Exploring the Loss Aversion Scale's psychometric properties in Spain.

Loss aversion is a psychological construct defined as a tendency to value potential losses more than gains in a situation that requires decision-making. The Loss Aversion Scale (LAS, eight items) measures an individual's loss aversion to various situations. However, the generalization of its psychometric properties to different population groups is unknown. This study aimed to validate the LAS instrument for use among Spanish university adults. To this end, two studies were conducted: a content validity study calculating the substantive validity (N = 24) of the instrument's translation from original English to Spanish and a study of internal structure and association (N = 766) among Spanish university men and women aged 18-35. The analyses performed for each sample indicated that the instrument had adequate validity and reliability values as a one-dimensional measure; however, items 5 and 8 had to be removed. Their scores indicated moderate-magnitude correlations with social desirability. This article debates the study's limitations, practical implications, and future lines of research based on the results. The conclusion is that the Loss Aversion Scale instrument suits general Spanish population samples and requires probable methodological control concerning social desirability.

Predictors of the quality of the relationship between informal caregiver and care recipient in informal caregiving of older people: presentation and evaluation of a new item.

BACKGROUND: An important factor that has not been directly addressed very often in caregiver (CG) counseling to date is the quality of the relationship between the CG and the care recipient (CR). One reason is the lack of availability of a suitable assessment tool that is not strongly influenced by social desirability. Here, we present and evaluate a new item for the assessment of relationship quality (RQ) in the context of informal caregiving of older people. METHODS: N = 962 informal caregivers of older people participated. Our item assessed RQ by providing three answer categories (positive, neutral, and negative) that were presented through the use of smiley faces. For evaluation, and to avoid bias due to social desirability, the neutral and negative categories were combined. We calculated a stepwise binary logistic regression. RESULTS: Expected associations with the variables care burden, perceived positive aspects, and care motivation were found (all p values < 0.01). An exploratory analysis revealed that additional predictors of RQ consisted of the CR's age as well as whether the CR's diagnosis was dementia, CG's amount of dysfunctional coping, and whether the CG was caring for more than one CR. CONCLUSIONS: We conclude that our item is well-suited for the assessment of RQ in the context of informal caregiving of older people. Because it uses language-free answer categories by means of smiley faces, our item can be applied easily. Bias due to social desirability can be minimized by dichotomization (i.e., combining the negative and neural answer categories). In future research, our tool should be evaluated in other contexts.

Why Forced-Choice and Likert Items Provide the Same Information on Personality, Including Social Desirability.

The forced-choice response format is often considered superior to the standard Likert-type format for controlling social desirability in personality inventories. We performed simulations and found that the trait information based on the two formats converges when the number of items is high and forced-choice items are mixed with regard to positively and negatively keyed items. Given that forced-choice items extract the same personality information as Likert-type items do, including socially desirable responding, other means are needed to counteract social desirability. We propose using evaluatively neutralized items in personality measurement, as they can counteract social desirability regardless of response format.

Percepções de enfermeiros da atenção primária sobre valorização no trabalho: o clamor de uma categoria / Perceptions of primary care nurses on value at work: the clamor of a category / Percepciones de las enfermeras de atención primaria sobre el valor en el trabajo: el clamor de una categoría

Objetivo: Conhecer as percepções de enfermeiros da Atenção Primária à Saúde sobre a valorização no trabalho. Métodos: Estudo qualitativo, descritivo e exploratório, realizado com 132 enfermeiros que atuavam na atenção primária à saúde, em 23 municípios do estado de Minas Gerais. Os dados foram coletados por meio de formulário on-line, analisados conforme pressupostos da análise de conteúdo, com amparo do software Iramuteq. Resultados: A maioria dos participantes eram do sexo feminino (114 - 86,37%), com idade entre 22 e 60 anos, com carga horária de trabalho semanal de 40 horas e recebiam entre 2- 4 salários mínimos. A partir das análises, os dados foram organizados em três categorias temáticas ­ Valorização: reconhecimento do trabalho do enfermeiro; Valorização: satisfação com o salário e Valorização: interdependência com as condições de trabalho. Conclusão: Os enfermeiros percebem que a valorização está atrelada ao reconhecimento profissional, à satisfação com o salário e às condições adequadas de trabalho, tais como: carga horária menor e recursos materiais. Consideraram que o reconhecimento externado por outros atores envolvidos na relação de cuidado, como gestores, usuários e profissionais de saúde, é essencial para a valorização do trabalho. (AU)

