f
F20101113_AAAMZF alqudah_a_Page_24.tif
16656a3471cb85fcdc47c0a0deb6c201
8ae7e3cc4991a2b6197b9577001c30534b40bf9c
6864 F20101113_AAANBF alqudah_a_Page_24thm.jpg
a9b29be4b0719566736befd2bf1b6ff1
900cc799ec2ba7ed668b36601574fa2eff8cb842
24258 F20101113_AAANLB alqudah_a_Page_25.QC.jpg
52046c3b8514922940fe26fb0592948f
9a395d9440afeda23d1cf3073cb6913b6c2289e5
101925 F20101113_AAANGD alqudah_a_Page_30.jp2
1e08602d012b4086c151d22f6c4ffb2c
0992910343abb3699badbed6ea06a85991cdfa55
F20101113_AAAMZG alqudah_a_Page_34.tif
575543c569e0c000f6843b3ec7c4c9ba
c22fc4e453aff22f0f0544446b4124087601f8f4
18499 F20101113_AAANBG alqudah_a_Page_42.QC.jpg
a599affcacb7411467db91b57cd8ce3c
da4d836cccbde9294a8a280a1321a833700a6dce
6928 F20101113_AAANLC alqudah_a_Page_26thm.jpg
5a62d6c9dd5bb3bfa15b5f4073169b0f
eca522a0f87783daae2f3cd0571c9ad58e32bf24
90398 F20101113_AAANGE alqudah_a_Page_34.jp2
f86d93cfdc4c7606c6545d9265e042c3
a0bdd14b59453d00e24c1ef36fd4d3c15ea58d3e
4770 F20101113_AAAMZH alqudah_a_Page_52thm.jpg
8e251220e22a44a0b5b411ddb72c4090
8d02c25be37be3fc5f4c65567f7968b1a812fbb6
7226 F20101113_AAANBH alqudah_a_Page_59thm.jpg
35cda716f92e3d7678872f863351de8b
805959a520645b37a098ccdbaebe730ae183159b
6853 F20101113_AAANLD alqudah_a_Page_27thm.jpg
8f7579c3d9b4cfb25330c63e611597c7
27272b21094752abc61c1c08535b1783c09eb154
94583 F20101113_AAANGF alqudah_a_Page_36.jp2
3214036c4339ff6b9ba5827e60982c65
195f4e285c31c5710e29daf5a75376c734b5ab26
3294 F20101113_AAAMZI alqudah_a_Page_02.QC.jpg
0ab0b7a3a4357ff9b7553d99497f65f1
96e78759740d70ea84d7c57633c28fc76b7c2c9a
76954 F20101113_AAANBI alqudah_a_Page_29.jpg
0c4c80e4a3e2d214802dbbdeaed98c09
c0440379d040fa4d3661d2ee8b63bea4c9f14d78
100572 F20101113_AAANGG alqudah_a_Page_38.jp2
73c6ae22c4b001c2cc8ebca34fde75a6
4fbabd9c73c819f58c743ff1c1742931f1d29073
83221 F20101113_AAAMZJ alqudah_a_Page_54.jpg
7070a0f782b8088ac559a1bd0696f03d
e1505872103574dab38560a1cba37de9315728fa
25657 F20101113_AAANBJ alqudah_a_Page_12.QC.jpg
ccff78fb544ff20e20cbf88bd7095ce4
1e3ae26d18eb1c5406c5533b61f3925bb4b45f1f
23779 F20101113_AAANLE alqudah_a_Page_29.QC.jpg
1071aa7c6e07777fc71d0361c4c66117
c8cd88f75cd855ff800b27f1d0fd369f5081d3f7
26828 F20101113_AAANGH alqudah_a_Page_39.jp2
c5acf1b39e308e2e4f6ea4c7e56d6298
7ca7fdcc81e5af338f1e363b70ccebeaa875222f
74333 F20101113_AAAMZK alqudah_a_Page_15.jpg
146ed72ae2d59eebf9d82a93b02aaf49
21d9edbf47125f9b3e9eeb56147d6a497c23e043
1996 F20101113_AAANBK alqudah_a_Page_09.txt
3b003e7476b5cd4402f54be2aa5c7d69
8bc64a8eb5d8c556e4bd8fa00da019cc08ba2e19
6476 F20101113_AAANLF alqudah_a_Page_29thm.jpg
221207c15241878ad7853f008e2a22ad
c59b95a4db6552ce699c8bc7e38b6766a19007e9
76985 F20101113_AAANGI alqudah_a_Page_42.jp2
7f012f07d7d0416e17112ce2929f86f4
1e6b1760a76cfef8b80bb77625cba7a281be63fb
20151 F20101113_AAAMZL alqudah_a_Page_45.QC.jpg
bbc4dee0a793a1bbec1bbf7fac438501
a49e16805a499c06442946387c14adb98abc4cc6
6639 F20101113_AAANBL alqudah_a_Page_13thm.jpg
3b519f8cff967ef78ae4c4e2e2efcf67
fcd292d70d6694461bca2c102411ac989385a1d1
21330 F20101113_AAANLG alqudah_a_Page_31.QC.jpg
8cc436cdc85edd059ce91e0048a364cf
26c019434e8d714ab8076a81ac650c625fcd7928
88185 F20101113_AAANGJ alqudah_a_Page_44.jp2
60edb2ba6b0c47edf6880f74d8502972
6b7e16f0eff40bbec72017f54b4ade90706478e8
3369 F20101113_AAAMZM alqudah_a_Page_05.txt
f0d81805fa9dbf0e43d39a331490bca5
c1bb6bf4e3a2bd738b76f0668ea8c72876a7aa45
115089 F20101113_AAANBM alqudah_a_Page_33.jp2
dd9f5ae6c61369e694eece7decf83349
3f47805a8b833d9bfcac2095e9562fc1f541cfd1
5440 F20101113_AAANLH alqudah_a_Page_34thm.jpg
24e3dfef8e922726ea4a2b67c973bc0c
6753f1fa1454abe8dfee811725337414dfa8507d
85017 F20101113_AAANGK alqudah_a_Page_46.jp2
342d2a7309dd8114b3b79e491aeb7e2f
2fb21f4d7f0a30347d7d3692b7457a072b025040
134253 F20101113_AAAMZN alqudah_a_Page_56.jp2
8114bb1214d151fd9af4b4114422da09
f2f5729a51c9792b61c4b2845eb28ad9759dedb1
986 F20101113_AAANBN alqudah_a_Page_02.pro
04999cfe6e6faa61325e408d23c944d1
d32577c8ded9ddf9e384caac2079137230a39832
5723 F20101113_AAANLI alqudah_a_Page_35thm.jpg
b80cacdcd3a72ff7221719a12e43980e
9e438a91e2789466ccf340918c12438b60e9332c
122295 F20101113_AAANGL alqudah_a_Page_48.jp2
c9345bc6dbdeae21da3fa3dec9f278b6
c3e318a481d6f1abe4e3fb4982236adaaac27990
77053 F20101113_AAAMZO alqudah_a_Page_32.jpg
4bcac72f95cd3c4e527fdc4b7a4c4f88
6c70e911c639336229dd4f4fe89c68f9f2d346b9
30022 F20101113_AAANBO alqudah_a_Page_07.QC.jpg
f5f58187f7a7a370549f6f6e0aeb4b51
ff275389288e5846c8a63021625992925f74c549
21039 F20101113_AAANLJ alqudah_a_Page_36.QC.jpg
a5ab8cea294934576ac2da8e99233ec0
77467f76100541a3ed7fe419a56be20457dcc159
