insights into the health control beliefs of american samoans, 2009, sara krosch

AMERICAN SAMOA COMMUNITY CANCER NETWORK

Insights into the Health Control Beliefs of American Samoans

Results of an Adapted Multidimensional Health Locus of Control Survey

Sara Krosch

[email protected]

2009

T O W A R D S T H E O R Y ‐ B A S E D I N T E R V E N T I O N S

Table of Contents Introduction .............................................................................................................................................................................................................. 3

Purpose .......................................................................................................................................................................................................... 3

Previous Research .......................................................................................................................................................................................... 3

Figure 1: M‐HLoC Profiles for Samoan Male ASCCN Prostate Clinic Attendees 2006‐07 ......................................................................... 5

The Multidimensional Health Locus of Control Survey .............................................................................................................................................. 6

Health Control ................................................................................................................................................................................................ 6

Locus of Control and Classification ................................................................................................................................................................. 6

Table 1: Four Loci of the Health Control .................................................................................................................................................. 6

Table 2: Individual Classifications based on M‐LoC Scores ..................................................................................................................... 7

The God Locus of Control ............................................................................................................................................................................... 7

Using M‐HLoC Scores to Predict Behaviors .................................................................................................................................................... 7

Table 3: Coping Styles & Perceptions of Active/Passive Self and God ..................................................................................................... 9

Self‐Efficacy ............................................................................................................................................................................................................... 9

Methodology ........................................................................................................................................................................................................... 10

Hypotheses .............................................................................................................................................................................................................. 11

Survey Results ......................................................................................................................................................................................................... 12

Respondents’ Demographics ........................................................................................................................................................................ 12

Tables 4‐8 Respondents’ Demographics ................................................................................................................................................ 12

Respondents’ M‐HLoC Profiles ..................................................................................................................................................................... 13

Figure 2: Average M‐HLoC Scores for All Females & All Males .............................................................................................................. 13

Table 9: Female Age Groups: M‐HLoC Survey Item Results ................................................................................................................... 14

Figure 3: Average M‐HLoC Scores for All Females & Female Age Groups .............................................................................................. 14

Table 10: Female Education Groups: M‐HLoC Survey Item Results ....................................................................................................... 15

Figure 4: Average M‐HLoC Scores for All Females & Female Education Groups .................................................................................... 15

Table 11: Female Cancer Status: M‐HLoC Survey Item Results .............................................................................................................. 16

Figure 5: Average M‐HLoC Scores for All Females, Female Cancer Survivors (n=9) & Female Family Cancer Survivors (n=53) ............ 16

Table 12: Male Age Groups: M‐HLoC Survey Item Results ..................................................................................................................... 17

Figure 6: Average M‐HLoC Scores for All Males & Male Age Groups ..................................................................................................... 17

Table 13: Male Education Groups: M‐HLoC Survey Item Results ........................................................................................................... 18

Figure: 7: Average M‐HLoC Scores for All Males & Male Education Groups .......................................................................................... 18

Table 14: Male Cancer Status: M‐HLoC Survey Item Results ................................................................................................................. 19

Figure 8: Average M‐HLoC Scores for All Males & Male Family Cancer Survivors (n=26) ...................................................................... 19

Findings Summary ................................................................................................................................................................................................... 20

Figure 9: M‐HLoC Items Scores ‐ All Females & All Males ...................................................................................................................... 20

Hypotheses Results ................................................................................................................................................................................................. 22

Using M‐HLoC Results ............................................................................................................................................................................................. 22

Figure 10: The Health Belief Model ....................................................................................................................................................... 23

Works Cited ............................................................................................................................................................................................................. 24

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch [email protected]

2

Introduction

Purpose

The mission of the American Samoa Community Cancer Network (ASCCN) is to reduce health disparities

that contribute to increased cancer incidence, morbidity and mortality in American Samoa via research

and the support of partners who provide education and services.

The survey reported in this document specifically aimed to understand the health control beliefs of

different segments of the American Samoa population in order to plan theory‐based health

promotion interventions.

A health promotion theory provides a systematic way to understand situations by explaining

relationships between variables. Models draw on several theories to understand a particular problem in

a certain setting. Theories and models are used to understand why a specific group behaves a certain

way and to plan the most effective strategies and messages for health programs (NCI, 2005).

Previous Research

To date, the ASCCN has not focused on health promotion theories or models to guide program

development or evaluation. However, ASCCN researchers and others have conducted measures to

better understand the population’s health awareness, knowledge, and behaviors.

Focus groups facilitated by the ASCCN in 2006 found that the majority of American Samoans feel cancer

is a new phenomenon stating that there is no Samoan word for the disease and they never heard about

cancer when they were young. Participants had negative and fatalistic associations with cancer. Cancer

meant hopelessness, worry, and that death was near. Fear of the disease deterred people from

screening or follow‐up hospital visits. There was widespread knowledge of smoking leading to cancer,

but beliefs about what causes other cancers were highly varied—not taking local herbal medicine in

time when feeling ill, a punishment from God, a result of spirit possession, or tuberculosis. Several

participants felt that cancer was caused by germs or uncleanliness. Others believed the disease is linked

to a shift in diet from traditional foods to processed foods containing “chemicals and preservatives.”

