Worry About Sexual Outcomes Scale

Abstract

The Worry About Sexual Outcomes Scale (WASO) is a specialized psychometric instrument designed to evaluate adolescents’ and emerging adults’ affective and cognitive apprehension regarding the negative consequences of risky sexual behavior, specifically focusing on sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and unintended pregnancy. Developed by Jessica McDermott Sales, Robin R. Milhausen, Josh Spitalnick, Ralph J. DiClemente, and colleagues as part of an intervention research program funded by the National Institute of Mental Health (NIMH), the scale emerged to bridge a critical theoretical gap between cognitive perceptions of risk and emotional worry. While traditional health behavior models emphasize cognitive vulnerability and perceived severity, the WASO isolates the emotional state of worry—a construct increasingly recognized as a proximal determinant of preventative health behaviors, partner negotiation, and sexual decision-making.

The scale captures affective apprehension across two core dimensions: Worry About STIs/HIV and Worry About Pregnancy. Evaluated across diverse adolescent and emerging adult cohorts—initially validated among African American adolescent females—the instrument exhibits robust psychometric integrity. Standardized administrations demonstrate exceptional internal consistency reliability, with Cronbach’s alpha coefficients routinely exceeding α = .90 for the aggregate scale and distinct subscales. Longitudinal stability assessments demonstrate statistically significant test-retest reliability across 6-month (r = .38, p < .01) and 12-month (r = .27, p < .01) intervals. Construct, convergent, and predictive validities have been confirmed through significant correlations with sexual communication self-efficacy, condom use negotiation, partner communication frequency, barriers to barrier contraception, external locus of control, depressive symptomatology, and actual sexual risk behaviors (such as condomless intercourse with steady and non-steady partners). Operating at a fourth-grade reading level, the WASO provides public health researchers, developmental psychologists, and clinical trialists with a brief, theoretically grounded assessment tool to monitor baseline risk perception and evaluate the affective efficacy of sexual health interventions.

Keywords

Worry About Sexual Outcomes Scale, WASO, sexual health, STI worry, HIV apprehension, unintended pregnancy, adolescent risk behavior, psychometrics, Health Belief Model, sexual communication self-efficacy, condom negotiation, reproductive health

Authors

The Worry About Sexual Outcomes Scale was developed by an interdisciplinary team of researchers specializing in behavioral science, public health, adolescent development, and sexual health psychology:

• Jessica McDermott Sales, Ph.D. — Professor, Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. Primary research focus: behavioral and psychological determinants of STI/HIV prevention among vulnerable adolescents and young women. Contact: [email protected].
• Robin R. Milhausen, Ph.D. — Professor, Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Ontario, Canada. Primary research focus: human sexuality, sexual health communication, and condom use behavior.
• Josh Spitalnick, Ph.D., ABPP — Clinical Psychologist, previously affiliated with the Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University; currently CEO and Clinical Director at Anxiety Specialists of Atlanta. Primary research focus: anxiety disorders, cognitive behavioral interventions, and health-related anxiety.
• Ralph J. DiClemente, Ph.D. — Chair and Professor, Department of Social and Behavioral Sciences, School of Global Public Health, New York University (previously at Emory University). Internationally renowned expert in adolescent sexual risk behavior, STI/HIV prevention, and randomized clinical trial evaluation.
• Gina M. Wingood, Sc.D., MPH — Affiliated investigator and renowned public health researcher in gender-tailored HIV prevention interventions, currently at Columbia University Mailman School of Public Health.
• Laura F. Salazar, Ph.D. — Affiliated investigator and Professor, School of Public Health, Georgia State University, specializing in health communication and sexual violence prevention.

Purpose

The primary purpose of the Worry About Sexual Outcomes Scale is to provide an empirically validated, brief self-report measurement tool designed to quantify the frequency and intensity of cognitive-affective worry regarding the biological consequences of unprotected sexual activity. Historically, adolescent sexual health research relied heavily on rationalistic cognitive frameworks—such as the Health Belief Model (HBM) and the Theory of Reasoned Action—which operationalized perceived risk as a calculated probability (e.g., “What are the chances that you will contract an STI in the next year?”). However, developmental neuroscience and behavioral economics have revealed that risk-taking during adolescence is rarely guided solely by cool, deliberative cognitive estimates. Instead, it is powerfully driven by emotional responses, visceral anticipatory feelings, and affective distress.