Objective: To understand the perceptions of Primary Health Care nurses regarding job appreciation. Methods: A qualitative, descriptive, and exploratory study conducted with 132 nurses working in primary health care across 23 municipalities in the state of Minas Gerais. Data were collected through an online form and analyzed using content analysis assumptions, supported by the Iramuteq software. Results: The majority of participants were female (114 - 86.37%), aged between 22 and 60, with a weekly working hours of 40, and earning between 2-4 minimum wages. Through analysis, data were organized into three thematic categories ­ Appreciation: recognition of the nurse's work; Appreciation: satisfaction with the salary, and Appreciation: interdependence with working conditions. Conclusion: Nurses perceive that appreciation is linked to professional recognition, satisfaction with salary, and appropriate working conditions such as reduced working hours and material resources. They considered external recognition from other stakeholders in the care relationship, such as managers, users, and healthcare professionals, as essential for job appreciation. (AU)

Objetivo: Conocer las percepciones de los enfermeros de la Atención Primaria a la Salud sobre la valorización en el trabajo. Métodos: Estudio cualitativo, descriptivo y exploratorio realizado con 132 enfermeros que trabajaban en la atención primaria a la salud, en 23 municipios del estado de Minas Gerais. Los datos se recopilaron a través de un formulario en línea y se analizaron según los supuestos del análisis de contenido, con el apoyo del software Iramuteq. Resultados: La mayoría de los participantes eran mujeres (114 - 86,37%), con edades entre 22 y 60 años, con una carga horaria de trabajo semanal de 40 horas y recibían entre 2-4 salarios mínimos. A través de análisis, los datos se organizaron en tres categorías temáticas: Valorización: reconocimiento del trabajo del enfermero; Valorización: satisfacción con el salario y Valorización: interdependencia con las condiciones de trabajo. Conclusión: Los enfermeros perciben que la valorización está vinculada al reconocimiento profesional, la satisfacción con el salario y las condiciones de trabajo adecuadas, como una carga horaria reducida y recursos materiales. Consideraron que el reconocimiento externo por parte de otros actores involucrados en la relación de cuidado, como gestores, usuarios y profesionales de la salud, es esencial para la valorización del trabajo. (AU)

Measurement Invariance of the Children's Social Desirability Scale-Short Version (CSD-S) Across Gender, Grade Level, and Race/Ethnicity.

Social desirability bias is a methodological challenge with participant self-reports. Social desirability measures are often used to control the potential effects of social desirability bias on participant self-reports, but whether these measures are interpreted similarly across different demographic groups remains unclear. This study examines the factor structure and measurement invariance of the Children's Social Desirability Scale-Short version (CSD-S) across gender, grade level, and race/ethnicity with a large sample of children and adolescents in the United States. Results indicate a close fit to a one-factor model. Tests of measurement invariance show partial strong invariance across gender (male vs. female) and grade level (elementary vs. middle vs. high schoolers) as well as strong invariance across race/ethnicity (Asian vs. Black/African American vs. Hispanic/Latine vs. White vs. Bi/Multiracial). Latent mean differences were found across grade level and race/ethnicity but not gender, with lower grades reporting higher social desirability than upper grades and Bi/Multiracials reporting lower social desirability than Asians and Hispanics/Latines. Findings provide preliminary evidence for the use of CSD-S in detecting social desirability bias and assessing meaningful social desirability differences in diverse children and adolescents.

Teacher's social desirability bias and Migrant students: A study on explicit and implicit prejudices with a list experiment.

Scholarly research has consistently shown that teachers present negative assessments of and attitudes toward migrant students. However, previous studies have not clearly addressed the distinction between implicit and explicit prejudices, or identified their underlying sources. This study identifies the explicit and implicit prejudices held by elementary and middle school teachers regarding the learning abilities of an ethnic minority group: Haitian students within the Chilean educational system. We use a list experiment to assess how social desirability and intergroup attitudes toward minority students influence teachers' prejudices. The findings reveal that teachers harbor implicit prejudices towards Haitian students and are truthful in reporting their attitudes, thereby contradicting the desirability bias hypothesis. We suggest that teachers rely on stereotypes associated with the students' nationality when assessing Haitian students' learning abilities. The implications of these results are discussed in relation to theories grounded in stereotypes and intergroup attitudes.