The mystery surrounding what causes cancer to lead many towards religious comfort evidenced in the

following quotations from focus group participants:


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“Because the disease is new we go to the doctor or to the Lord. The Lord is the

only cure. The Father in Heaven is the Doctor of all doctors.”

“If I were diagnosed I would rely on God.”

“[If diagnosed], all we can do is pray.”

People report receiving information about cancer from four equally mentioned sources: the hospital,

Samoan “doctors” (Taulasea/Fofo), church pastors, and those already diagnosed with cancer and their

families (Krosch, 2008).

The Samoan way of life (fa’aSamoa) consists of a chief system responsible for the organization and

leadership of family and villages, family‐based activities (including diet), churches and religious beliefs.

Emphasis is placed on living one’s life to the benefit of the greater family. It is largely dictated by males,

traditional leaders (matais) and church ministers age 50 and older. A qualitative study with this target

group, none of whom were cancer survivors, reported that disease prevention is not part of the

fa’aSamoa. Preventative care is difficult to get because health providers are not oriented towards

prevention in American Samoa (Hubbell, et al., 2005). They stated that “fa’aSamoa is based on fear and

respect” and it negatively influences the population by reinforcing and perpetuating

shame/embarrassment and a reluctance to discuss personal (bodily) issues. Samoans remain silent due

to ignorance of the disease and out of “respect for the doctor.” They “refuse treatment out of pride”

and seek it “only when they are near their death bed (Puaina, et al., 2008).

Studies have shown that American Samoans believe failure to follow the fa’aSamoa—characterized by

eating unhealthy foods (high‐fat, imported, canned, refrigerated), smoking cigarettes, drinking too much

alcohol, breathing polluted air, and general neglect of one’s body—could lead to cancer and that a

return to the fa’aSamoa could prevent cancer (Hubbell, et al., 2005; Puaina, et al., 2008). This

complements the beliefs that cancer is not “part of Samoan culture” and that it is a relatively new

disease brought by Westerners or brought on by western ways (APIAHF, 2006; Hubbell, et al., 2005;

Puaina, et al., 2008).

Cancer may also be God’s will. Some Samoan ministers explain cancer as an “act of God” or that

“people made it God’s will by participating in unhealthy or unwise behaviors and that God’s will should

be accepted to avoid worry and anger. Few believe that spirits (aitu—the cause of most illnesses in

traditional Samoan culture) cause cancer (Hubbell, et al., 2005)


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To further explore these notions about perceived health control related to cancer, namely the influence

of Powerful Others (the pillars of fa’aSamoa) and God, and the tug of war between Chance and Internal

will (linked to many causes of cancer that are perceived to be within or beyond and individual’s control),

an adapted Multidimensional Health Locus of Control survey was administered to 15 Samoan males age

40 or older in 2008 who had attended prostate cancer education sessions and screening clinics in 2006‐

07. The men were divided into three groups of five based on their screening behaviors and test results:

(1) Low PSA Men who had screened once and were at low risk for prostate cancer—low prostate‐

specific antigen (PSA) scores; (2) Repeat PSA Men with low PSA results scores who had repeatedly

screened for prostate cancer over the project period; and (3) High PSA Men most at risk for prostate

cancer and who had been referred for further screening.

0

20

40

60

80

100

Low PSA Repeat PSA High PSA

Figure 1: M‐HLoC Profiles for Samoan MaleASCCN Prostate Clinic Attendees 2006‐07

Internal

Powerful Others

God

Chance% in Agreemen

t

Results from this small sample showed all three groups felt control over their health was mostly under

Internal control (Internal scores highest). The most distinct differences were seen in the Repeat PSA

group which had the highest possible Internal score (100%) while the other domains were influential to

only half of this group. See Figure 1 above. What is unknown is whether the Repeat PSA Men had high

perceived Internal control that prompted them to screen for cancer given the opportunity or did this

group develop higher Internal control as a result of added awareness, knowledge and screening

experience. Men with the highest PSA scores felt that many forces were responsible for their health as

shown by their equal Internal, Powerful Others and Chance scores. Interestingly their God domain

scored lowest.


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In order to further explore health control beliefs amongst the broader American Samoa population, 200

residents were surveyed using the same adapted Multidimensional Health Locus of Control survey

completed by male prostate clinic attendees with a specific aim of gaining insight into relative levels of

active and passive health control beliefs and behaviors in females and males age 13‐75.

The Multidimensional Health Locus of Control Survey

Health Control

When individuals are able to influence or determine what is happening to them, or will happen to them,

they are “in control.” Beliefs about control in the context of health refer to the thoughts an individual

has about her/his ability to influence health behaviors, health status, health outcomes and/or health

care. Personal control is usually linked to positive health outcomes (Wallston, et al, 1991). However,

when one lacks actual control over health matters the perception of being in control is often sufficient to

reap benefits (Wallson, 2004).

Locus of Control & Classification

Julian Rotter first coined the term “locus of control” (location) in 1966 as part of his Social Learning

Theory referring to an individual’s belief as to whether control over health outcomes lies internally (a

consequence of what one does) or externally (due to the actions of other people or due to chance).