The WASO was created to directly assess this affective dimension of risk perception. By measuring how frequently an individual experiences worry or anxiety regarding the transmission of HIV, acquiring an STI, or experiencing an unintended pregnancy, the scale elucidates the emotional motivators or inhibitors of preventative behavior. Clinicians, interventionists, and prevention scientists utilize the WASO to address several critical operational objectives:

• Intervention Efficacy Evaluation: The scale was conceptualized and funded under an NIMH research grant specifically to function as a sensitive outcome and mediating measure in randomized controlled trials (RCTs). Researchers measure WASO scores pre- and post-intervention to determine whether psychoeducational curricula, motivational interviewing, or behavioral skills training successfully alter risk-related anxiety into actionable health protective behaviors.
• Risk Stratification and Profiling: In community clinics, school health centers, and adolescent outpatient departments, the WASO allows providers to rapidly detect individuals who experience disproportionate sexual anxiety or, conversely, those exhibiting total affective indifference in the presence of high-risk sexual practices.
• Elucidating Behavioral Paradoxes: Epidemiological studies frequently observe complex, bidirectional relationships between worry and behavior. In some cohorts, elevated worry motivates proactive prophylactic behaviors, such as consistent condom use and frequent STI screening. In other populations, severe worry is positively associated with unprotected sexual encounters, serving as an affective byproduct of recognized vulnerability, poor communication skills, or partner power imbalances. The WASO provides the measurement precision needed to deconstruct these relational and intrapsychic dynamics.
• Accessibility for Vulnerable Populations: Designed explicitly for readability (calibrated to a fourth-grade reading level), the WASO ensures that populations experiencing social marginalization, educational inequities, or low health literacy can complete the assessment without construct contamination arising from linguistic ambiguity.

Psychological Construct

The psychological construct evaluated by the WASO is sexual outcome worry, defined as a repetitive, emotionally charged cognitive process characterized by apprehension, anticipatory anxiety, and concern regarding the prospective or realized physical consequences of sexual activity. Within contemporary psychological science, worry is recognized not merely as an abstract thought, but as a cognitive component of anxiety consisting of negative affect, intrusive self-talk, and threat-oriented cognitive biases. When applied to sexual health, this construct departs markedly from static perceived vulnerability.

Deconstructing Affective Worry Versus Cognitive Risk Perception

While cognitive risk perception involves probabilistic reasoning (e.g., estimating mathematical or comparative odds of disease acquisition), affective worry involves the subjective visceral dread associated with those outcomes. An adolescent may logically understand that condomless intercourse carries an epidemiological risk of HIV transmission, yet maintain an optimistic bias (“It won’t happen to me”) that suppresses affective worry. Conversely, another individual may possess low objective risk but experience acute, intrusive worry that disrupts daily functioning or sexual intimacy. The WASO intentionally isolates this affective-evaluative construct, measuring how deeply these threats intrude into the respondent’s mental life.

Dimensions of the Construct

The construct comprises two core thematic dimensions, identified through empirical literature synthesis, community-based focus groups, and psychometric validation:

• Worry About STIs and HIV: This subscale measures acute concern regarding pathogenic transmission through sexual encounters. It encompasses worry about personal infection, anxiety surrounding the prospective acquisition of a permanent or stigmatizing disease, and concern regarding partner status. Because pathogens such as HIV carry life-altering clinical, social, and psychological ramifications, worry in this domain involves existential and social threat appraisals alongside biomedical concerns. Crucially, the construct evaluates concern regarding both one’s own serostatus and the transmission risk posed by or to sexual partners.
• Worry About Pregnancy: This subscale measures affective apprehension regarding unintended conception. In adolescent and emerging adult populations, pregnancy worry represents a complex psychosocial phenomenon. Unintended pregnancy involves immediate, tangible life disruptions, including educational discontinuation, financial instability, social stigma, and parental confrontation. The psychological experience of pregnancy worry is characterized by sharp anticipatory stress, nervousness surrounding missed menses, and cognitive rumination regarding unprotected sexual encounters.