120060 F20101113_AAANGM alqudah_a_Page_49.jp2
c6547889d2cc5e6c58c7710da7cfe618
f158fbddea07963f7ca0db1e063cf4c4fdbef09d
55129 F20101113_AAAMZP alqudah_a_Page_14.pro
0deef5245b46c6e22cf2ac94403fc6c3
027efe5659dfef00f202afff7ba02395c4bb1da1
37385 F20101113_AAANBP alqudah_a_Page_44.pro
57cf1964db7d3b58ba5297f358793c4d
588ff5edbb7b1d7f170159a52bea65aa4991db66
6093 F20101113_AAANLK alqudah_a_Page_36thm.jpg
3c5a89ac6a5093b60949111357642c1d
d5f972182cc2e6827135fc71369ab70d879e8bfd
118434 F20101113_AAANGN alqudah_a_Page_51.jp2
17f2010108594447ba46e1ab5feca571
9809e9d811f8f2e7c859e66e93a0c87aa047b630
7011 F20101113_AAAMZQ alqudah_a_Page_48thm.jpg
899ec09f66b506b1c79d273cc6a36a4e
0b8b8ea84cde63fd9df8bb6c811756175a4d7d13
4236 F20101113_AAANBQ alqudah_a_Page_41thm.jpg
10623056cb386ffe1389b6cd81c45a44
cee22d9cd508202232bc0f0d14c29437aa2b5f87
5834 F20101113_AAANLL alqudah_a_Page_37thm.jpg
742e64ea57eb49782e5dd4ca8dab3e1d
c306faaa97a38dc9c58c9a51557eb30ef110f4cf
73196 F20101113_AAANGO alqudah_a_Page_52.jp2
9bf0b88a7427b1a56eab62a9cfdcd6b8
5816416124423876f777c25ac6a9c472f5b291e0
419859 F20101113_AAAMZR alqudah_a_Page_06.jp2
048fe2691dcf646ed16a3086991643f3
6927742fc3321be251e1e9838b52260bea481f8d
20441 F20101113_AAANBR alqudah_a_Page_30.QC.jpg
b605eb8ea5152611b384427d683ca122
82e46d122a1c4e9bd0539cad674a2cf257f6e345
6429 F20101113_AAANLM alqudah_a_Page_38thm.jpg
e42a86c1164689aebd34bd4e65dcbcba
0e36cd7a162f8b51b75ab37e63c4a5b0a3bf7244
130816 F20101113_AAANGP alqudah_a_Page_53.jp2
555695fa42d13349580d9d9eefc6e274
5e8aada3ec75c4ec61e6092fbb09dcb5bf6ad722
5405 F20101113_AAAMZS alqudah_a_Page_42thm.jpg
2d9e4ac2a69d2ca6263a5bc374a42235
165f15bbff826f2ff412ea7a4287f32a6b08f25e
92 F20101113_AAANBS alqudah_a_Page_02.txt
8750ede48159655a096ec2c414d90457
c94370662c7d613a4f49efa3de9a3e0c1e0b0eb4
7206 F20101113_AAANLN alqudah_a_Page_39.QC.jpg
e0046cfd7301eb6403ef9092cd225bd9
4dcf1330fa5cc0772a9cee2c8107fb4f2d5c49f8
127984 F20101113_AAANGQ alqudah_a_Page_54.jp2
78d20f1e053a204b987d901e7555f2be
dbd95143e67f1f3a61b065f1dde7f5b51d65ff6b
F20101113_AAANBT alqudah_a_Page_27.tif
9eb3e1ee423aa33a16148359c793fb12
bc113313ba226c0cf28a2282986d247229834e94
20860 F20101113_AAANLO alqudah_a_Page_40.QC.jpg
6697d267b89266dd1dc1abcb98b481bf
7e6d4c251c3188c0c5bde9bbbc98f5bc37e1154f
137162 F20101113_AAANGR alqudah_a_Page_55.jp2
a8e49ef72726ebb012c91fdd2053a941
035f53750dd32fbcd6f1eb1c629e5f8f003457eb
21332 F20101113_AAAMZT alqudah_a_Page_37.QC.jpg
3c57395bf45cc3d88d353b32071d4e30
c307d29079cda4d1ca23d6299c4bab2996f2c121
1660 F20101113_AAANBU alqudah_a_Page_08.txt
e23af265010fddc713c0259987f0d92d
97e6492a4f30321a632508cb2cdf1b19ca363da6
5846 F20101113_AAANLP alqudah_a_Page_40thm.jpg
8d6190d4c41aa9770e806994b562c187
18bc045b4c6fc7a43d668f502e058caa3294942f
126090 F20101113_AAANGS alqudah_a_Page_57.jp2
38cead2284183e7a69e3fe0292e2a06e
b59e2844f30673fa280d3be76df857323544afac
F20101113_AAAMZU alqudah_a_Page_21thm.jpg
667a3992f2041135c1dcce633612da1a
eedc31792933874a1d0f1b0d5859b115d7da729a
13513 F20101113_AAANBV alqudah_a_Page_62.QC.jpg
7f23e2cdb1d803ce91673898c6bab61f
0a42608605fee4fa8a8fd54b5625eb3e00a318d0
21143 F20101113_AAANLQ alqudah_a_Page_43.QC.jpg
be267feb5330bf9fd1a4c7fd758ca95d
f7eb6e078e8522dea1a9c8147eaa69383391766c
129410 F20101113_AAANGT alqudah_a_Page_60.jp2
7b922804a86f63e06a1f405c546ae48c
c3492e32a1f34220819f8b5ed306c61399a0e279
F20101113_AAAMZV alqudah_a_Page_28.tif
557e1632cc3547ed0094d2f7263676e5
3eaa3970fd421c7e2eaaa5f20ce6a580d01a4096
F20101113_AAANBW alqudah_a_Page_36.txt
db3c352d7c163af4d25d2121aa3102da
1366a2fb1d3dd37510ffad0b6631f27b9bdfa61c
6069 F20101113_AAANLR alqudah_a_Page_43thm.jpg
901b92130666f9b98f039629ff78a353
1fb60f6926b48b6c88edc4a7f012bd899f54ccbc
62806 F20101113_AAANGU alqudah_a_Page_61.jp2
fad23018779919da1a10f51bf1d4df3c
0db7265942ef14707aa97d8f1f478cdb84c13d70
4458 F20101113_AAAMZW alqudah_a_Page_08thm.jpg
20bf3b9089866210418cc6246e0d5bc1
c88cf492fa9851249e54b464ac32f627ced2ee3c
78037 F20101113_AAANBX alqudah_a_Page_28.jpg
10db3809bb353283f48cfacb92686a74
aac1203caa830d8dbfcb75239d885337b69bc704
5901 F20101113_AAANLS alqudah_a_Page_44thm.jpg
9957dda4d13f306a76920edd65f101a6
4d1c8ef04e69449e010a5ce8070b29b78896dbdf
68724 F20101113_AAAMZX alqudah_a_Page_30.jpg
1e5768093feb57f906c9f9a0c5fd1d87
d847d313a045ea7abb79c6be01df08894154f790
F20101113_AAANBY alqudah_a_Page_39.tif
7c68ab5283d469401e4dcc5bf43365cb
487d07bad46273d7c3a3e85e58216845374a72f4
F20101113_AAANGV alqudah_a_Page_01.tif
de1e2a32570b04a3af8540268051a28b
1707bcad3b8c13a83903c2709fcbcd276bcd2ac8