In the mid 1970’s, Kenneth Wallston and colleagues developed the Multidimensional Health Locus of

Control (M‐HLoC) scales (Wallston, 2004). They measure a respondent’s beliefs about four domains of

influence over general health:

Table 1: Four Loci of the Health Control (Source Wallston, et al. 1991)

Domain Type Locus Name Description Internal Internal personal control over health status and outcomes External Powerful Others health care professionals, family, friends, and

influential others control over health External Chance Fate, luck or unchangeable/unexplainable reasons for

health status and outcomes Internal or Internal/External Collaborative

God A supreme being’s control over one’s health status and outcomes


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Today, the M‐HLoC is one of the most widely used health belief measurements for the planning of

health education programs (Moshki, 2007). The original M‐HLoC scale included three loci: Internal,

Powerful Others and Chance. These dimensions were used to classify individuals in to 1 of 8 ‘types’ in

order to predict behavior and thought patterns relevant to mental and physical health (Masters and

Wallston, 2005; Wallston, et al., 1999).

Table 2: Individual Classifications based on M‐LoC Scores (Source: Masters and Wallson, 2005)

Example Classifications Internal Score Powerful Others Score Chance Score

“Pure Internal” High Low Low

“Believer in Control” High High Low

“Nay‐Sayer” Low Low Low

The God Locus of Control

In response to cancer studies and other research into chronic disease, Wallston and colleagues (1999,

2005) added a forth locus, the God Locus of Health Control (GLoC), to assess the extent to which people

attribute their health status to a supreme being. The GLoC scale items can be used along with the

original M‐HLoC or as a separate instrument. The God control dimension may represent either an

external or an internal‐collaborative locus.

Using M‐HLoC Scores to Predict Behaviors

It is most important for the individual to believe that health behavior control exists. Only then does the

place where the control resides, the locus, become a factor in predicting behaviors. Consistent findings

have shown that high Internal HLoC correlates with carrying out recommended health behaviors and

self‐reported good health status whereas high Chance HLoC is related to depression and other

psychological distress. Further, in most populations, Internal and Powerful Others scores are

uncorrelated, Internal and Chance scores are negatively correlated (when one variable increases the

other deceases) and Powerful Others and Chance are positively correlated (when one variable increases

or decreases the other variable also increases or decreases) (Wallston, 2004).

Masters and Wallston (2005) performed comparisons (canonical correlations) to show relationships

between the different loci of health control and other health and quality of life measures such as


7


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positive and negative affect1, coping, and values. Their research aims to help predict thought and

behavior patterns:

Positive/Negative Affect

• collaborative control between Internal and God relates to high positive affect (better mental

and physical health) and low negative affect in generally healthy populations

Coping

• high God control indicates high use of religious coping (active in religion and frequent prayer)

• high Powerful Others and Chance scores are related to passive coping strategies2

• high Powerful Others and Chance scores correlate with use of venting, non‐acceptance of

responsibility, self‐blame and humor as coping strategies

• high Internal control is related to healthy or active coping strategies3

• individuals who value health and have high Internal scores are likely to be active copers

Values

• high Internal control is correlated with happiness and good health

• high God control indicates high value placed on religion/spirituality

• low God and Chance control are related to high value of inner harmony and low value of an

exciting life and social recognition

In particular, Wallston and associates (1999) found that a subject’s age, gender or income level have no

significant relationship with God LoC scores but this locus is significantly negatively correlated with level

of education—higher education is related to lower GLoC scores. 4 The GLoC is significantly positively

correlated with Powerful Others survey items (other than item specifically about Doctors) meaning

people with high God scores also tend to perceive sources of health control in the non‐health

professional people in their lives. God control is unrelated with Internal and Powerful Others items

related to Doctors. The GLoC is also significantly positively correlated with Chance.

1 High positive affect shows a person is enthusiastic, alert, active, and energetic, has high concentration, and enjoys interacting with others. Low positive affect indicates sadness and lethargy. High negative affect indicates a person who feels distressed, depressed, angry, fearful and/or nervous. Low negative affect score reflect calmness and serenity (Masters and Wallston, 2005). 2 Passive coping strategies include behavioral disengagement, emotional support and self‐distraction. 3 Active coping included active behavior change and positive reframing. 4 This finding is consistent with surveys showing that highly educated people tend to be less religious (Wallston, et al., 1991).

Higher GLoC scores are related to poorer adjustment to chronic illness in these populations whereas

high GLoC scores are associated with healthy behaviors in generally healthy populations. (Wallston, et

al., 1991). To further understand these findings we can look to Hathaway and Pargament’s research

(1991) about the relationship between beliefs about God and coping strategies. They describe three

coping styles:

Table 3: Coping Styles & Perceptions of Active/Passive Self and God (Source: Hathaway and Pargament, 1991)

Coping Style Description Health Outcome Deferred Style Passive self, coping is under God’s active

control Poorer adjustment to stress

Self‐directed Style

Active self, passive God Positive adaption

Collaborative Style Self and God are active, working together to cope with stressor

Positive adaption

Masters and Wallston (2005) suggest that the GLoC score be considered in light of a person’s current

disease status, depth of religious commitment and overall LoC profile.

