Spiritual Health Locus of Control
Spiritual health locus of control (SHLOC) is a concept recently developed by Holt and her colleagues (Holt, Clark, & Klem, 2007; Holt, Clark, Kreuter, & Rubio, 2003a; Holt, Lukwago, & Kreuter, 2003b). Based on research that shows complex relationships between a person's religious beliefs, spirituality, and health, spiritual health locus of control was developed to link religious and spiritual beliefs to how health outcomes are controlled. Specifically, this measure is built on the Health Locus of Control (HLC) Scale (Wallston, Wallston, Kaplan, & Maides, 1976) and the Multidimensional Health Locus of Control (MHLC) Scale (Wallston, Wallston, & DeVellis, 1978).
The underlying structure of this concept is that individuals vary on how much they believe they have control over their own health outcomes. Individuals with an internal locus of control believe that they have control, whereas individuals with an external locus of control believe that their outcomes are controlled by outside forces. However, this dimension did not include all factors perceived to be important in determining one's health for all populations (Holt et al., 2003a; Wallston et al., 1999; Welton, Adkins, Ingle, & Dixon, 1996). Holt et al, (2003a) determined that this may be particularly true for African Americans, who perceive a strong role of God in their health. Separate measures—spiritual health locus of control (Holt et al., 2003a) and God locus of health control (GLHC; Wallston et al., 1999)—were developed independently.
Spiritual health locus of control involves the belief that God has control over one's health. These beliefs involve an active/passive dimension, where individuals may vary on the role both God and the self play in one's health. Individuals who are active believe that both God and themselves influence their health. Individuals who are Passive believe that God controls their health (and therefore are less likely to engage in protective health behaviors; Holt el al., 2003a). The first spiritual health locus of control measure had four dimensions made up of ten items (Holt et al., 2003a): 1) Internality (e.g., keeping my health depends on having a healthy lifestyle, 2) Externality (e.g., If it is meant to be, I will stay healthy; from Wallston, Wallston, & DeVellis, 1978), 3) Active spirituality (e.g., If I lead a good spiritual life I will stay healthy), and 4) Passive spirituality (e.g., I rely on God to keep me in good health). Recently, Holt and her colleagues (Holt et al., 2007) developed a more extensive measure, still with four dimensions, but with 13 items (four of which were retained from the shorter index). Also, the factor structure was different in the latter study than it was for the earlier SHLOC. The four factors in the latter index were labeled: 1) Spiritual Life/Faith (e.g., If I lead a good spiritual life, I will stay healthy); 2) Active spiritual (e.g., Even though I trust God will take care of me, I still need to take care of myself); 3) God's grace (e.g., If I stay well, it is because of the grace of the good Lord); and 4) Passive spiritual (e.g., There is no point in taking care of myself when it's all up to God anyway).
From: Holt, C.L., Clark, E.M., & Klem, P.R. (2007). Expansion and validation of the spiritual health locus of control scale: Factor analysis and predictive validity.
Journal of Health Psychology, 12(4) 597-612.
Spiritual Life/Faith (α = .81)
Through my faith in God, I can stay healthy
If I lead a good spiritual life, I will stay healthy
If I stay healthy, it's because I am right with God
Active Spiritual (α= .66)
Living the way the Lord says I'm supposed to live means I have to take care of myself
Even though I trust God will take care of me, I still need to take care of myself
God gives me the strength to take care of myself
God's Grace (α = .63)
I rely on God to keep me in good health
God works through doctors to heal us
Prayer is the most important thing I do to stay healthy
If I stay well, it is because of the grace of the good Lord
Passive Spiritual (α = .51)
It's ok not to seek medical attention because I feel that
God will heal me
There is no point in taking care of myself when it's all up to God anyway
God and I share responsibility (reverse)
Responses collected using a five-point Likert-type response scale (strongly disagree to strongly agree).
Holt, C.L., Clark, E.M., Kreuter, M.W., & Rubio, D.M. (2003). Spiritual health locus of control and breast cancer beliefs among urban African American women. Health Psychology, 22(3), 294-299.
Internality (α = .73)
Keeping my health depends on having a healthy lifestyle.
Whether or not I stay healthy is up to me.
It's my own behaviors that keep me healthy.
I am the one who's in charge of keeping myself healthy.
Active spirituality (α= .76)
If I lead a good spiritual life, I will stay healthy.
If I stay healthy, it's because I am right with God.
I rely on God to keep me in good health.
Through my faith in God, I can stay healthy.