5823 F20101113_AAANLT alqudah_a_Page_45thm.jpg
2c244705c4d6bbb000c2abbdaa9f2da7
ba6ebc49702f80c576283551dc46d4431790c380
7007 F20101113_AAAMXA alqudah_a_Page_19thm.jpg
bf4118ce210a5c9148348976bdebfba7
1a93b6c7175e0ddf93c3b76cc86dc6a11ab49dbe
118112 F20101113_AAAMZY alqudah_a_Page_50.jp2
3d198d3fcda947ce37694ae43fae3310
5946b3d70bc2b703a10acb9acfeefaaa1a73ab4d
26108 F20101113_AAANBZ alqudah_a_Page_26.QC.jpg
325dfff72c2854b21c3deaa3dbdc7b1a
79a467fcdd49bde4d9a3d19096df8b361a7cb7e6
F20101113_AAANGW alqudah_a_Page_02.tif
eae4afcfce9014e603ecf8a2983b6d41
31c49fa08427c722d374777ec95d64e413735040
20310 F20101113_AAANLU alqudah_a_Page_46.QC.jpg
a9ace4d004400dc6714dd6e70a280a92
667a3a83c862315ad3a671cafd31d257655d2324
6132 F20101113_AAAMZZ alqudah_a_Page_31thm.jpg
4697a6485522bd0b9811d476322410f6
c33cb69245481dab4ba5969d770309d0316149d4
F20101113_AAANGX alqudah_a_Page_05.tif
80bbc55891c81d7f9de04ca0c6a07182
ba73a0a49afcd0debda4a87794e19e40c92883ff
F20101113_AAAMXB alqudah_a_Page_36.tif
54e45c6859975147ce8debb05cbc9c83
7f9f90b2b4c9b5d72470b95c0749b54023a69bdd
5883 F20101113_AAANLV alqudah_a_Page_46thm.jpg
6e555e73a8febc7cfd00ba3a9c1f36df
c48fc885923771786425c49096fb1f24ba23c8ff
F20101113_AAANGY alqudah_a_Page_06.tif
677845d942dc7513ecbea35bf9d14a36
69ad59366d830f097ad25d9fe177e29ebc1fe905
65034 F20101113_AAAMXC alqudah_a_Page_08.jpg
ef92eee24e0669d6d3402247079d6cef
a4a16545c6aae8b0941591cdb69bcfef0c1f79ab
25880 F20101113_AAANLW alqudah_a_Page_49.QC.jpg
fd507b1810540889e8dee53ec54edf1a
0595b97739600d9aa52edb7858f30655650a712f
2199 F20101113_AAANEA alqudah_a_Page_26.txt
8d3e41e28cd0603e3100f3c26e308c73
e993b41cfed00c6d326f1bc8e744ec19bd0e2ff5
F20101113_AAANGZ alqudah_a_Page_10.tif
8629a558a4d823e4238cfa4d907b743e
eb716fc23ee3930e071ad0205ef2b184c737b7a2
54302 F20101113_AAAMXD alqudah_a_Page_24.pro
d86e07bff7714721c5ae43d17c78f5a4
11befef8a1affb9be29e277d4aeba3e4aeffb633
F20101113_AAANLX alqudah_a_Page_49thm.jpg
7d3249fc66c37d12a362e7a0ee75a19a
22ec43176fe721156b99c0a0c148abfcc128ba83
8118 F20101113_AAANEB alqudah_a_Page_04.pro
65609d9f8ab49bafb46d554b91209920
c80aa26f79614140a798bd93ebcd7f6e39848b16
2130 F20101113_AAAMXE alqudah_a_Page_33.txt
8aa6299fd1c29bae7c145f53e30ff6da
ff92ce982fc6d77ce4e0be6924e9d99b0d4ff23d
25543 F20101113_AAANLY alqudah_a_Page_50.QC.jpg
aaab7aba45270e070df07d44d8059fc9
5b53be9086d79e5f34b96ab6a0cb6eaa4e92c4ca
55272 F20101113_AAANJA alqudah_a_Page_51.pro
95a21afa5bca1891537f3c2cbd9bd78b
22b7812eb68b2dd12ca44139b431cc103bc053b4
3769 F20101113_AAANEC alqudah_a_Page_62thm.jpg
819b0a939dbfb5ea69b36009d59d032a
5b60e72d48bf10c912b79959ca1453ddd6f9b4f4
20656 F20101113_AAAMXF alqudah_a_Page_05.QC.jpg
50ddbe7804a0d37b4069ea573263230b
9cdbd8467d119b4e35e0845f80c5df26203fe97d
6999 F20101113_AAANLZ alqudah_a_Page_50thm.jpg
cf00db1a883ac4ceea507033fe19af00
a07e818c2e2f8f5146551a367658534e8d064d84
33127 F20101113_AAANJB alqudah_a_Page_52.pro
7d744786a45c8d15dcecc65de8341b7a
39da29e532201f9e9433811d3fdbd2164ff567b9
25319 F20101113_AAANED alqudah_a_Page_22.QC.jpg
5c081ea30e9833146cf768e4ff49189a
02eb7a19188c00cab18ea2481766e916ba1ff435
2424 F20101113_AAAMXG alqudah_a_Page_54.txt
ec2562b49cd65fd980bc61397796e445
151514e6c45558a933e88cd1b50bcfa9741cf0a8
25605 F20101113_AAANEE alqudah_a_Page_17.QC.jpg
e07d6942fe3a05e43f37ac2ab62d7209
92f19184f0247a7ce3d725aa07eae4e1778b8132
47594 F20101113_AAAMXH alqudah_a_Page_30.pro
e28ee962c5b7bb37f45300b6a0174b2d
fd0765e7e376027c9081a30c8529696b17f075a2
62438 F20101113_AAANJC alqudah_a_Page_53.pro
79d2226209ad26dad26bd1304d556622
f9c93555fe477c3c3404ec3334b56dda7c660feb
1849 F20101113_AAANEF alqudah_a_Page_43.txt
e16201bcd06af311fbb5fc50ed5cc9e7
224ca93a75134197efe9cd6b6923e4012e911014
64317 F20101113_AAAMXI alqudah_a_Page_37.jpg
500150d2a5830dced355df913ab7c4f8
a6d61a8fcb6a1f7187c87ee273e11b6b108faff9
59352 F20101113_AAANJD alqudah_a_Page_54.pro
b30d0ee08924ea95447298293b4b7281
3e66025db1525037e91456ca6d2eeca2fdbf3833
10063 F20101113_AAANEG alqudah_a_Page_02.jpg
ed09872bcb36f48c6731f9d390213de0
eab42f2fc48b13578c884486e2972bda0de92238
2609 F20101113_AAAMXJ alqudah_a_Page_56.txt
5df9ca35acb29c00421f6a6d980b17a9
80593846723110b2af7c819021dfcb6b6dced402
65315 F20101113_AAANJE alqudah_a_Page_55.pro
c68d5bdb6093142a3d56e1a3f7342378
cb0beca4c5f16bf3bcc7a75914be2ca476fe7a6f
91131 F20101113_AAANEH alqudah_a_Page_56.jpg
006ac554caaf014a35b3596c138f9ac1
57b105eeb71de6b679974e074d166b296bddbfa5
25677 F20101113_AAAMXK alqudah_a_Page_10.pro
3b722cc80164d061de0e056dbca70afb
a4dbde514eef0056a73fe34fe7b25f873186984f
63819 F20101113_AAANJF alqudah_a_Page_56.pro