SelfEfficacy

Most health education and disease prevention aims to give individuals more control, or a greater sense

of control, over health behaviors and outcomes. Many programs assess participants’ control beliefs or

self‐efficacy to determine if the program reached its objectives (Wallston, 2004). This research was

conducted under the assumption that high levels of Internal HLoC may be indicators of strong self‐

efficacy, believing one can take action and overcome barriers to meet her/his needs in whatever

situation. Self‐efficacy is a key variable in the widely applied Health Belief Model and Social Cognitive

Theory (NIH, 2005).

The opposite of being in control or having strong self‐efficacy is helplessness—believing there is nothing

one can do to improve a bad situation such as being diagnosed with a terminal illness or being told there

are no treatments for a medical condition. High HLoC scores in the external categories of Powerful

Others and Chance may be indicative of feelings of helplessness.


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Methodology

The ASCCN choose items from Forms A and B5 of the M‐HLoC to develop a 16‐item, agree/disagree

format survey measuring the four LoC: Internal, Powerful Others, Chance and God. The God dimension

was included in the ASCCN survey because previous research has found religious affiliation to be nearly

universal in American Samoa—greater than 90% of the population (Krosch, 2008).

A convenience sample survey of 200 American Samoa residents was conducted September – November

2008. The sample was stratified by gender and age group such that 100 males and 100 females

responded, 40 from each age group: under age 20; 20 – 29 years; 30 – 39 years; 40 – 49 years; and age

50 and older. The self‐administered survey was made available in English and Samoan. Samoan

translations and English back‐translations were completed by the Department of Samoan Studies at the

American Samoa Community College. Surveys were administered at the 2008 Annual ASCCN Cancer

Symposium (September), at workshops sponsored by the ASCCN (September – November), at an

American Samoa Community Cancer Coalition Policy Skills Training Workshop (October), at the LBJ

Tropical Medical Center Billing Office (October), and in the villages of ASCCN staff and partners. On

most occasions respondents were given the opportunity to win a prize (computer flashdrive or calling

card) after completing the survey and all respondents were given a free pencil.

The survey contained 4 parts: demographics, opinions about cancer prevention billboards, media habits

and preferences and the 16‐item adapted M‐HLoC survey. The original 18‐item M‐HLoC survey

measures on a 6 point Likert Scale (strongly agree to strong disagree). However, McCallem and

associates (1988) determined that the agree/disagree response format yields comparable data to those

obtained with the 6‐level format, particularly when classification of subjects is the goal. And local pre‐

testing of the instrument found that the concepts of strongly agree, moderately agree and agree and

strongly disagree and moderately disagree and disagree were confusing and lacked distinctive

translations in the Samoan language. Therefore, a simplified agree/disagree format was devised and

each locus contained 4 items chosen from Form A or Form B versions of the M‐HLoC survey6.

5 Forms A and B of the M‐HLoC were designed to measure perceptions of control of overall health among generally healthy populations. Form C is used to measure perceptions of control in subjects with a particular health condition such as cancer or diabetes (Masters and Wallston, 2005). 6 See the original M‐HLoC scales at http://www.vanderbilt.edu/nursing/kwallston/mhlcscales.htm

More than 200 residents responded to the survey. One hundred (100) female and 100 male surveys, 20

per age group were analyzed. Incomplete M‐HLoC surveys were excluded from analysis. If more than

20 surveys were completed for a gender’s age group, surveys were randomly selected for inclusion.

Three (3) survey respondents identified their gender as “Other” (neither male nor female). Given the

small, unrepresentative proportion of this demographic, the 3 surveys were not included in the analysis.

Survey data was analyzed for differences between genders, age groups and education groups.

Education groups were defined as ≤ secondary diploma, 2 year college degree and ≥ 4 year college

degree.

Hypotheses

Based on previous ASCCN research and other studies, the following hypotheses were made before administering the M‐HLoC survey:

1. Internal control scores would be highest regardless of gender, age, and education level or cancer

status.

2. Education status will impact all loci: higher education will be related to higher Internal control

and lower Powerful Others, God and Chance control scores.

3. The Chance and Powerful Others locus item scores for all groups will have more internal

variability than Internal and God control items.


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Survey Results

Respondents’ Demographics

The following is a summary of the survey respondents’ traits.