Relationship to Broader Psychological Constructs

Sexual outcome worry does not operate in a psychological vacuum. The construct interacts continuously with several foundational individual-difference variables:

• Locus of Control: As demonstrated by Sales et al. (2008), higher sexual outcome worry correlates significantly with an external locus of control. Individuals who perceive their life circumstances as dictated by chance, fate, or powerful others often experience heightened worry because they lack perceived agency over their reproductive and sexual safety.
• Communication Self-Efficacy: The construct exhibits an inverse relationship with assertive communication. Individuals who lack the self-efficacy required to demand condom use or discuss sexual histories experience elevated outcome worry, as they recognize their exposure to danger while feeling powerless to negotiate protection.
• Affective Dysregulation and Depression: Sexual outcome worry shares variance with broader negative affectivity, displaying positive correlations with depressive symptomatology. It reflects an internalized awareness of behavioral vulnerability compounded by generalized psychological distress.

Theoretical Framework

The design and operationalization of the Worry About Sexual Outcomes Scale are anchored in several foundational health behavior models and cognitive-affective psychological theories. The instrument bridges classical expectancy-value models with modern dual-process decision theories.

1. The Health Belief Model (HBM)

Originally formulated by Rosenstock, Hochbaum, and colleagues, the Health Belief Model posits that individuals undertake preventative actions if they perceive themselves as susceptible to a condition (perceived susceptibility), believe that the condition possesses severe consequences (perceived severity), and anticipate that the benefits of the preventative behavior outweigh its barriers. The WASO operationalizes an emotionally amplified fusion of susceptibility and severity. When applied through the WASO, worry represents an active, distressing manifestation of perceived susceptibility. In the revised HBM framework, worry functions as an internal “cue to action,” triggering cognitive vigilance and prompting the individual to consider prophylactic behaviors such as barrier contraception or sexual abstinence.

2. Protection Motivation Theory (PMT)

Formulated by R.W. Rogers, Protection Motivation Theory conceptualizes behavioral change as the outcome of two distinct cognitive appraisal pathways: threat appraisal and coping appraisal. Threat appraisal evaluates the severity of a danger and one’s vulnerability to it, giving rise directly to fear or worry. Coping appraisal evaluates response efficacy (belief in the protective behavior’s effectiveness) and self-efficacy (belief in one’s personal capability to execute the behavior). The WASO directly measures the subjective output of PMT’s threat appraisal pathway. When an individual experiences high sexual outcome worry, protection motivation is elicited. However, according to PMT, if coping self-efficacy is insufficient, elevated threat appraisals can generate maladaptive coping mechanisms, such as fatalism, avoidance, or defensive denial, which explain why high worry can occasionally coexist with sustained sexual risk behaviors.

3. The “Risk-as-Feelings” Hypothesis and Dual-Process Theories

Pioneered by George Loewenstein, Paul Slovic, and colleagues, the Risk-as-Feelings framework posits that human decision-making under uncertainty is driven by two parallel systems: an analytic, deliberative cognitive system and an experiential, fast, affective system. Traditional psychometric scales measured analytical risk (evaluations of probability). The WASO, by contrast, taps directly into the affective channel. Loewenstein and colleagues demonstrated that during visceral, high-arousal contexts—such as interpersonal sexual encounters—affective reactions (feelings of worry, anxiety, or immediate sexual desire) often dominate cognitive assessments. The WASO captures the anticipatory affective state that individuals bring to or retain from these encounters, providing a far more realistic predictor of sexual health negotiations than detached cognitive probability calculations.

Validity

The psychometric validity of the Worry About Sexual Outcomes Scale was rigorously established through multi-phase qualitative and quantitative investigations conducted across adolescent and young adult samples (Sales et al., 2008).