ba126a4360deb00e74d2a122d8038bc8
3c392c368fa2ef10265fe693b85bcd71e0f81ee9
2145 F20101113_AAANEI alqudah_a_Page_20.txt
5cb4be9e876effe580f20358d6b7de94
db86da4b020bf0adeed857c2692a95dab5e63184
16229 F20101113_AAAMXL alqudah_a_Page_03.jp2
5d050f3e3ea38a188018a4b256b355e2
396ce3785240f1068127690afed222291d055b78
60077 F20101113_AAANJG alqudah_a_Page_57.pro
91bb68cf164c35a49465586e2b9a2bbb
f477e34209d3377f368f2c22d5cec0eb18ab2ab9
95687 F20101113_AAANEJ UFE0021122_00001.xml FULL
61815f13125d75ae8d30204a03093920
17b4fcc8dfd871bcbe569eb0955076de6217dd95
3133 F20101113_AAAMXM alqudah_a_Page_07.txt
5184d1a789263e25cdae7aa6d97babdb
6cacbbd2f737c8af0034331fbfaa1e7898008c1e
60889 F20101113_AAANJH alqudah_a_Page_58.pro
2665f2d4c4cf8004d5cf0be0c8ed40db
1d8a0c11f6cdea142e6b9a26e779fc4c20dfc43e
2182 F20101113_AAAMXN alqudah_a_Page_51.txt
8d2d9c21c503d98ffe1c88376d1d54ba
dedd504cf44299d6a321e65bef79edc7b7de6b07
60866 F20101113_AAANJI alqudah_a_Page_60.pro
3a34f84bb6fcd28543e3f6291956933b
a183a2f02f02f73ed70c59db4359a6d7553708f4
91932 F20101113_AAAMXO alqudah_a_Page_35.jp2
e30e9bc73995091145b78ffec2a4a9ec
ddc05a6ce2198f7c8a60fdac06cf52e9afc36bf7
28049 F20101113_AAANJJ alqudah_a_Page_61.pro
e07d2d0804b62a5ef6543c2b581616d4
1c444ad1366cbabce7c3d5956026c078f12dcc86
26409 F20101113_AAANEM alqudah_a_Page_01.jpg
eb66b000f61b872e3be75974c608ccda
0316a14fb10506647062783e5e884d7d4ca7c1b8
16568 F20101113_AAAMXP alqudah_a_Page_52.QC.jpg
b1b9983149d7862f185e4cfe5dd155b0
796f476dbd7b839f194b6a7aeac6923557f648c0
24225 F20101113_AAANJK alqudah_a_Page_62.pro
c9654c1dbcea812dffcec8b26e9951c6
021b89c86988f861a4f3197efad2b4a08d3fd855
16861 F20101113_AAANEN alqudah_a_Page_03.jpg
959be6981215bfd10019e614f4e38810
287e833c7263caea3b879610abe5c594398366dc
60364 F20101113_AAAMXQ alqudah_a_Page_41.jp2
e0a601972f7303ea1d63fda8fbbea28a
6d450b669a9e3fabc00f4405637dcb905c3c88d0
485 F20101113_AAANJL alqudah_a_Page_01.txt
1594e241997222da930b94ca955bb2ee
4e3c6e72c251e0a09de815a2aa93024e7987175b
81476 F20101113_AAANEO alqudah_a_Page_05.jpg
962aca59b8f84dd5c9387ecb0a09847b
69f3a2725824d9bc1974092065b2a2a749878ac7
559 F20101113_AAANJM alqudah_a_Page_06.txt
3d8006bf9adcc233829e58b349abbc5b
9c7ca9f26d28ec4302a76f9a937a66fdcceda75e
21704 F20101113_AAANEP alqudah_a_Page_06.jpg
5cf57bb932dd6ec21912d19614f991db
3164065eeef281cc1ed2798de2684b474bc2cddd
96383 F20101113_AAAMXR alqudah_a_Page_37.jp2
a028d728ed54dcc4d8390e7e00399118
4a850d22076626b355a0227eb3ccdb24f023957c
1018 F20101113_AAANJN alqudah_a_Page_10.txt
f7f7cd0ed769583a40b9fafd5e77348b
3fd90d50c3c5397b95df3dbd82ee290f41661423
113588 F20101113_AAANEQ alqudah_a_Page_07.jpg
5cc6deafaf9862078e6175b50cd40b91
21b401d8391384934c21d9999072f5abb72b82d0
F20101113_AAAMXS alqudah_a_Page_56.tif
f896b171a2a6a1f00e1df6aa4824416a
e7c5a4b58e0f587b45e12020d93bb7b0fd44bdfb
1992 F20101113_AAANJO alqudah_a_Page_11.txt
0d58886471616b7aecdd729be48e3e72
0c5dfbb232b666c8265b82c11fa3562639133367
41841 F20101113_AAANER alqudah_a_Page_10.jpg
b8fa9fe91bf3f4cdde1fe52310cf32af
e07afcf1786c20dc0431d653060615da26333825
F20101113_AAAMXT alqudah_a_Page_45.tif
2436e514987ddbe344211c4495f81d19
6fdaee27d7ca389952abef7c59b605bca66fb3c3
2134 F20101113_AAANJP alqudah_a_Page_13.txt
be4b98b5b9a819569f36d9fb407fb182
a7b7f3f08f1014a07252a3c79cd70c125a4826bf
78022 F20101113_AAANES alqudah_a_Page_12.jpg
e2a80f2546a4f3fb0bc5554d6251d389
abe9d05ae0b2c560b6e61762357b530c05976daf
24619 F20101113_AAAMXU alqudah_a_Page_53.QC.jpg
5fb7322978f62774a1d1a36a03d943f8
0810f46cd3265acd2e771e911a5d6ece40aafb5c
2164 F20101113_AAANJQ alqudah_a_Page_14.txt
c58819330f9a46655277837fc9693ac0
13ab9d302093b539f72b60ceabed7a78263aea97
75674 F20101113_AAANET alqudah_a_Page_13.jpg
99b218c7933d091329793185ce4bf1f3
bf0f465d387a1f7b3e64c046a332b8aa8ce71eef
40399 F20101113_AAAMXV alqudah_a_Page_43.pro
a24e8f7b45fff7794414c2def990b206
1141d0ef88f01451c218a8e73c250d9b680dfafc
78658 F20101113_AAANEU alqudah_a_Page_14.jpg
1f56bb5aac23b5254196afd4d3984d76
5fe6901216c0de32d950d18f21798c8e44464b0d
16741 F20101113_AAAMXW alqudah_a_Page_08.QC.jpg
709a2935e07a9cd43d0db616001487a7
994172fa0cbff323f66ee765d2c06305d4945bd0
2172 F20101113_AAANJR alqudah_a_Page_17.txt
454c058a2b5af87977bce28f286d833e
9eeb9bbe0f19ee52de960ed9cf11aa78806bb86a
76676 F20101113_AAANEV alqudah_a_Page_20.jpg
30f64aa3bb5ca319445feb5d9aae4e67
a00c7174157e82e78878754d3c0e09c3e5ed2bf7
52817 F20101113_AAAMXX alqudah_a_Page_33.pro
aebbeef5966c8778bfc09dc5df638070
c77936a3c22a9e05d77466151a0cb38333e22e10
2229 F20101113_AAANJS alqudah_a_Page_23.txt
1b1fdfd9f2b8204c9607111ecf547bae
00a110e97d52627f38558a205fa335a27e5c39b3