Table 4: Respondents’ Demographics

Number Respondents‐ 200, 100 females (50%) and 100 males (50%)

Ages‐ 40 respondents from each age group (20 female, 20 male): under 20 years, 20‐29 years, 30‐39 years, 40‐49 years, and 50 and older Villages‐ Respondents came from 38 of the 65 (58%) villages on Tutuila Island; 1 respondent was from Aunu’u Island Claim Religious Affiliation‐ 94% females and 91% males

Birth Country‐ 52% American Samoa, 21% Samoa , 21% USA, 4% Other Pacific Island, 2% no response

Ethnicity: 81% Samoan, 7% other Pacific Islander, 6% Asian, 4% Caucasian, 2% no response

Marital Status: 45% single, 46% married, 3% divorced, 4% widowed, 2% no response

Current Employment Status: 56% Employed, 36% Unemployed, 4% Retired, 4% no response

Highest Education Level: 41% Elementary/Secondary, 25% 2 year College, 31% 4 year college or more, 3% no response Personal Cancer Status: 5% Cancer survivor, 90% Non‐cancer survivor, 5% no response

Family Cancer Status: 40% At least one family member diagnosed with cancer, 55% No known family cancer diagnosis, 5% no response

Table 5: Personal Cancer Status

Yes No

No Response

Female 9 86 5 Male 1 95 4 Total % 5% 90% 5%

Table 6: Frequency Personal Cancer Site Breast 5 Stomach 1 Lung 1 Skin 1 Unknown/ No Response 2

Table 7: Family Cancer Status

Yes No

No Response

Female 53 41 6 Male 26 70 4 Total % 40% 55% 5%

Table 8: Frequency Family Cancer Site

Breast 38 Cervix 6 Stomach 3 Leukemia 7 Lung 9 Ovarian 3 Skin 1 Prostate 2 Brain 5 Pancreas 5 Liver 2 Throat 2 Lymph 1 Uterus 2 Unknown/ No Response 13 Colon 3


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Respondents’ M‐HLoC Profiles

Notable Findings‐

Internal control scores are highest both females and males. This may be an indication of high levels of

health behavior self‐efficacy and low levels of helplessness.

Internal control scores ware nearly twice as high as Powerful Others, God and Chance control scores for

both females and males. However, the combined influence of the two external dimensions of Powerful

Others and Chance equal perceived Internal health control. Further investigation is needed to

determine the nature of perceived God control as an external force beyond the control of the individual

or as a collaborative‐Internal dimension possibly adding to the perceived dominance of Internal health

control.

Males felt that Powerful Others and God were slightly more in control of their health then did females.

0

20

40

60

80

100

Internal Powerful Others

God Chance

Figure 2: Average M‐HLoC Scores for All Females & All Males

All Females

All Males

Average Num

berin Agreemen

t

Table 9: Female Age Groups: M‐LoC Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Females Age Groups

< 20n=20

20‐29n=20

30‐39 n=20

40‐49 n=20

≥ 50n=20

Internal 1. If I get sick, I can do things to become well again. 89 80 80 95 90 1002. I am in control of my health. 95 100 90 85 100 1003. When I get sick, it is my fault. 59 65 50 35 70 754. If I take the right actions, I can stay healthy. 95 95 90 100 95 95

Powerful Others

1. Whenever I don’t feel well I should see a doctor or nurse.

58 60 40 50 60 80

2. My family and other people have a lot to do with my becoming sick or staying healthy.

45 65 30 30 40 60

3. Health professionals control my health. 15 20 10 10 20 154. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

62 85 50 35 65 75

God 1. God is directly responsible for my healthy getting better or worse.

31 35 15 20 30 55

2. God is in control of my health. 44 60 25 30 45 603. Whatever happens to my health is God’s will. 42 70 40 30 30 404. If my health worsens, it is up to God to decide if I will get better again.

40 65 20 25 35 55

Chance 1. I feel no matter what I do, if I am going to get sick I will get sick.

31 40 35 20 25 35

2. I cannot control how quickly I will recover from an illness.

43 65 45 15 35 55

3. I am healthy because I am lucky. 34 25 40 20 40 454. If it is meant to be, I will stay healthy. 64 75 60 35 80 70

0

20

40

60

80

100

All Females

F <20 F 20‐29 F 30‐39 F 40‐49 F ≥50

Figure 3: Average M‐HLoC Scores for All Females & Female Age Groups

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Notable Findings‐

Females <20 years old and ≥50 years old have similar M‐HLoC profiles.

God Control and Powerful Others perception of control fluctuates most with age.

Powerful Others item 3 and Chance item 4 stand out and greatly impact overall averages of these loci.


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Table 10: Female Education Groups: M‐HLoc Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Females Education Groups

≤ secondaryn=37

2 yr college n=26

≤ 4 yr collegen=33

Internal 1. If I get sick, I can do things to become well again. 89 78 92 972. I am in control of my health. 95 95 96 943. When I get sick, it is my fault. 59 73 58 394. If I take the right actions, I can stay healthy. 95 95 89 100

Powerful Others


58 65 73 33


45 54 42 39

3. Health professionals control my health. 15 24 4 124. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

62 68 69 49

God 1. God is directly responsible for my health getting better or worse.

31 32 35 18

2. God is in control of my health. 44 51 46 273. Whatever happens to my health is God’s will. 42 62 31 244. If my health worsens, it is up to God to decide if I will get better again.

40 46 39 33


31 49 31 12


43 60 58 12

3. I am healthy because I am lucky. 34 54 23 214. If it is meant to be, I will stay healthy. 64 84 58 49

0

20

40

60

80

100

All Females F elm/sec F 2yr col F ≥4 yr col

Figure 4: Average M‐HLoC Scores for All Females & Female Education Groups

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Notable Findings‐

Internal control scored highest for all education groups. However, the more education a female has the lower Powerful Others, God and Chance scores get.

