Table 1.

Example themes and quotes across study phases.

Themes	Quote
Phase I
Physical traits
Facial expression	Yes, because when there is pain, the face that it makes is mean. When you are hurting and it has a mean face, then that is not good for you. The face is grimacing and crying. (Participant 25)
Skin color	When a person is in pain, if they are having severe pain, their face would be all yellow. (Participant 24) When you have severe pain, you are pale, you don’t have blood anymore. You don’t have blood anymore so then your face would be all pale. (Participant 34)
Structure of scale
Use scale of 0–10 and include numbers under each face	A pain of 10 would make you most distressed, your pain would be able to tell you that the pain is the worst and there’s no climbing down. (Participant 54) If it is up to 10, that is when you are unable to tolerate it because the pain is severe. (Participant 47)
Include Hmong	Writing in Hmong would help those who don’t know how to read in English. So, writing in Hmong would help. (Participant 23)
Six faces and no body needed	6 faces is fine. 10 is too much …. Just the face is fine. (Participant 25)
Phase II
Facial expression	That the facial expression, like the frowning and stuff is helpful, but I feel like looking at the scale, it doesn't help me to like to describe. Like I can see the level of changes if I look at them all together. But if I were to look at number 6, that could potentially be normal. You know, and number 8, it doesn't look like they're in a lot of pain to me. It doesn’t translate into a lot of pain. And 10, because of the tears, it does help but you can’t really see it. (Participant 43)
Use of color	If you are going to fix it, make the colors stand out more. (Participant 2) I would switch the coloring of 8 and 10. Flip them over because I think the paler coloring should be 10 and not 8. (Participant 46)
Facial features
Change shape of face	I think you should make the face less oval and more face-shaped with a chin. (Participant 45)
Increase wrinkle lines	When they barely open their eyes. And maybe, I think the mouth makes a difference too umm, trying to think of how’d that change. I think maybe some changes in the nose, a little more scrunchy? Yea, the mouths are all different so you can kinda see there's a difference in everything. And also, even the wrinkles on the forehead, it changes too. (Participant 43)
Lip coloring and open mouth	When you are doing good, you are healthy, and the cheeks are not as pale. When you are experiencing a little more pain, the person is burning or not healthy, so the cheeks are a little redder and then become paler. When it hurts a lot, then it will go home [metaphor for dying] and become pale. (Participant 1)