Risk of Eating Disorders and Social Desirability among Higher Education Students: Comparison of Nutrition Students with Other Courses.

The transition to college is a period of higher risk of the development of eating disorders, with nutrition/dietetics students representing a group of particular vulnerability. Hence, it is interesting to assess eating disorders, taking into consideration potential sources of bias, including social desirability. Our aims were to compare the risk of eating disorders between students of nutrition/dietetics and those attending other courses and to study potential social desirability biases. A total of 799 higher education students (81.7% females) aged 18 to 27 years old completed a questionnaire assessing the risk of eating disorders (EAT-26) and social desirability (composite version of the Marlowe-Crowne Social Desirability Scale). The proportion of students with a high risk of eating disorders was higher among females (14.5% vs. 8.2%, p = 0.044). Nutrition/dietetics students did not differ from those attending other courses regarding the risk of eating disorders. The social desirability bias when assessing the risk of eating disorders was overall low (EAT-26 total score: r = -0.080, p = 0.024). Social desirability correlated negatively with the Diet (r = -0.129, p < 0.001) and Bulimia and food preoccupation subscales (r = -0.180, p < 0.001) and positively with Oral self-control (r = 0.139, p < 0.001).

Impact of social desirability bias on the CoPsoQ-ISTAS 21 psychosocial risk assessment questionnaire.

BACKGROUND: Self-reported test is one of the main psychosocial risk assessment tools. However, this test it is susceptible to certain sources of error, including social desirability. Since psychosocial risks are emerging, there are not many studies on their assessment. OBJECTIVE: The aim of this work is to analyze the impact of social desirability on the short version of the CopSoq-ISTAS 21 assessment tool. METHOD: A total of 563 workers (45.10% women and 54.90% men) participated in this study. The short version of the CoPsoQ-Istas21 questionnaire with four Likert scale questions as markers, which correspond to the Eysenck Personality Lie Scale Questionnaire Revised (EPQ-r), were used. The sample was divided into two halves, and both a confirmatory analysis and an exploratory analysis were carried out to find out the factorial structure of the scale and, with it, apply the bias filtering method. RESULTS: The results indicate that 10% of the scale is biased due to social desirability, and that there are significant differences between the group with bias clean scores and the group with scores without bias control. CONCLUSIONS: The effects of social desirability on the scale are verified, so it is concluded that in a psychosocial risk assessment is not enough to apply a self-report test and interpret its results, being necessary to minimize the sources of error.

Social desirability bias is related to children's energy intake in a laboratory test meal paradigm.

Dietary intake is notoriously difficult to measure in children. Laboratory test meals address some of the methodological concerns of self-report methods, but may also be susceptible to social desirability bias, referring to the tendency for individuals to adjust their behaviors in order to be perceived more positively. The aim of the current study was to evaluate whether social desirability bias was associated with children's energy intake during a laboratory test meal, and whether this association varied by food type (total caloric intake, snack food intake, fruit/vegetable intake) and sex. A total of 82 children (M age = 9.45 ± 0.85; 50 % girls; 84.1 % rural; 85.4 % White) completed several surveys, including the Children's Social Desirability Scale and had their body composition measured. At lunchtime, they were granted access to a multi-array test meal (>5000 kcal). After adjusting for lean mass, fat mass, depressive symptoms, and parental food restriction, children who reported higher social desirability bias consumed fewer calories from snack foods (B = -11.58, p = .009, semi-partial correlation = -0.28). Boys with higher social desirability bias consumed less calories from fruits and vegetables (B = -6.47, p = .010, semi-partial correlation = -0.411); this association was not significant in girls. The desire to be perceived in a positive manner may influence children's eating behaviors in experimental paradigms. Replication studies with larger, more diverse pediatric samples are needed, as are strategies to reduce the effects of social desirability bias on test meal intake in order to enhance the validity of this dietary assessment approach.

Death Anxiety is Associated With Less Health Behavior for Individuals Low in Action Orientation.