62386 F20101113_AAANEW alqudah_a_Page_35.jpg
5bd18cb779523ce8a30743e10bf0272e
9ee4c2dd20387617d5289250015d265ced32c77f
78025 F20101113_AAAMXY alqudah_a_Page_51.jpg
66c5f008f327d5df10b6134723c3df84
a3d41f37e41ecd302cbc652b80c0dced81b951e2
F20101113_AAANJT alqudah_a_Page_24.txt
7da2b96c2e1c3c7c4a44d846a31409d8
58b4a152d50ee43f0665046cedc3e8adeb9dbba5
63696 F20101113_AAANEX alqudah_a_Page_36.jpg
5d4a8dae7cc076502dc2730ade9721d8
a25792888409e2f68fc7dbd7fcad0b00e60e28c7
25161 F20101113_AAAMXZ alqudah_a_Page_41.pro
956a0fae59c5574d791b8efbd9d15736
4ec2dedb144f008d249031e700d7517f891543a1
1998 F20101113_AAANJU alqudah_a_Page_25.txt
da702d07ee23ed6a5468d1b3e65ecf14
6fc7e2aa2bf5d5258d14642bb770cf0a524d0da2
67497 F20101113_AAANEY alqudah_a_Page_38.jpg
111f42f61c62653c60b1ed2bf9a558c3
18c7e48879e48a203ccb81962b4159062b51ae8a
2280 F20101113_AAANJV alqudah_a_Page_29.txt
a6e956311caf32c30eb9ba03b59016f1
b6da6b028b6dad6cb200d94a28be298d47fd97f6
2482 F20101113_AAANCA alqudah_a_Page_60.txt
fdfee678da00b6484e6569f2d8f1b73f
125991fef854dae5729b7579768a28b4474be76d
21657 F20101113_AAANEZ alqudah_a_Page_39.jpg
66ca01dffc93067528723a4dac3011b7
eebe90601f94d1acbc2efa28c9f30b77f95b64e7
1916 F20101113_AAANJW alqudah_a_Page_31.txt
cca369d9207901547ab18fede15c9602
084810ec0aa2c46fe0ac580b9be8ac6cae7c473a
14391 F20101113_AAANCB alqudah_a_Page_41.QC.jpg
138a99fbd8137bdeebd8a242baac144e
83dc028b9142e3897945df467508908991d3d5d2
2139 F20101113_AAANJX alqudah_a_Page_32.txt
c27394bf4dac12b83bdf52a99053c170
a47408590788ab4d1926005052c531d448d7f0ff
6983 F20101113_AAANCC alqudah_a_Page_51thm.jpg
6a16255e2024fd229fb38742b1bbcaba
cf2e9b1ff59a4f3e1aee0a139b24efccd4873afc
1593 F20101113_AAANJY alqudah_a_Page_34.txt
8f4a1db1cf0a4e22825f93c7618a59c1
49c18f421bb1be3c5b898a73ac170733847e5c34
19812 F20101113_AAANCD alqudah_a_Page_44.QC.jpg
604060ea9d038cd9eac7f1a433df86a8
b85ade712173dd3a5bdb3f2d6c4da70c8684e1fa
F20101113_AAANHA alqudah_a_Page_13.tif
ae70221d1d28cba2f226340fb96d31c6
ac0db4708c8796d2c28131a0b63c2772fe66ff57
1778 F20101113_AAANJZ alqudah_a_Page_35.txt
6cfdd4fc5e1d9fe42754b8496a6b268f
3c937c7ef041e7adb4c8b72b6bbe33ac76004e8f
F20101113_AAANHB alqudah_a_Page_16.tif
4d33b1922ae083b38bb9b0ba6df65ad7
96aa2129ea5a8f72b8342c442d2531cb0e8b7f7a
118997 F20101113_AAANCE alqudah_a_Page_22.jp2
d28242176f756a98471aed52eaeacb67
4da71b328a15c000460700082f4bf51d20cc8e48
25570 F20101113_AAANMA alqudah_a_Page_51.QC.jpg
f1e369dce7ea2331320ae279bd188473
d233afe21a2dc8e81c632b8bf1c939108059aeae
F20101113_AAANHC alqudah_a_Page_17.tif
5e34f32b5c39518f8a9ae97801a9964c
8d669a9c38111308ac7e1bb2db62794a6c88c99f
363 F20101113_AAANCF alqudah_a_Page_04.txt
ab533c0c6cebc326554df24c1c7fcf50
30a87b6143946a12b65447b04f69d59cff0bce98
6837 F20101113_AAANMB alqudah_a_Page_53thm.jpg
40216517298f7b09409e76938c85f29a
e8e6b2b952bce3b95a71838120358d5fada55807
F20101113_AAANHD alqudah_a_Page_18.tif
69c6cbef3e5d715a44df60effe1c2321
d6cb89ca356e2f4f95de44fe82af3e687c64b83a
39131 F20101113_AAANCG alqudah_a_Page_08.pro
9011d9e471b6afe1e851e7d3fe151b1f
c187037563abda483a1bbfdfa887c5e4474034d6
25499 F20101113_AAANMC alqudah_a_Page_54.QC.jpg
551e75cf326d6407f79e8a954f8e3a08
d6d55cc7f47036d4fc6eef1dc1470fec74c6ddf3
F20101113_AAANHE alqudah_a_Page_19.tif
62c759cb44928fa6d1927058baf164f1
c084558ce6756538ce8a501153486411746a2e6a
7088 F20101113_AAANCH alqudah_a_Page_23thm.jpg
8260894b15dd29884392b71e394a0018
a987a627f85820e9f99e02f2d0e8bbdef0a321da
6774 F20101113_AAANMD alqudah_a_Page_54thm.jpg
fe8a28428c47122bf00140803812fa7b
de62f317c7a30b8c8b39cf3666174ca8445e35c2
F20101113_AAANHF alqudah_a_Page_21.tif
058ff18b61b489672e5e6399f956e390
8e8d22b08543e77ce0948b0f71d7a8feb40a5742
7019 F20101113_AAANCI alqudah_a_Page_55thm.jpg
100e637b8861032496b0480a2a08df25
bffbe382a5b690d9cb0e0733692c6f547456f578
26788 F20101113_AAANME alqudah_a_Page_55.QC.jpg
b03db408623d8db51fdaa4d14775a832
b6c5d4c8fb5915757af19f5d8238f5c3039ef2ac
F20101113_AAANHG alqudah_a_Page_22.tif
70b83c7baecf3861fc4ce15e98092a90
af57709897952c2c104b2955c8da49ed022186b2
98168 F20101113_AAANCJ alqudah_a_Page_31.jp2
c52e6fc08f976edb0da42fd441504320
30e15d3ee4c7f8f6bbabe4223be672c637a69f2f
F20101113_AAANHH alqudah_a_Page_25.tif
76b851b446d781080004b096e1c57350
48500c05f0a0aeff329ab462545e62c239d8be10
1740 F20101113_AAANCK alqudah_a_Page_45.txt
f102d24bb2fd656a0d468822721e1950
c15a5065305cd2f2ebd70e8cddc952e67a497721
7390 F20101113_AAANMF alqudah_a_Page_56thm.jpg
a7da4fd9c037e7131b0deebc07c1f451
75d65bfd7f020493a543e44356034568f28ece1a
54870 F20101113_AAAMVO alqudah_a_Page_29.pro
