Worry
Kevin D. McCaul and Paul W. Goetz

2 Use in Health Behavior Theories

Worry per se, whether assessed as a trait or as a temporary feeling, has been ignored by all health behavior theories. Of course, affect in the form of feelings (as opposed to "affective judgments") does not appear in most health behavior theories. No mention of feelings is made in these commonly used theoretical approaches to health and behavior: the Health Belief Model (Hochbaum, 1998 xClose
Hochbaum, G. M. (1958). Public participation in medical screening programs: a socio-psychological study. Washington, D.C.: U.S. Dept. of Health, Education, and Welfare. ), the Theory of Reasoned Action (Fishbein & Ajzen, 1975 xClose
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: an introduction to theory and research. Reading, Mass.: Addison-Wesley, 1975. ) (and its extension, the Theory of Planned Behavior, Ajzen, 1991 xClose
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. ), and the Transtheoretical Model (DiClemente et al., 1991 xClose
DiClemente, C.C., Prochaska, J.O., Fairhurst, S.K., Velicer, W.F., Velasquez, M.M., & Rossi, J.S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304. ).

Three models do explicitly acknowledge the potential role of feelings. The first model was introduced by Ronald Rogers (e.g., Rogers & Prentice-Dunn, 1997 xClose
Rogers, R.W., & Prentice-Dunn, S. (1997). Protection motivation theory. In David S. Gochman (Ed.), Handbook of Health Behavior Research. Vol.1. New York: Plenum Press, pgs 113-132. ) to explain how people respond to threatening messages. In the model, called Protection Motivation Theory, emotion is produced by the interaction of two perceptions created by the message: the severity of the health threat and one's vulnerability to the health threat. Thus, the threat of lung cancer could cause fear among people who a) know about the short life expectancy for people with the disease and b) feel at personal risk because of their smoking behavior. Rogers was interested in when people are motivated to protect themselves from a health threat, and it is interesting to note that he did not provide any role for fear as a contributor-one way or the other-to self-protective motivation. Instead, he proposed that the cognitions did the work and fear was merely present. In a recent meta-analysis of variables in the theoretical model, the authors neglected to discuss fear, illustrating the minimal causal importance they attached to the construct (Floyd, Prentice-Dunn, & Rogers, 2000 xClose
Floyd, D.L., Prentice-Dunn, S., & Rogers, R.W. (2000). A meta-analysis of research on protection motivation theory. Journal of Applied Social Psychology, 30, 407-429. ).

A second theoretical approach explicitly provided a role for emotions in health behavior. Specifically, Leventhal's Common-Sense Model of Health and Illness Self-Regulation (Leventhal, Brissette, & Leventhal, 2003 xClose
Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The common-sense model of self-regulation of health and illness. In L.D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behaviour (pp.42-65). London: Routledge. ) suggests that a health threat prompts parallel motives to cope with the a) threat itself and b) emotions caused by the threat. Thus, in Leventhal's approach, emotion is motivating. Some authors include a variety of emotions in Leventhal's model, but Leventhal's initial ideas arose out of his research on fear messages for communicating threat (cf. Cameron, 2003 xClose
Cameron, L.D. (2003). Anxiety, cognition, and responses to health threats. The common-sense model of self-regulation of health and illness. In L.D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behaviour (pp.42-65). London: Routledge. ). In keeping with those initial ideas, Witte (1998) xClose
Witte, K. (1998). Fear as motivator, fear as inhibitor: Using the extended parallel process model to explain fear appeal successes and failures. In P.A. Anderson and L.K. Guerrero (Eds.), Handbook of Communication and Emotion: Research, Theory Applications, and Contexts. 423-450. Academic Press.  identified fear as the crucial emotion in her discussion of an "Extended Parallel Process Model"(an extension of Leventhal's common-sense model). Witte predicted that when people are exposed to a threatening message, they will do something to ameliorate the threat, if possible; otherwise, they will experience fear. In the latter case, according to Witte, people will be motivated to reduce the negative emotion but not necessarily by engaging in self-protective actions. Both Leventhal and Witte would suggest that emotion drives actions, with slightly different theoretical twists. For Leventhal, expectations about the affective outcomes of the self-protective behavior (will cancer screening make me feel better?) determine the course of action; for Witte, expectations about one's ability to perform the self-protective behavior (can I easily obtain a cancer screening?) will determine the course of action. In both cases, however, low levels of emotionality will not be motivating.

The third approach that acknowledges feelings is Suzanne Miller's Cognitive Social Health Information Processing (C-SHIP) model (Miller, Shoda & Hurley, 1996 xClose
Miller, S. M., Shoda, Y., & Hurley, K. (1996). Applying cognitive-social theory to health protective behavior: Breast self-examination in cancer screening. Psychological Bulletin, 119, 70-94. ). Miller considers many feelings in her model; worry is just one of many potential reactions in decision making about health behaviors. Miller et al. also propose that the relationship between worry and behaviors will depend on the intensity of emotionality, with either very low or very high levels of worry impeding action. This proposal is also known as a "curvilinear" or "inverted U-shaped" hypothesis, and is prominently embedded within the model. The notion of a curvilinear relationship between emotion and behavior is an old idea in psychology (Teigen, 1994 xClose
Citation needed ). It is worth noting that existing empirical evidence is much more likely to support a linear, positive relationship between worry and self-protective behaviors (McCaul & Mullens, 2003 xClose
McCaul, K.D., & Mullens, A.B. (2003). Affect, Thought, and Self-Protective Health Behavior: The Case of Worry and Cancer Screening. In J. Suls and K. Wallston (Eds.), Social Psychological Foundations of Health and Illness, Blackwell: Malden, MA. ; Hay, McCaul, & Magnan, 2006 xClose
Hay, J.L., McCaul, K.D., & Magnan, R.E. (2006). Does worry about breast cancer predict screening behaviors? A meta-analysis of the prospective evidence. Preventive Medicine, 42, 401-408.). Part of the problem with the curvilinear hypothesis is that it is imprecise. For example, it is unclear how to define "very high levels of worry." Miller et al. also suggest that high worry can lead to both avoidance of a self-protective response but also excessive performance of the response, without explaining when one behavioral solution is more likely to be adopted than the other. Finally, it is important to acknowledge that Miller's theory is one of the few to explicitly incorporate individual differences (though not dispositional worry, which deserves greater theoretical attention).