Externality (α = .45, r=.29; pilot study (Kreuter, 2000, α = .81; r=.72)
If it's meant to be, I will stay healthy.
No matter what I do, if I'm going to get sick, I will get sick.
All measured in 4-point Likert-type scale (4 = I strongly agree, 1 = I strongly disagree).
Rationale for Selection
These indexes were chosen because the represent the current thinking about SHLOC. The index seems to be best utilized for African American samples, particularly African American women, for whom spirituality appears to play an important role in their health beliefs. African American women who have breast cancer rely on God to a greater extent than family or friends (Henderson & Fogel, 2003). This group also relies on prayer to cope with breast cancer, among other coping strategies such as maintaining a positive attitude and the will to live (Henderson, Gore, Davis, & Condon, 2003).
Alphas of both SHLOC sub-scales are moderate to good (.51-.81). As more research is conducted and as more samples are utilized, it is likely that new items will be identified that will increase reliability.
Use of Measure (with examples)
Holt et al. (2007) conducted the study that tested the newer SHLOC index. Their data were collected from 108 African American women, with an age range of 40 to 79 (mean = 55.7 years). The predictive validity of the SHLOC sub-scales was tested by using the four factors to predict perceived barriers to mammography, breast cancer-related knowledge, and mammography utilization. The spiritual life and faith factor was negatively associated with mammography knowledge; the passive spiritual factor was negatively associated with mammography, breast cancer, and breast cancer treatment knowledge, and with mammography utilization.
Holt et al. (2003), using a much larger sample of African American women (N > 1200) found that two items each represented the latent constructs of active and passive spiritual health locus of control. However, the Holt et al. (2007) study employed a sample of N=108, which did not support that factor structure —hence, the revised instrument. The items that previously represented the active dimension later loaded on the Spiritual life and faith dimension. Also, the two original passive items loaded this time on the God's grace and spiritual life and faith dimensions. Holt et al. (2007, p.606) state: "Upon closer examination, this may not be surprising, in that the premise for revising the instrument was that the Active and Passive Spiritual dimensions were not very well differentiated." Further, only four items are common to the 10-item and 13-item indexes, so it is not unusual for the common items to load differently in each sample.
Theory would predict that the active spiritual dimension would be positively associated with knowledge, mammography utilization, and would be negatively associated with barriers. This is was not the case in the 2007 study, although the correlations were in the predicted direction. The lack of statistical significance is likely influenced by the small N of the study.
There are two key differences between the GLHC research by both Wallston et al. (1999) and Welton et al. (1996) and the SHLOC research by Holt and her colleagues. The first is that the GLHC assessed the God control dimension with a unidimensional construct, while the SHLOC uses a multidimensional one. The second is that the GLHC items (Wallston et al., 1999) measure beliefs of the role of God in the context of the progression of a specific condition. In contrast, SHLOC assesses perceptions of the role of God in one's health in general.
Henderson, P. D., & Fogel, J. (2003).Support network used by African American breast cancer support group participants.
Association of Black Nursing Faculty Journal, 14, 95-98.
Henderson, P. D., Gore, S. V., Davis, B. L., & Condon, E. H. (2003).African American women coping with breast cancer: A qualitative analysis.
Oncology Nursing Forum, 30, 641-647.
Hold, C.L., Clark, E.M., & Klem, P.R. (2007).Expansion and validation of the spiritual health locus of control scale: Factor analysis and predictive validity.
Journal of Health Psychology, 12(4), 597-612.
Holt, C.L., Clark, E.M., Kreuter, & Rubio, D.M. (2003a).Spiritual health locus of control and breast cancer beliefs among urban African American women.
Health Psychology, 22(3), 294-299.
Holt, C.L., Lukwago, S.N., & Kreuter, M.W. (2003b).Spirituality, breast cancer beliefs and mammography utilization among urban African American women.
Journal of Health Psychology, 8(3), 383-396.
Kreuter, M. W. (2000).[Test-retest pilot data.] Unpublished raw data.
Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978).Development of the multidimensional health locus of control scales.
Health Education Monographs, 6, 161-170.
Wallston, B. S.,Wallston, K. A., Kaplan, G. D., & Maides, S. A. (1976).Development and validation of the Health Locus of Control (HLC) Scale.
Journal of Consulting and Clinical Psychology, 44(4), 580-585.
Welton, G. L., Adkins, A. G., Ingle, S. L., & Dixon, W. A. (1996).God control: The fourth dimension.
Journal of Psychology and Theology, 24(1), 13-25.