2b844961f845badbdc1a48800e826354
bf7d86099de20e6b355b7435df1038fc7ca340db
F20101113_AAANHI alqudah_a_Page_30.tif
db514cffa4266dd9cf81b9105f02b595
55e7aa43d121055692abdab2bb2e57f27276fc45
77421 F20101113_AAANCL alqudah_a_Page_24.jpg
20435824a0b483200b47d996896bded3
a1f7c8cd407ea95f8318856e24ae1220d0bce2fb
25867 F20101113_AAANMG alqudah_a_Page_59.QC.jpg
69eef51073b36efa423451769c384afc
35345a7affe0e23bd132f2c30eff6c6577cc4e7d
F20101113_AAANHJ alqudah_a_Page_31.tif
d56b3e32fe5e99f7b1d17246b862698b
adae3e6a3f8c1151b32568703fff876d9e59e308
6914 F20101113_AAANCM alqudah_a_Page_32thm.jpg
9d68bc53714f12c5f05e9c8a9303db47
53e648ee8d65587fd21974d2ac65a15645b559c4
25228 F20101113_AAANMH alqudah_a_Page_60.QC.jpg
6d02aaca49485fd3abd3d32fbf206de1
bc82d228474cf4af0e577fdf8970d82e844857a0
27064 F20101113_AAAMVP alqudah_a_Page_47.QC.jpg
773ff6b13f904d06cdb551011cc07d2e
3cb433a4fcd9d076bc16411473f383fb1ca0b3a1
F20101113_AAANHK alqudah_a_Page_32.tif
50e5099038721c52026c4f43bfacb8b7
36865280b15d0db27e7c3e8c8679cc2556121ac5
2044 F20101113_AAANCN alqudah_a_Page_15.txt
6db3f0777a1f9edb96e8daab328fd3f2
301a6b5a1265bd8ad8c00ddb305824310210209b
6937 F20101113_AAANMI alqudah_a_Page_60thm.jpg
867893f089fa6d952a303cab34271da7
9886968ca9cc22ff88dd361207de58a7bc995a8c
65999 F20101113_AAAMVQ alqudah_a_Page_31.jpg
106c3ea396b710c7f86cb3bf78898d17
1d47f4964a45c2f5b2c76f3a0d811b51a37c793a
F20101113_AAANHL alqudah_a_Page_33.tif
84a9ceade7b41af713388206edaccca6
62abc8fbaa608e4cf2e81ccd07bbd804cd7b2c86
3858 F20101113_AAANCO alqudah_a_Page_61thm.jpg
1e31b2ff0bcfbd8e53e7471e0043ac16
c9337ee5c20a9855c0aebe70095c9c64471c63db
13671 F20101113_AAANMJ alqudah_a_Page_61.QC.jpg
734557b1b677db602c1d69975b3ff2f4
74a95ee4837780d619b7528a1f894c2e0ac2e124
79389 F20101113_AAAMVR alqudah_a_Page_26.jpg
ff4df40f5df0a4761625afe26b82c7f8
8ece5c80477d0a2992181a900df7c80be0eea2d6
F20101113_AAANHM alqudah_a_Page_35.tif
0e790c738e8816799ee181b6cc9165b8
f6de9971fc1ee5aae1d889cfbf030c5c597495b0
F20101113_AAANCP alqudah_a_Page_49.tif
4e7d8ecbfb92d738a8f52631fc74f519
58bd6a63e571b158fbfcae39b34a01a0332fe048
74277 F20101113_AAANMK UFE0021122_00001.mets
ad3502c35e55b8224ad3927c25db296b
09375d4184b418cde1de38f128145013e724bac9
79632 F20101113_AAAMVS alqudah_a_Page_23.jpg
8418cbcf8cc8435da61b3ad87b4d60c9
0063dc217e16c5f044a391a233ade27b9eab0095
F20101113_AAANHN alqudah_a_Page_37.tif
db967b8141264a379741f8b7ff1d8841
b7ce08d9259258144bc244e9dac6e483ff9c4439
1051924 F20101113_AAANCQ alqudah_a_Page_05.jp2
e298af8b2719cf871a820494802e0c56
6af5e57c18b69b8b0cb914f8958d49bacb5fc8f5
62906 F20101113_AAAMVT alqudah_a_Page_59.pro
0cd08950a76224e4dcc0e26e55815c2f
b854b12e2ef4ad98d1fd7f513414a1b7c57a0a5f
F20101113_AAANHO alqudah_a_Page_38.tif
98ed55cf77219946b9f739b89ad565e5
bca36aea840b39f23ea03485205cba7a3346f0f4
24990 F20101113_AAANCR alqudah_a_Page_58.QC.jpg
a21804e231c3d357c41f1c9ad8ed8ba6
fd6048fad8bdb453e075d986eb552696ba05ce48
78132 F20101113_AAAMVU alqudah_a_Page_22.jpg
3f087f7160482ec081bfb876bce05631
67bc22e615b8a284ed765ad8de84979e578e17f4
F20101113_AAANHP alqudah_a_Page_42.tif
df7ac8612b9d162fcf78e05791935e82
6844db5e77b51519a1b7a316b5230a3ffed3b9c4
54901 F20101113_AAANCS alqudah_a_Page_26.pro
181d190b02067e0504b56f45e8c4bc5b
608f18e0b96562ee07c64b62d0d266f930a106bf
26632 F20101113_AAAMVV alqudah_a_Page_56.QC.jpg
00445687b812ac3e8e56aade5b6dc439
24dc248f97d942b6a493507252203b531d49d8a1
F20101113_AAANHQ alqudah_a_Page_43.tif
72de9bc8b557060414d5b8f31db3fc86
e552962b81fba827b9aff8db2135d8dca214ec0b
1051981 F20101113_AAANCT alqudah_a_Page_07.jp2
232204a8f64ad372173eee3990b8f21f
5b29753c929406c4baa90a08ec9e3f35a580fb6f
78172 F20101113_AAAMVW alqudah_a_Page_21.jpg
22f469ac383801753e5876af76893c53
0b63c2677dd7d4220b1159a4737cff408405091d
F20101113_AAANHR alqudah_a_Page_44.tif
30118d91b1da1ad140dab9a430bb13e3
3fbb2875e4be6ea3e08fe64c6c935ef694ffad98
25347 F20101113_AAANCU alqudah_a_Page_24.QC.jpg
bd288ffd538662c0365a302aea486a28
87e2dd53b3dfc642332e39bf7c3268084b5b1b20
F20101113_AAAMVX alqudah_a_Page_09.tif
9e031afadf5fc5fc075421b2b6f1a342
3d7a9c18b9a05c8087b66d7ae7a95e9d86e0f07d
F20101113_AAANHS alqudah_a_Page_46.tif
40369debc479845e79acd288d2264f93
7fcc027a51acc33cfa16a457c0da79730fb8f75a
120489 F20101113_AAANCV alqudah_a_Page_26.jp2
704bd1cbc7506a7be2b784cecc8e59fe
54c7b63b9b452bd4df67c159eeebaa9c40cf146d
23230 F20101113_AAAMVY alqudah_a_Page_11.QC.jpg
ad0652500ec4f65e12b8444e837ff744
bc119d91db8459960a9e7b97f24617d1a1b072b7
F20101113_AAANHT alqudah_a_Page_47.tif
6f0c8146d4be0079523847feca65dd72
86910aa57242ab9f1fe2d1575a9db864b9a19bb9