Research has shown that death anxiety relates to less health behavior. The present study proposes that action orientation moderates this association. That is, it is hypothesized that death anxiety and health behavior relate negatively only in individuals low in action orientation. German adults (N = 187; aged 19-86) provided self-reports on health behavior, action orientation, death anxiety, social desirability, and sociodemographics. Analyses yielded a significant moderation effect of action orientation on the link between death anxiety and health behavior over and above significant relationships of action orientation, social desirability, age, and gender, respectively, with health behavior. As hypothesized, a significantly negative association of death anxiety and health behavior was found only given low action orientation but not among high action orientation individuals. This suggests that self-regulation plays a decisive role in whether death anxiety and health behavior relate to each other.

Impact of a pre-test measurement of alcohol craving in cue-exposure studies: Relationship with social desirability and demand effects.

Craving is one of the most studied concepts in the field of addiction. It is often investigated with repeated-measure experimental designs using self-reported scales. However, the explicit nature of self-reported craving scales may make them vulnerable to social desirability and demand effects. The aim of the present study was to test whether a pre-experimental measurement of craving affects its post-experimental assessment after an alcohol video exposure and whether these changes relate to social desirability, demand effects, and alcohol consumption. Seventy-five healthy volunteers aged 18-30 years were randomly assigned to two experimental groups: a pre-post and a post-only craving assessment group. They were invited to watch an alcohol-related video. Social desirability, demand effects, engagement toward the video, and severity of alcohol consumption were assessed in all participants. The results showed a significant effect of alcohol consumption (p < .001, η2p = .09) on post-experimental craving. The main effect of the repeated measure of craving was also significant (p = .04, η2p = .001), together with the interaction between these two variables (p = .03, η2p = .06). The pre-experimental craving measurement increased its post-experimental levels, but only in heavy drinkers. However, no evidence was found that these changes were related to social desirability or demand effects. Additional exploratory analyses indicated that craving increase in high alcohol drinkers was mediated by a stronger engagement toward the alcohol-related video. In summary, the repeated measurement of craving with explicit scales has a significant impact on the results of alcohol craving studies and may not always be desirable, especially when the true purpose of the study needs to be hidden from the participants. However, the present results also suggest that the pre-post experimental design is advisable when the experimenters seek to maximize the relationship between the individual levels of alcohol consumption and alcohol cue-exposure craving changes.

Social desirability, dietary intakes, and variables related to attitudes and behaviours towards eating among French-speaking adults from Quebec, Canada: The PREDISE study.

The primary objective of this study was to examine how social desirability is associated with self-reported measures of dietary intakes and variables related to attitudes and behaviours towards eating. This analysis was conducted in 1083 adults (50.0% women) from the PREDISE study. Social desirability was assessed using the Balanced Inventory of Desirable Responding (BIDR) questionnaire, which includes two subscales: (1) self-deceptive enhancement (SDE), i.e., having an overly positive self-image and (2) impression management (IM), i.e., intentional response distortion to please. BIDR total score and IM subscore were positively associated with the Canadian Healthy Eating Index (C-HEI) (ß = 0.24 and ß = 0.50; p ≤ 0.0003), calculated using data from three self-administered 24 h food recalls. All BIDR scores were positively associated with self-determined motivation for eating regulation (0.03 ≤ ß ≤ 0.06; p < 0.0001), measured by the Regulation of Eating Behavior Scale, and with the intuitive eating score (0.02 ≤ ß ≤ 0.05; p < 0.0001). Also, all BIDR scores were negatively associated with hunger and disinhibition scores measured by the Three-Factor Eating Questionnaire (-0.17 ≤ ß ≤ -0.09; p < 0.0001). All these associations were adjusted for age, sex, BMI, and the education level. Furthermore, controlling for both dimensions of social desirability did not impact the magnitude of the association between self-determined motivation (the strongest predictor of healthy eating in the PREDISE study) and C-HEI. According to our results, associations are observed with diet quality, as well as with attitudes and behaviours towards eating; therefore, a measurement of social desirability responding would be pertinent in studies using those or related variables.

Contributions to Constructing Forced-Choice Questionnaires Using the Thurstonian IRT Model.

Forced-choice questionnaires involve presenting items in blocks and asking respondents to provide a full or partial ranking of the items within each block. To prevent involuntary or voluntary response distortions, blocks are usually formed of items that possess similar levels of desirability. Assembling forced-choice blocks is not a trivial process, because in addition to desirability, both the direction and magnitude of relationships between items and the traits being measured (i.e., factor loadings) need to be carefully considered. Based on simulations and empirical studies using item pairs, we provide recommendations on how to construct item pairs matched by desirability. When all pairs contain items keyed in the same direction, score reliability is improved by maximizing within-block loading differences. Higher reliability is obtained when even a small number of pairs consist of unequally keyed items.