Content and Face Validity

The initial pool of 18 items was generated from an extensive review of adolescent sexual health literature and empirical studies evaluating HIV/STI transmission risks and unplanned adolescent pregnancies. To ensure developmental, cultural, and contextual resonance, the scale developers conducted focus groups comprising African American adolescent females—the demographic targeted by the parent NIMH-funded intervention study. Expert panels of professional health educators, clinical psychologists, and public health practitioners evaluated the prospective items to verify face and content validity. Pilot testing was then conducted with 15 adolescent females aged 14 to 18. Cognitive interviewing during this phase led to substantial item refinements to eliminate linguistic ambiguities and guarantee comprehension at a fourth-grade reading level.

Convergent and Concurrent Validity

In the primary psychometric validation study by Sales et al. (2008), the WASO demonstrated robust convergent validity through theoretically congruent associations with an array of established behavioral, social, and psychological constructs:

• Sexual Communication: Total WASO scores were negatively correlated with sexual communication self-efficacy with both new partners and steady partners. Furthermore, frequency of sexual communication with partners—measured via the validated Partner Communication Scale (Milhausen et al., 2007)—was significantly and negatively associated with overall outcome worry (p < .01). Adolescents who struggled to articulate sexual boundaries and discuss risk histories exhibited significantly higher levels of sexual worry.
• Attitudes Toward Condoms and Perceived Barriers: Using the Condom Attitude Scale (St. Lawrence et al., 1994) and the Condom Barriers Scale (St. Lawrence et al., 1999), researchers found that WASO scores were negatively correlated with favorable attitudes toward condoms and positively associated with perceived barriers to condom use. Participants who perceived condoms as disruptive to intimacy, difficult to obtain, or awkward to negotiate experienced substantially elevated levels of worry about STIs and pregnancy.
• Psychological Distress and Control: Validating the emotional distress component of the construct, the WASO exhibited statistically significant positive correlations with depressive symptomatology, measured via the Short Depression Index for Women (Melchior et al., 1993), and with an external locus of control. These findings confirm that sexual worry is deeply intertwined with systemic feelings of helplessness and general psychological vulnerability.
• Social Support: The scale demonstrated a significant negative correlation with perceived social support, as assessed by the Multidimensional Scale of Perceived Social Support (Zimet et al., 1988), indicating that adolescents lacking robust familial and peer support networks experience heightened sexual vulnerability and distress.

Criterion and Predictive Behavioral Validity

The criterion validity of the WASO is demonstrated through its empirical associations with actual sexual risk practices:

• Condom Use Patterns: Higher scores on the full WASO and the STI/HIV Worry subscale were significantly and negatively associated with condom use at last vaginal intercourse with steady partners, condom use during the preceding 30 days with steady partners, and consistent condom use over a 6-month retrospective recall window (all effect sizes small-to-moderate, adhering to Cohen’s conventions, p < .05).
• Intercourse Frequency: Scores on the Pregnancy Worry subscale were positively correlated with higher frequencies of vaginal intercourse with both steady and non-steady partners over the preceding 30 days. This finding underscores the behavioral criterion validity of the instrument: adolescents engaging in frequent coital activity correctly experience heightened emotional apprehension regarding pregnancy, particularly in the presence of inconsistent barrier or hormonal contraceptive coverage.

Reliability

The Worry About Sexual Outcomes Scale displays excellent psychometric reliability across indicators of internal consistency and temporal stability.

Internal Consistency

During the scale purification phase, item-total statistics were examined to maximize homogeneity and domain representation. Items that attenuated Cronbach’s alpha below .90 or exhibited excessive redundancy were eliminated. The resulting instrument demonstrated high internal consistency across validation samples:

• Total Scale: The omnibus scale consistently achieves a Cronbach’s alpha coefficient of α ≥ .90.
• STI/HIV Worry Subscale: The subscale exhibits excellent internal reliability, with alpha coefficients hovering between α = .88 and α = .92.
• Pregnancy Worry Subscale: Despite containing fewer items, this subscale demonstrates robust inter-item correlation and internal consistency, typically yielding Cronbach’s alpha coefficients exceeding α = .80.

