Pain is one of the most common and clinically important symptoms, reflecting disease onset, progression, and treatment response. However, pain is difficult to accurately capture and interpret from medical text, as its expression varies across languages, documentation types, and patient demographics, and is often embedded in terminology, negation, temporality, and contextual descriptions. Existing pain-related studies remain largely monolingual or limited to narrow clinical settings. In this study, we introduce PAINT, a multilingual framework for studying pain representation across medical exams and real-world clinical texts. PAINT includes nine pain-focused dataset partitions spanning English, Spanish, Portuguese, and Japanese, with clinician annotations in all four languages. We curated a structured schema covering pain relevance, pain presence, anatomical location, pain descriptors, and demographic information. To capture multilingual pain representations, we leverage large language models (LLMs) and adopt an ensemble strategy to improve performance. Ten clinicians across four languages validate the labels: the ensemble reaches macro-F1 of 0.91–1.00 on pain relevance and pain presence and 92–100% accuracy on demographics, with inter-annotator κ of 0.82–1.00. We release the WorldMedQA-Pain ensemble labels, the extraction pipeline, validation scripts, and clinician annotation sheets for publicly licensed corpora, providing a foundation for pain-centered clinical NLP and for studying pain documentation across languages and healthcare contexts.

We present an end-to-end framework for generating synthetic users for evaluating interactive agents designed to encourage positive behavior changes, such as in health and lifestyle coaching. The synthetic users are grounded in health and lifestyle conditions, specifically sleep and diabetes management in this study, to ensure realistic interactions with the health coaching agent. Synthetic users are created in two stages: first, structured data are generated grounded in real-world health and lifestyle factors in addition to basic demographics and behavioral attributes; second, full profiles of the synthetic users are developed conditioned on the structured data. Interactions between synthetic users and the coaching agent are simulated using generative agent-based models such as Concordia, or directly by prompting a language model. Using two independently-developed agents for sleep and diabetes coaching as case studies, the validity of this framework is demonstrated by analyzing the coaching agent’s understanding of the synthetic users’ needs and challenges. Finally, through multiple blinded evaluations of user-coach interactions by human experts, we demonstrate that our synthetic users with health and behavioral attributes more accurately portray real human users with the same attributes, compared to generic synthetic users not grounded in such attributes. The proposed framework lays the foundation for efficient development of conversational agents through extensive, realistic, and grounded simulated interactions.