A Comparison of Self-reported Condomless Sex and Yc-DNA Biomarker Data from Young Women Engaged in High Risk Sexual Activity in Kampala, Uganda.

Reporting of condom-use can limit researchers' understanding of high-risk sexual behaviours. We compared self-reported condom-use with the Yc-DNA biomarker data and investigated potential factors influencing participation in, and reporting of, sexual behaviours. Self-reported data were collected using Audio Computer Assisted Self Interviews (ACASI) and samples for Yc-DNA biomarker were collected using self-administered and health worker-collected vaginal swabs from 644 women (aged 15-24 years) who were not living with HIV. Yc-DNA results and interview data were compared using McNemar-Bowker Analysis and Cohen's Kappa. Test statistics for Yc-DNA biomarker were calculated. Log Binomial models for Yc-DNA and self-reported results were conducted to assess for association. We found strong evidence (p < 0.001) for a difference between Yc-DNA and self-reported results. 13.7% of participants reported consistent condom-use with all partners, regardless of HIV status. Self-reported condom-use was discordant in 50.0% (n = 206) of cases, when compared to Yc-DNA results. Positive Yc-DNA results were found to be associated with older age (RR 1.36; 95%CI 1.04, 1.76 p = 0.023). Self-reported condom-use with partners with unknown HIV status was associated with higher education (RR 0.76; 95%CI 0.58,0.99 p = 0.043). Sensitivity analysis did not determine difference between methods for controlling for missing data. We found significant under-reporting of condomless sex in the self-reported data when compared to Yc-DNA results.

People Declare Lowered Levels of Sociosexual Desire in the Presence of an Attractive Audience.

Due to social desirability bias, people tend to self-present themselves in the presence of others in a favorable light, which sometimes may lead to deviations from reality. This phenomenon is particularly pronounced when controversial or strictly norm-bounded matters are considered. Here, we tested how a presence of an attractive model-either male or female-influences people's declarations on their sociosexual orientation-the degree of their sexual permissiveness in terms of their past behavior, attitudes toward uncommitted sex, and desire for sexual intercourse with individuals they are not in a relationship with. The participants (N = 244, 52% men) answered questions about their sociosexuality in solitude, or out loud with an attractive model present. The results show that both men and women declare lowered levels of their desire, but not behavior or attitude, in the presence of both male and female attractive models. A follow-up study (N = 188, 51% men) showed that this effect was not due to the differing conditions of responding (out loud vs written down). The research points out to an area of human sexuality that is prone to being falsified in research and which serves as an important factor in self-presentation.

Is football coming out? Anti-gay attitudes, social desirability, and pluralistic ignorance in amateur and professional football.

Past work consistently points to improved attitudes towards gay athletes and growing support for homosexuality, yet reports of a homophobic climate in amateur and professional football persist. Here, we explore two potential explanations for the prevalence of homophobia in football despite low levels of anti-gay attitudes: social desirability and pluralistic ignorance. We conduct an online survey among a football-affine and socio-demographically diverse sample in the UK. We find that anti-gay attitudes are rare. Importantly, estimates from a list experiment do not differ from the prevalence measured by direct questions, providing no evidence of social desirability. By contrast, second-order beliefs about anti-gay attitudes substantially and consistently exceed attitudes, pointing towards pluralistic ignorance as the most likely explanation. We conclude by emphasizing the need for transparent communication to reduce pluralistic ignorance and correct misperceptions among players, officials and supporters.

The effect of survey administration mode on youth mental health measures: Social desirability bias and sensitive questions.