87362 F20101113_AAANCW alqudah_a_Page_40.jp2
46a96a317e0d5fc17fb99036346b71ed
9dbf060e5556b2dd3622c6f7275004aa94a199ce
F20101113_AAANHU alqudah_a_Page_48.tif
4556517b1d7005689c66806c3b9da719
f2617a2906b412458d772cdde7e38b0f51ae18e0
1320 F20101113_AAANCX alqudah_a_Page_52.txt
95c41a7577020d838add68ede3d42117
73a3ed844379d1fb7bb6f1439189593e37cfe0c5
19518 F20101113_AAAMVZ alqudah_a_Page_34.QC.jpg
25c6b26d8f08c571c2585eca0dbd83a7
62462b72c68f4352303eaf8cc2a7ab6a25402042
F20101113_AAANHV alqudah_a_Page_51.tif
6c876a638cb3b121c1e3119bbdbfe11c
c6509bea4bb8987513ea0a18f763e47d64fd6548
1967 F20101113_AAANCY alqudah_a_Page_30.txt
43bab963a4ebc463437545803c71a19b
2a712eb810298ffef88cc2ade7676e7ef4baff8b
F20101113_AAANHW alqudah_a_Page_52.tif
80448aaf2d4d5c9ef587c7f42cf4276d
37fd6b5079035028882ff22f6a53bfb321acbf40
65060 F20101113_AAAMYA alqudah_a_Page_46.jpg
d91647da7f409e65e8929a768055edcb
78b183da14e9e4b4a23c103d0204b023b74b605d
119124 F20101113_AAANAA alqudah_a_Page_12.jp2
0c8bed62338472f72e7e137db7f31744
4e551bca2800ae3c671b0b7b5a269569a68004e8
53835 F20101113_AAANCZ alqudah_a_Page_50.pro
0a3423cb2dd6c4f4fcbb0e2af730e939
ca72c12f7c34e8ed4fd93cbcd2b1b85a7347af81
F20101113_AAANHX alqudah_a_Page_53.tif
f01a7397112b4c91358684e70ea0d42c
856fa7264544eb2d793c70eb8a89806d68d30f5e
73817 F20101113_AAAMYB alqudah_a_Page_07.pro
76ed6a63b56e8b607f497a3ef0222479
b87efcc00908d117b7ef81710389f1326d2bb0ba
83730 F20101113_AAANAB alqudah_a_Page_53.jpg
008aa63ff23adec6c285e95d219ededb
258a5ff3dfd45434befa476561a8a8d6dc1ed338
F20101113_AAANHY alqudah_a_Page_54.tif
30bf0b2aabac593ffc5a34a45eb911db
27408ed5ed7bad7c4975401a2225e32ebb32810b
1708 F20101113_AAAMYC alqudah_a_Page_44.txt
e2122d4aee8fe6d6461125fa8b1f6e48
33e1a99315702863bdc395be96de81ac1ab04412
6592 F20101113_AAANAC alqudah_a_Page_25thm.jpg
a11335b0b1ff2c808fa4a97df06ea8c3
43b2920a003784d5bcd7f32fa6512e6310512352
F20101113_AAANHZ alqudah_a_Page_57.tif
7df799a91123504aaab5e7ddbe6579e9
8437e4118123e1bdde313ec2ff391e2a26f77174
106703 F20101113_AAAMYD alqudah_a_Page_11.jp2
8cd27fc723c2a2aa4627e9e1302f4eaf
c4494be6d15f32e13ec831802e3f6ca2a9d675ab
7247 F20101113_AAANAD alqudah_a_Page_58thm.jpg
22733fbae57a94046184f35ebd091b04
c75c5523517f6858b794171c749afc7c507a1123
46431 F20101113_AAANFA alqudah_a_Page_41.jpg
ae9a4a12e8fd87935c90be0ba1452ec9
f3ffbe9b1f7feed0e96327866c784d3e59fe4f7a
1003 F20101113_AAAMYE alqudah_a_Page_62.txt
f2719179bea57c44ce67472dd25136aa
e6d92fea9a727d7963d4776f99de7672685a1bd2
75564 F20101113_AAANAE alqudah_a_Page_18.jpg
b100f526257a3dae8a8b560dda670b45
c8d715c6bcf7b9c5ffd2a98f59e591066a466115
56432 F20101113_AAANFB alqudah_a_Page_42.jpg
773754f4ee7df9f8e889ac62536b4fa1
13d22e3eb4916e13d7ad34c0a7cec45970bc2523
9393 F20101113_AAAMYF alqudah_a_Page_01.pro
31f10493debe262e18a98361da3a0e12
42f92db4526a5052c6c319044d9f9c4430217f78
80893 F20101113_AAANAF alqudah_a_Page_19.jpg
aad436de3df118f42fcb2311508d413d
26842c34bea6dcc5d8205141f65cc99e2ca1ff29
1846 F20101113_AAANKA alqudah_a_Page_38.txt
ec062e67cba54e754fab082a2eab57be
557cdab99a0e89bd847d3b224c75fda98226d67b
67061 F20101113_AAANFC alqudah_a_Page_43.jpg
c64ef02d9b398475684222e0d59aa78f
04f9e7f14d00e038971a46a3073b8ac25b0df4fd
25734 F20101113_AAAMYG alqudah_a_Page_28.QC.jpg
f4a85e77645d6b8f202a539e5f882b5b
334af08612091f6945d284b744dc288702b2e641
26492 F20101113_AAANAG alqudah_a_Page_48.QC.jpg
1f5c84c58b6dcb5232fd727155254f7b
daf9336debbb9beda9578cb81489dcd010e6b607
424 F20101113_AAANKB alqudah_a_Page_39.txt
0b7e7433c525b5894cd817b655216cbd
0781601f4af3e831270cd9b82ae37f9580814784
65288 F20101113_AAANFD alqudah_a_Page_44.jpg
ddaadad3a4da69b45b306781b1772fa6
337bd32a5c24d42a0467b315b23a7d2192586012
1859 F20101113_AAAMYH alqudah_a_Page_03thm.jpg
c997bf1d30e50bdf5cda8c2b44f57ce5
42362f636511f85acdaf33daae90d00766353a25
7232 F20101113_AAANAH alqudah_a_Page_47thm.jpg
ca693ef2b1f7deff5f5b4f54f1166688
dc9f87d43a99b13d0c805535883906261a6400d1
1751 F20101113_AAANKC alqudah_a_Page_40.txt
9ad8dc38cf0109ccfa49a399bef2623d
f53bd72558141b410326b02962673be6b6217032
79267 F20101113_AAANFE alqudah_a_Page_49.jpg
932d355eb89b8ef81b0ef0159fdde630
3d5b5de66734173df8f173ca007b85acd0eeaff2
316 F20101113_AAAMYI alqudah_a_Page_03.txt
76f5c911e133d2acd97bbd849f41a197
217d17e263faccd36b2b8f085563fd404f4f169b
65613 F20101113_AAANAI alqudah_a_Page_40.jpg
968cc2a0d5cdc95af6b4b90b789ee7d8
840afc62668864f1cc7e62cd55126752e8d76cdd
77952 F20101113_AAANFF alqudah_a_Page_50.jpg
ff6b5bc4bd354084f8c33b044858735d
bd52fc693baa411b16ad0d63919b3773e5823ab7
59765 F20101113_AAAMYJ alqudah_a_Page_34.jpg
86c663439928949dce260826a410104f