Chance items 2 and 3 and God items 1‐3 show dramatic decreases in perceived control as educational attainment rises.


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Table 11: Female Cancer Status: M‐HLoc Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Females Cancer Status

cancer survivors n=9

family cancer historyn=53

Internal 1. If I get sick, I can do things to become well again. 89 100 932. I am in control of my health. 95 100 943. When I get sick, it is my fault. 59 56 494. If I take the right actions, I can stay healthy. 95 89 98

Powerful Others


58 78 53


45 56 42

3. Health professionals control my health. 15 11 94. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

62 67 51


31 44 32

2. God is in control of my health. 44 56 433. Whatever happens to my health is God’s will. 42 33 364. If my health worsens, it is up to God to decide if I will get better again.

40 67 32


31 44 26


43 67 38

3. I am healthy because I am lucky. 34 33 264. If it is meant to be, I will stay healthy. 64 67 47

0

20

40

60

80

100

All Females F Survivors F Fam Hist

Figure 5: Average M‐HLoC Scores for All Females, Female Cancer Survivors (n=9) &

Female Family Cancer Survivors (n=53)

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Notable Findings‐

Internal control remains high despite cancer diagnosis or known family history of cancer. Female cancer survivors are more likely to perceive health control in the hands of Powerful Others, God and Chance than the average population of women or women with a family history of cancer.

God item 4 and Chance item 2 show significant differences between cancer survivors, family survivors and/or the general female population.


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Table 12: Male Age Groups: M‐HLoc Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Males Age Groups

< 20n=20

20‐29n=20

30‐39 n=20

40‐49 n=20

≥ 50n=20

Internal 1. If I get sick, I can do things to become well again. 89 85 95 80 90 952. I am in control of my health. 84 90 80 85 90 753. When I get sick, it is my fault. 74 75 75 70 75 754. If I take the right actions, I can stay healthy. 87 90 65 95 95 90

Powerful Others


58 55 55 60 55 65


44 50 35 45 55 35

3. Health professionals control my health. 32 35 25 40 40 204. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

63 80 65 60 65 45


38 40 30 25 40 55

2. God is in control of my health. 58 65 60 55 40 703. Whatever happens to my health is God’s will. 37 70 30 30 20 354. If my health worsens, it is up to God to decide if I will get better again.

43 70 45 35 15 50


35 30 55 30 20 40


48 60 40 20 75 45

3. I am healthy because I am lucky. 29 30 30 25 40 204. If it is meant to be, I will stay healthy. 65 70 60 65 70 60

0

20

40

60

80

100

All Males M <20 M 20‐29 M 30‐39 M 40‐49 M ≥50

Figure 6: Average M‐HLoC Scores for All Males & Male Age Groups

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Notable Findings‐

Males of all age groups perceive strong Internal control over health. Similar to females, males <2O years and ≥50 years old have similar M‐HLoC profiles.

Perceived God control steadily declines with age until age 50 especially for items 2 and 4. Compared to females (Figure 5) more males of all age groups perceive Powerful Others to control health.


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Table 13: Male Education Groups: M‐HLoc Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Males Education Groups

≤ secondaryn=44

2 yr college n=23

≤ 4 yr collegen=28

Internal 1. If I get sick, I can do things to become well again. 89 82 96 962. I am in control of my health. 84 82 83 863. When I get sick, it is my fault. 74 77 74 714. If I take the right actions, I can stay healthy. 87 77 91 96

Powerful Others


58 57 61 54


44 48 48 39

3. Health professionals control my health. 32 36 35 184. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

63 73 57 46

God 1. God is directly responsible for my health getting better or worse.

38 39 44 39

2. God is in control of my health. 58 61 52 613. Whatever happens to my health is God’s will. 37 43 26 394. If my health worsens, it is up to God to decide if I will get better again.

43 50 44 36


35 39 35 29


48 59 44 36

3. I am healthy because I am lucky. 29 32 30 294. If it is meant to be, I will stay healthy. 65 61 74 64

0

20

40

60

80

100

All Males M elm/sec M 2yr col M ≥4 yr col

Figure 7: Average M‐HLoC Scores for All Males & Male Education Groups

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Notable Findings‐

More education amongst males increases Internal control and decreases the influence of Powerful Others, God and Chance. Perceived God control increases slightly amongst males with ≥4 year college education, but this could be more a factor of age.

Males with ≤secondary education are twice as likely to feel health professionals control their health (Powerful Others item 3).


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Table 14: Male Cancer Status: M‐HLoc Survey Item Results

Locus of Control

Survey Item

% in Agreement All

Males Cancer Status

cancer survivors7 n=1

family cancer historyn=26

Internal 1. If I get sick, I can do things to become well again. 89 ‐‐‐ 1002. I am in control of my health. 84 ‐‐‐ 853. When I get sick, it is my fault. 74 ‐‐‐ 584. If I take the right actions, I can stay healthy. 87 ‐‐‐ 89

Powerful Others


58 ‐‐‐ 42


44 ‐‐‐ 31

3. Health professionals control my health. 32 ‐‐‐ 84. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

63 ‐‐‐ 50


38 ‐‐‐ 31

2. God is in control of my health. 58 ‐‐‐ 503. Whatever happens to my health is God’s will. 37 ‐‐‐ 234. If my health worsens, it is up to God to decide if I will get better again.