Aim: Research on trends in youth mental health is used to inform government policy and service funding decisions. It often uses interviewer-administered surveys, which may be affected by mode effects related to social desirability bias. This study sought to determine the impact of survey administration mode on mental health measures, comparing mode effects for sensitive mental health measures (psychological distress and wellbeing) and non-sensitive (physical activity) measures. Methods: Data were from two large national community samples of young Australians aged 12-25 years conducted in 2020 (N = 6238) and 2022 (N = 4122), which used both interviewer-administered and self-report modes of data collection. Results: Results showed participants reported lower psychological distress and higher wellbeing in the interviewer-assisted compared with the self-report mode. No mode effects were found for the non-sensitive physical activity measures. No interaction between mode and gender was found, but an age group by mode interaction revealed that those in the 18-21 and 22-25-year age groups were more strongly affected than younger adolescents. Conclusions: These findings suggest underestimates of mental health issues from interview survey formats, particularly for young adults. The results show how even a weak mode effect can have a large impact on mental health prevalence indicators. Researchers and policy makers need to be aware of the impact social desirability bias can have on mental health measures and consider taking steps to mitigate this effect.

Overcoming defensive responding in the estimation of prevalence of non-medical use of prescription stimulants.

BACKGROUND: Prevalence of Non-Medical Use of Prescription Stimulants (NMUPS) is estimated to be high among young adults enrolled in college. However, precise estimation of the prevalence of NMUPS is challenging owing to biases affecting self-report of sensitive and potentially illegal behaviors. OBJECTIVE: This study aimed to estimate the prevalence and risk factors of NMUPS using the crosswise randomized response technique (CRRT) and compare findings to the traditionally-used direct self-report (DSR) method. METHODS: This study utilized a cross-sectional, randomized experimental design to survey adult undergraduate students at a major southeastern university in the United States. Eligible respondents were randomly assigned to a DSR group or a CRRT group. Those in the DSR group were presented a direct question about NMUPS, but those in the CRRT group were asked to indicate whether their response to the NMUPS question was the 'same' or 'different' compared to a random non-sensitive question. RESULTS: Prevalence of NMUPS was found to be 18.6% (95% CI:18.5%-18.7%) in the DSR group and 32.5% (95% CI:32.1%-32.9%; p = 0.003) in the CRRT group. Logistic regression analysis predicting NMUPS in the DSR group showed that it was significantly associated with positive expectancies (OR:3.50; 95% CI:2.44-5.02), negative expectancies (OR:0.49; 95% CI:0.35-0.68), perceived norms (OR:1.71; 95% CI:1.27-2.29), and religious beliefs (OR:0.69; 95% CI:0.52-0.92). CONCLUSIONS: The setting and mechanism of the survey is likely closely related to the validity of prevalence estimation of sensitive behaviors. This study found that prevalence of sensitive behaviors such as NMUPS is significantly higher when respondents are provided increased anonymity.

A Comparison of Person-Fit Indices to Detect Social Desirability Bias.

Social desirability bias (SDB) has been a major concern in educational and psychological assessments when measuring latent variables because it has the potential to introduce measurement error and bias in assessments. Person-fit indices can detect bias in the form of misfitted response vectors. The objective of this study was to compare the performance of 14 person-fit indices to identify SDB in simulated responses. The area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis was computed to evaluate the predictive power of these statistics. The findings showed that the agreement statistic (A) outperformed all other person-fit indices, while the disagreement statistic (D), dependability statistic (E), and the number of Guttman errors (G) also demonstrated high AUCs to detect SDB. Recommendations for practitioners to use these fit indices are provided.

The relationship between response style and symptom reporting in cancer patients.

PURPOSE: Patient-reported outcomes are considered the gold standard for documenting treatment-related toxicities and cancer-related symptoms in the management of oncology patients. Poor concordance between patients and health care professionals (HCPs) on patients' symptoms has been documented. The purpose of this study is to examine the association between social desirability, a response style, and symptom reporting in a colorectal cancer clinic. METHODS: Patients being treated for colorectal cancer completed a social desirability measure and a symptom measure before their appointment in the oncology clinic. The HCP who saw the patient completed a symptom measure for the patient after the clinic visit. RESULTS: One hundred sixty-nine patients consented to participate in the study. The majority of the patients had stage 4 disease. There was a statistically significant positive correlation between social desirability and overall reported symptom burden. There was a statistically significant negative correlation between social desirability and concordance between the patient and the HCP on the patient's symptoms. Social desirability scores were stable over the course of 1 year. CONCLUSION: Sensitivity to social desirability effects seems to play an important role in patient self-report of symptoms. As social desirability is a stable quality, patients sensitive to it may be persistently at risk for undertreatment of symptoms due to limited symptom reporting.