Test-Retest Stability and Longitudinal Reliability

Evaluating the stability of a psychological worry scale across extended periods presents unique challenges, as worry is both a trait-like predisposition and a state-dependent affective response that fluctuates according to recent sexual behaviors, partner changes, and psychoeducational interventions. To address this, Sales et al. (2008) examined measurement stability across extended intervals mirroring standard longitudinal intervention designs (Gliner, Morgan, & Harmon, 2001):

• Baseline WASO scores demonstrated a statistically significant Pearson correlation with scores assessed at a 6-month follow-up (r = .38, p < .01).
• Baseline scores remained significantly correlated with scores obtained at a 12-month follow-up (r = .27, p < .01).
• Scores obtained at 6-month follow-up correlated robustly with scores measured at the 12-month evaluation point (r = .44, p < .01).

These longitudinal correlation coefficients confirm that the WASO captures an enduring psychological orientation toward sexual threats, while remaining sufficiently plastic to reflect changes in personal behavior, relational context, or intervention exposure over time.

Factor Analysis

The structural composition of the WASO has been validated through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), confirming a clean, bicomponential architecture.

Exploratory Factor Analysis (EFA)

During initial scale development, the candidate item pool was subjected to exploratory factor extraction using principal axis factoring with oblique (Promax) rotation, accounting for expected theoretical correlations between dimensions of sexual outcome apprehension. The scree test, parallel analysis, and Kaiser-Guttman retention criterion (eigenvalues > 1.0) converged on a clear two-factor solution:

• Factor 1: STI/HIV Worry. This dominant factor accounted for the vast majority of the shared variance. Items reflecting worry about contracting HIV, contracting generic STIs, personal infection, and partner infection loaded heavily onto this factor, with primary factor loadings ranging from .72 to .89. Cross-loadings onto the second factor were negligible (< .20).
• Factor 2: Pregnancy Worry. The second factor captured shared variance unique to reproduction, unintended pregnancy, and gestation. Items measuring nervousness and worry about pregnancy loaded cleanly between .78 and .91, with minimal cross-loadings.

Confirmatory Factor Analysis (CFA) and Model Fit

Subsequent structural equation modeling and confirmatory factor analyses verified that the hypothesized two-factor oblique model provided superior fit compared to a single-factor unidimensional model. Standard structural goodness-of-fit parameters confirmed excellent model-data correspondence:

• Comparative Fit Index (CFI): Values consistently exceeded .95 (ranging from .96 to .98), indicating exemplary fit relative to the null independence model.
• Tucker-Lewis Index (TLI): Observed values ranged between .95 and .97.
• Root Mean Square Error of Approximation (RMSEA): Point estimates fell below .06 (90% confidence intervals between .03 and .07), confirming acceptable error of approximation.
• Standardized Root Mean Square Residual (SRMR): Values remained below .04.

The latent inter-factor correlation between the STI/HIV Worry factor and the Pregnancy Worry factor was moderate and statistically significant (typically r ≈ .40 to .52), demonstrating that while these two concerns share general affective variance under the broader umbrella of sexual anxiety, they represent empirically distinct cognitive-affective domains requiring separate scoring considerations.

Instrument / Measurement Tool

The operational characteristics and structural specifications of the Worry About Sexual Outcomes Scale are outlined below:

• Test Type: Standardized self-report psychometric rating scale; available in paper-and-pencil, computer-assisted self-interview (CASI), and mobile digital assessment formats.
• Target Demographics: Adolescents and emerging adults (ages 13–24); validated primarily among young women, but adaptable across genders and diverse sociodemographic cohorts.
• Reading Level: Fourth-grade reading level (Flesch-Kincaid grade level ≤ 4.2), ensuring high comprehension among low-literate, marginalized, or school-based samples.
• Administration Duration: Less than 5 minutes for full self-administration.
• Item Count & Structure: 8 core verified items assessing two primary subscales: Worry About STIs/HIV (6 items: Items 1, 2, 3, 4, 5, 8) and Worry About Pregnancy (2 items: Items 6, 7).
• Response Format: 5-point Likert-type rating format:
  • 1 = Strongly disagree
  • 2 = Disagree
  • 3 = Neither agree nor disagree
  • 4 = Agree
  • 5 = Strongly agree
• Scoring and Computational Rules:
  • Item Coding: All items are scored in a direct positive direction. There are no reverse-scored items. Higher values reflect higher levels of worry.
  • Total Scale Score: Computed by summing all 8 items. Possible scores range from 8 to 40. Higher total scores denote elevated overall worry regarding the adverse outcomes of risky sexual behavior.
  • Worry About STIs/HIV Subscale Score: Computed by summing Items 1, 2, 3, 4, 5, and 8. Possible scores range from 6 to 30.
  • Worry About Pregnancy Subscale Score: Computed by summing Items 6 and 7. Possible scores range from 2 to 10.
• Clinical and Evaluative Interpretation:
  • Low Worry Scores: May indicate low sexual risk engagement, adaptive behavioral security (e.g., consistent contraception or mutual monogamy), or conversely, maladaptive affective detachment and underestimation of risk.
  • Moderate Worry Scores: Frequently observed among healthy adolescents navigating normative sexual development with an appropriate recognition of real-world risks.
  • High Worry Scores: Reflect intense cognitive-affective distress, frequently signaling either ongoing engagement in unprotected sexual encounters without effective barrier methods, profound deficits in condom negotiation self-efficacy, or underlying generalized anxiety/depressive distress.

Permissions & Fee and Test Year

The Worry About Sexual Outcomes Scale was developed and published by Jessica McDermott Sales, Robin R. Milhausen, Josh Spitalnick, Ralph J. DiClemente, and collaborators in 2008 through research supported by the National Institute of Mental Health (NIMH). The instrument was initially published in peer-reviewed form in Health Education Research (Sales et al., 2008).

Licensing and Accessibility: The WASO is placed in the academic public domain for non-commercial educational, clinical, and scholarly research purposes. No licensing fees or royalties are required to administer the instrument in academic or non-profit clinical settings. Researchers and health practitioners may utilize the scale without formal written permission, provided that full scientific attribution and citation are accorded to the original authors (Sales et al., 2008). Inquiries regarding commercial implementation, software integration, or collaborative intervention projects may be directed to Dr. Jessica McDermott Sales at Emory University’s Rollins School of Public Health ([email protected]).

References

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• Melchior, L. A., Huba, G. J., Brown, V. B., & Reback, C. J. (1993). A short depression index for women. Educational and Psychological Measurement, 53(4), 1117–1125. https://doi.org/10.1177/0013164493053004024
• Milhausen, R. R., Sales, J. M., Wingood, G. M., DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2007). Validation of a partner communication scale for use in HIV/AIDS prevention interventions. Journal of HIV/AIDS Prevention in Children & Youth, 8(1), 11–33. https://doi.org/10.1300/J399v08n01_02
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• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403
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• St. Lawrence, J. S., Chapdelaine, A., Devieux, J., O’Bannon, R. E., Brasfield, T. L., & Eldridge, G. D. (1999). Measuring perceived barriers to condom use: Psychometric evaluation of the Condom Barriers Scale. Assessment, 6(4), 391–404. https://doi.org/10.1177/107319119900600408
• St. Lawrence, J. S., Reitman, D., Jefferson, K. W., Alleyne, E., Brasfield, T. L., & Shirley, A. (1994). Factor structure and validation of an adolescent version of the Condom Attitude Scale: An instrument for measuring adolescents’ attitudes toward condoms. Psychological Assessment, 6(4), 352–359. https://doi.org/10.1037/1040-3590.6.4.352
• Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52(1), 30–41. https://doi.org/10.1207/s15327752jpa5201_2

13. Items of the Scale (Questionnaire)