43 ‐‐‐ 39


35 ‐‐‐ 31


48 ‐‐‐ 46

3. I am healthy because I am lucky. 29 ‐‐‐ 154. If it is meant to be, I will stay healthy. 65 ‐‐‐ 58

Notable Findings‐ Only 25% of males, compared to 50% of females, were aware of a blood relative who had been diagnosed with cancer.

Males with a family history of cancer have equal levels of perceived Internal control but lower levels of Powerful Others, God and Chance control compared to the general male population. But they are far less likely than the general male population to believe their health is based on luck (Change item 3) or that health care professionals control their health (Powerful Others item 3).

7 Due to the small sample, only 1 male respondent was a cancer survivor, this data was not included in analysis.

0

20

40

60

80

100

All Males M Fam Hist

Figure 8: Average M‐HLoC Scores for All Males & Male Family Cancer Survivors (n=26)

Internal

Powerful Others

God

Chance

Average Num

berin Agreemen

t

Findings Summary

0

10

20

30

40

50

60

70

80

90

100

I1 I2 I3 I4 PO1 PO2 PO3 PO4 G1 G2 G3 G4 C1 C2 C3 C4

Figure 9: M‐HLoC Items Scores‐ All Females & All Males

All Females

All Males

% in

agreemen

t

Internal Powerful Others God Chance

• The M‐HLoC measurement appears to have demonstrated that the four different loci of health

control are relevant to the American Samoa population as shown by the different profiles that

emerge depending on gender, age and education status.

• Both females and males perceive Internal control to be strongest in determining health status

and outcomes. However, more than half of all males agreed with specific items within each of

the other loci. Less than half of all females agreed with any God control item.

• Males perceive themselves (Internal), Powerful Others and God to be more in control of their

health than do females.

• Internal items 2 and 4 had the highest percentage of females in agreement (95%): When I get

sick it is my fault; and If I take the right actions, I can stay healthy. Males agreed most (89%)

with Internal item 1: If I get sick, I can do things to become well again.

• Females perceived God control steadily declines with age until age 50 especially for items 4: If

my health worsens, it is up to God to decide if I will get better again.

• Powerful Others item 3 saw the fewest females in agreement: health professionals control my

health. Males were least in agreement with Chance item 3: I am healthy because I am lucky.


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• Compared to other Chance items, more than half of females and males (64%) agreed with item

4: If it is meant to be, I will stay healthy.

• Only 15% of females and 32% of males surveyed feel health professionals are Powerful Others in

control of their health. But 62% of females and 63% of males agreed that recovering from an

illness was due to other people (doctors, nurses, family and friends) taking care of them. This

distinction between Powerful Others items 3 and 4 seems to reveal a split in the Powerful

Others category between perceived power held by medical professionals and power held by

other ‘influentials.’

• As other research has shown, groups with the highest relative God scores (males; <age 20; ≥age

50; ≤secondary education; and cancer survivors) also tended to agree that Powerful Others

besides doctors determine illness recovery (higher percentages in agreement with Powerful

Others item 4).

• Females and males under age 20 and over age 50 perceive God and Powerful others to be more

in control of their health than do respondents ages 20‐49.

• More education results in less external health influence from Powerful Others, God or Chance

and higher perceived Internal control (presumably more self‐efficacy) regardless of gender.

Specifically higher educated females are significantly less likely to feel they cannot control how

quickly they recovered from an illness and that their health outcome was God’s will. Both

females and males with ≤secondary education are twice as likely as those with ≥4 year college

education to agree with Powerful Others Item 3: Health professionals control my health.

• Not surprisingly, female cancer survivors are more likely to perceive health control in the hands

of Powerful Others, God and Chance than the average population of women or women with a

family history of cancer. More than twice as many cancer survivors than family survivors agreed

with God item 4: If my health worsens, it is up to God to decide if I will get better again.

• Only 25% of males, compared to 50% of females, were aware of a blood relative who had been

diagnosed with cancer. Both female and male family cancer survivors were less likely than the

general population to feel that Powerful Others, God or Chance was in control of their health.


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Hypotheses Results

1. Internal control item scores were the highest amongst females and males regardless of age,

education or family/cancer survivor status. But consistently agreement was also shown,

especially by older respondents and those with less education, for Chance item 4, If it is

meant to be, I will stay healthy. This item should be further validated by asking respondents

what they understand “meant to be” to mean to them as this could be linked to religious

beliefs more than chance.

2. Higher education is related to higher perceived Internal control and lower perceived control

by Powerful Others, God and Chance for all categories except males with ≥4 year college

education, but this could be more a factor of age.