84cae4a692802157ce55d29cdd4710e7ef761051
2571 F20101113_AAANAJ alqudah_a_Page_53.txt
eefcee28ddde7eaeef4489b2fa402c01
a778246bf02a1fa68335575028c7372edde7fefb
1627 F20101113_AAANKD alqudah_a_Page_42.txt
3ebbb4796b718acd7409381598240a2f
8e7b3f7750a3d212b824539af159258c1b45c2a5
50067 F20101113_AAANFG alqudah_a_Page_52.jpg
749d2d0200b1c4cdebc4fbffe800a68c
ad1f9538199710bebb9d88c96a09337ac865a421
7576 F20101113_AAAMYK alqudah_a_Page_07thm.jpg
afe97c3484a2606079d426079f93abd6
7605ff4cc8b91af3e7d59a7a6dec87f30e729b0a
80479 F20101113_AAANAK alqudah_a_Page_48.jpg
614fabbaff40a73a8b3edc51d1c24857
f2ec9b5691cb1fefa4d11d648b59c4f89c6a35d4
1716 F20101113_AAANKE alqudah_a_Page_46.txt
d5e7962a2be3adaa1c1ebafbddbe74c2
540e64a67410d3d774f76ab25028dcc2353bf7ef
90668 F20101113_AAANFH alqudah_a_Page_55.jpg
958fd78addcac96491667173525c6f20
f44bdb7c97cd1a1640de5d1ff4aac9e4bbe49670
F20101113_AAAMYL alqudah_a_Page_14.tif
a428a7def8f88b5da89da455469c9276
38501ee6fa5c1c6c182a39191335a1700264ac8c
2392 F20101113_AAANAL alqudah_a_Page_01thm.jpg
59ec79af25686f90baf88e34a325d3b7
4faad7c748040302be70b14164f75ee7e4926fa7
2195 F20101113_AAANKF alqudah_a_Page_47.txt
781a08c6e49f7a9a529c538081b9cb52
93fed26324e1453f1f51e6328dd739a3deaaab95
85058 F20101113_AAANFI alqudah_a_Page_58.jpg
bf1f241c6e815a69f356d344175f3333
7bf6f996ef0e620b97c37f3d09ce62e2cc9aea21
55707 F20101113_AAAMYM alqudah_a_Page_49.pro
3cb30831146d863357e70340582cbfc6
49c6662027a2ae6c78c703ad47954d482ba25d92
6170 F20101113_AAANAM alqudah_a_Page_04.QC.jpg
b768975e77b17a5a7abc5ee37fd778b5
038b57c83a856b285186378303ec02d2e70e4d0b
2238 F20101113_AAANKG alqudah_a_Page_48.txt
2adc351ba80ea0e44ad8772ef1f89cc8
36469b926b2274c2a5e7589b4130afb4b333369a
88489 F20101113_AAANFJ alqudah_a_Page_59.jpg
d2632477985758af43c082b9cacc12e0
665773a46b8cea2233b3532defce35e79ee86732
26130 F20101113_AAAMYN alqudah_a_Page_16.QC.jpg
6db628757195c7bb0277d2d414442d3f
20e02718e7de73088c84f64fc1bf13ddf5c5e435
2656 F20101113_AAANAN alqudah_a_Page_55.txt
d94d812ecfed85a34db4fdc78bc88288
00631889764be3aebf5dfb7efe20f54cc3f01b4d
2569 F20101113_AAANKH alqudah_a_Page_59.txt
7695ce9afacc41673c2b2613d60a41db
c599c587efe2d7c8ff57ea5c97c2a6397fa5968b
83598 F20101113_AAANFK alqudah_a_Page_60.jpg
f721f6f1f65fb7b1a19e91dc8e58b2c2
f795a52af68e726e7dbed0c5842f6c3a3aee36aa
24937 F20101113_AAAMYO alqudah_a_Page_32.QC.jpg
25c20429f982edf79d9e75843106be46
beb99d4ebcba50756e4bd827160b5a09097f3438
2460 F20101113_AAANAO alqudah_a_Page_57.txt
0bb89a09773e66db747726d7d45bc4bb
3606ac5ab05164698ffb21e444f8aebcbce1d224
567726 F20101113_AAANKI alqudah_a.pdf
8060bd7ea4ebd489b5b8bc4d32289828
24c0b41cf5453a1ef859ae32d1ca9eacf682d1df
43750 F20101113_AAANFL alqudah_a_Page_61.jpg
773ee0ac9edcd84b4a339ff5e0980737
bf60fd824b587d15215724fd13b99cab6e061057
71549 F20101113_AAAMYP alqudah_a_Page_11.jpg
8da90991144c22fa4d928b15f549f058
d5d5078588f9849114449f43d287b569f4b7d766
F20101113_AAANAP alqudah_a_Page_08.tif
b9a70f4ae49ca9c3e8de964c87b1ef6d
00435b852de75b67d0e97e0384041f70ace80f67
8138 F20101113_AAANKJ alqudah_a_Page_01.QC.jpg
673a7a201af71dffec2334bad642aad5
7225e4eb1dbefc40523f481a9a0524b65f631a35
40559 F20101113_AAANFM alqudah_a_Page_62.jpg
86d95dd984552306277e4af9a284fcdb
77f4f01a6de151cb5460a93443cc817ab811a81a
7222 F20101113_AAAMYQ alqudah_a_Page_57thm.jpg
e1fe95440ffc66bb106b54da2d48bb98
fe76f78d0d8653f0a999d188c6f641874a052b7f
F20101113_AAANAQ alqudah_a_Page_26.tif
9e651a0f8c74a4d1f58416a737593329
ca3cab4a0e5de6ddf7bd8ef9fe79dee27ca0adb6
1345 F20101113_AAANKK alqudah_a_Page_02thm.jpg
16b3205f6a53f2447c5f74175f4e3517
21b98dd7e7a91dbfdb8819fcef654de63c0c724b
21383 F20101113_AAANFN alqudah_a_Page_04.jp2
5933207717b7180259e99e64098897b7
057f22d4de0f055e95578f666d339f4f52647d1e
2162 F20101113_AAAMYR alqudah_a_Page_27.txt
abd96f8d2bc563010b83910e2186d2dc
685667c21567eb5ed23db2de01b9d8104735b307
118501 F20101113_AAANAR alqudah_a_Page_24.jp2
5797f56b79d6ef7e76b12b4cf2eff419
66a8129894388b2d8f893a448e61c4a3f195d61b
5240 F20101113_AAANKL alqudah_a_Page_03.QC.jpg
83bda1647a0f9b42296c9427dd16956f
b0bd1f3ac55f9f6ee4d1168205e780e221fa9694
1051976 F20101113_AAANFO alqudah_a_Page_08.jp2
2bab8009b2320266a12850878f572866
d13f635427f9994691ec1d70e3569ecc0bf90e9d
F20101113_AAANAS alqudah_a_Page_12.tif
d189a8d7cee71d4cfca7a0922a5a0c90
32540d9f7915507e21749a10b1b7ec1703988d41
5382 F20101113_AAANKM alqudah_a_Page_05thm.jpg
ca85bd6e9b137589c88890fcf5b7e4ff
8a9a0c05f434a0b7dae1ce708219ea53567767e4
102892 F20101113_AAANFP alqudah_a_Page_09.jp2
59460f9d3039899835d76ac78f8a8a55
9de51fa64b4c3db1c115ae2fc60600e49e221912