3. Powerful Others and Chance locus items showed more internal variability than Internal and

God items scores. Item scores under Powerful Others were most variable for females in

general, females <20 years old – 39 years old, males ages 20‐29, females and males ≥50

years old, females and males with ≤ a secondary education, females with a 2 year college

degree, female cancer survivors, female family cancer survivors. Chance control items were

the most variable for males in general, males ages 30‐49, females ages 40‐49, and males

with a 2 year college degree. Powerful Others and Chance item scores were equally variable

for both females and males with ≥ a 4 year college degree. This clustering calls for closer

investigation of different the facets that make up these domains especially within the

American Samoa cultural and health environment with special attention given to non‐health

professionals influence over health and distinguishing between notions of faith and fate.

Using MHLoC Results

The results of this M‐HLoC survey along with findings from other studies can be fed into models and

theories in order to predict the health behaviors of American Samoans and develop effective behavior

change interventions. The Health Belief Model (HBM) is one of the most widely applied in the field of

health promotion. It is made up of six constructs that influence whether an individual takes action to

prevent, screen for and control illness:

• Perceived Susceptibility: I believe I am at risk of the illness/disease

• Perceived Severity: I believe the illness/disease has serious consequences


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• Perceived Benefits: I believe taking action will reduce my risk or the severity of the

illness/disease

• Perceived Barriers: I believe the costs of taking action are outweighed by the benefits

• Cues to Action: I have opportunities, support and reminders to take action

• Self‐efficacy: I am confident in my ability to successfully act for better health (NIH, 2005).

These six constructs are also impacted by demographics—age, gender, education status, etc.. Self‐

efficacy can be linked to high Internal HLoC scores whereas high perceived Powerful Others or Chance

control can be considered barriers to action. God control could aid Internal self‐efficacy or be a barrier

to individual action. The diagram below illustrates the HBM with data gleaned from ASCCN research and

other studies about the general American Samoa population. However, the HBM is a more effective

tool for predicting behavior when data from specific groups are examined (females under age 30 with

less than a 2 year college degree versus females in general) so disaggregated data should be gathered

whenever possible.

Health Problem: Few take advantage of cancer screening services. Why? 1) Perceived Susceptibility is Low “Cancer is a disease people hardly get. We should be afraid of diabetes.” 2) Perceived Severity is High “Cancer means hopelessness, worry, and that death is near.” 3) = Perceived Threat is Moderate 4) Perceived Barriers are Moderate to High based on lack of local treatment and moderate Powerful Others, Chance and God HLoC scores 5) Perceived Benefits are Low “We should pity those who have cancer because there is no testing, cure.” 6) = Outcome Expectations are Low because benefits of screening do not outweigh the barriers 7) Self‐efficacy is Moderate to Low based on High Internal HLoC scores – Moderate perceived threat – Low Outcome expectations 8) Action probability (screening for cancer) remains Moderate to Low unless constructs 1,2,4 and 5 change.

Demographics1) Perceived Susceptibility

2) Percieved Severity

4) Percieved Barriers

3) Percieved Threat

6) Outcome Expectations

7) Self‐Efficacy

8) Action or Inaction

5) Percieved Benefits

Figure 10: The Health Belief Model

Interventions should focus on changing these constructs to increase self‐efficacy and

motivate action


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Works Cited

Asian and Pacific Islander American Health Forum (APIAHF). (2006) Health Brief: Samoans in the United States.

Hathaway, W and K. Pargament. (1991) The religious dimensions of coping: implications for prevention and promotion. Religion and Prevention in Mental Health: Conceptual and Empirical Foundations. 9:65‐92.

Hubbell, FA, et al. (2005). Exploring beliefs about cancer among American Samoans: focus group findings. Cancer Detection and Prevention. 29:109‐115.

Krosch, Sara. (2008) Cancer Prevention Billboard Evaluation Report – December 2008. American Samoa Community Cancer Network.

Krosch, Sara. (2008) Prostate Cancer Screening Clinic Program Impact Evaluation. American Samoa Community Cancer Network.

Masters, Kevin and Kenneth Wallston. (2005) Canonical Correlation Reveals Important Relations between Health Locus of Control, Coping, Affect and Values. Journal of Health Psychology. 10(5): 719‐31.

McCallum, DM., et al. (1988) Comparison of response formats for Multidimensional Health Locus of Control Scales: six levels versus two levels. Journal of Personality Assessment. 52(4): 732‐6.

Moshki, M., et al. (2007) Validity and reliability of the multidimensional health locus of control scale for college students. BCM Public Health. 8(7):295.

National Institutes of Health (NIH). (2005) Theory at a Glance: A Guide for Health Promotion Practice. second edition.

Puaina, Seumaninoa, et al. (2008) Impact of traditional Samoan lifestyle (fa’aSamoa) on cancer screening practices. Cancer Detection and Prevention. 32S:S23‐S28.

Wallston, Kenneth, et al. (1991) Does God Determine Your Health? The God Locus of Control Scale. Cognitive Therapy and Research. 23(2): 131‐42.

Wallston, Kenneth. (2004) Control and Health. Encyclopedia of Health and Behavior. Thousand Oaks: Sage. 217‐220.

Wallston, Kenneth. (2004) Multidimensional Health Locus of Control Scale. Encyclopedia of Health Psychology. New York: Kluwer Academic 171‐2.

insights into the health control beliefs of american samoans, 2009, sara krosch

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