Multidimensional Health Locus of Control

Abstract

The Multidimensional Health Locus of Control (MHLC) scale is one of the most widely utilized psychometric instruments in health psychology, behavioral medicine, and clinical nursing research. Developed by Kenneth A. Wallston, Barbara Strudler Wallston, and Robert F. DeVellis in 1978, the MHLC was engineered to operationalize generalized expectancies regarding the locus of control over health-related outcomes. Evolving from Julian B. Rotter’s unidimensional social learning theory and Hanna Levenson’s tripartite conceptualization of control beliefs, the MHLC assesses three distinct, statistically independent dimensions: Internal Health Locus of Control (IHLC), which reflects the belief that one’s personal behaviors directly influence health outcomes; Powerful Others Health Locus of Control (PHLC), measuring the perception that physicians, nurses, and family members govern health; and Chance Health Locus of Control (CHLC), gauging the belief that health and recovery are dictated by luck, fate, or serendipity.

The standard instrument exists across parallel general formats (Form A and Form B), each comprising 18 items distributed equally across the three subscales (6 items per dimension). A subsequent condition-specific adaptation, Form C, was introduced in 1994 to assess control beliefs in populations diagnosed with chronic illnesses, subdividing the Powerful Others factor into “Doctors” and “Other People.” Each item is scored on an authentic 6-point Likert response format ranging from 1 (“Strongly Disagree”) to 6 (“Strongly Agree”), producing discrete dimensional scores without a composite global score. Psychometric investigations demonstrate moderate-to-high internal consistency across subscales (Cronbach’s alpha typically ranging from .67 to .86), solid test-retest reliability, and robust construct, convergent, and discriminant validity across diverse demographic and clinical populations worldwide.

Keywords

Multidimensional Health Locus of Control, MHLC, Internal Health Locus of Control, Powerful Others, Chance Locus of Control, Health Beliefs, Health Psychology, Psychometrics, Behavioral Medicine, Patient Adherence

Authors

The Multidimensional Health Locus of Control scales were authored and validated by an interdisciplinary team of behavioral scientists and nursing scholars:

• Kenneth A. Wallston, Ph.D. — Professor Emeritus of Psychology in Nursing at Vanderbilt University School of Nursing, Nashville, Tennessee, United States. Dr. Wallston was a pioneer in health psychology and behavioral measurement, serving as a founding figure in the empirical study of health-related control expectancies.
• Barbara Strudler Wallston, Ph.D. (1943–1987) — Former Professor of Psychology at George Peabody College of Vanderbilt University. A distinguished social psychologist, Dr. Wallston made foundational contributions to gender studies, social support, and patient empowerment in healthcare decision-making.
• Robert F. DeVellis, Ph.D. — Professor Emeritus in the Department of Health Behavior at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Renowned for his seminal textbook Scale Development: Theory and Applications, Dr. DeVellis provided structural and methodological oversight in the factor design and psychometric validation of the MHLC.

Academic correspondence historically associated with the instrument has been curated by the Health Psychology Measurement Group at Vanderbilt University School of Nursing.

Purpose

The primary purpose of the Multidimensional Health Locus of Control instrument is to provide an empirically sound, theoretically grounded measurement of an individual’s dispositional expectancies regarding what forces determine their physical well-being, illness onset, and recovery. In clinical and epidemiological research, healthcare providers frequently encounter substantial variance in how patients respond to health recommendations, preventive regimens, and chronic disease management protocols. The MHLC was formulated to explain and predict this behavioral variance by capturing stable cognitive attributions regarding causality in health states.

Clinical applications of the MHLC span a wide spectrum of medical disciplines:

• Chronic Illness Self-Management: In conditions such as type 1 and type 2 diabetes, hypertension, rheumatoid arthritis, and end-stage renal disease, treatment success hinges on rigorous daily self-care. Clinicians utilize the MHLC to identify patients with low internal locus of control who may feel powerless to alter their glycemic or cardiovascular markers, allowing targeted psychoeducational interventions.
• Medical Adherence and Treatment Compliance: Understanding whether a patient attributes therapeutic efficacy to medical professionals (PHLC) or perceives outcomes as entirely random (CHLC) informs communication strategies. High PHLC patients often display superior adherence to prescribed pharmacological regimens when instructed by an authoritative clinician, whereas high IHLC individuals respond best to shared decision-making models.
• Preventive Health Behavior and Health Promotion: In public health campaigns focusing on smoking cessation, dietary modification, mammography screening, and physical exercise, the MHLC serves as a diagnostic indicator of behavioral readiness. Individuals who harbor strong Chance beliefs are less likely to initiate lifestyle modifications because they do not perceive a causal link between personal action and disease prevention.
• Rehabilitation and Pain Management: Within chronic musculoskeletal pain and post-surgical physical therapy programs, IHLC scores correlate significantly with active coping strategies, functional recovery, and resilience, whereas high CHLC scores correlate with pain catastrophizing and learned helplessness.

Psychological Construct

The psychological construct evaluated by the MHLC is health locus of control, conceptualized as a multi-faceted cognitive schema regarding the contingency between individual behavior and health outcomes. Unlike general personality traits, health locus of control is a domain-specific construct, reflecting expectancy beliefs situated specifically within the realm of health, disease, and bodily recovery. The MHLC delineates this construct across three core subscales:

1. Internal Health Locus of Control (IHLC)

The IHLC subscale measures the degree to which an individual believes that their internal actions, personal choices, habits, and self-care routines serve as the primary determinants of their health status. Individuals scoring high on this dimension view health maintenance and disease recovery as directly contingent upon self-initiated actions (e.g., maintaining a balanced diet, exercising, abstaining from substances, and actively seeking evidence-based information). Conversely, low IHLC scores signify a sense of personal passivity or perceived incompetence regarding physiological outcomes.

2. Powerful Others Health Locus of Control (PHLC)

The PHLC subscale captures the extent to which a person attributes their health outcomes to external agents who possess perceived authority, expertise, or direct caregiving capability. In Form A and Form B, these powerful agents encompass physicians, nurses, allied healthcare providers, and family members. A high PHLC score indicates that the individual entrusts their physical well-being to external professionals and significant others, viewing obedience to medical advice and reliance on external interventions as the principal mechanism of staying healthy. In clinical environments, high PHLC can promote adherence to prescribed treatments, though excessive reliance can foster passive dependence.

3. Chance Health Locus of Control (CHLC)

The CHLC subscale quantifies the belief that health, illness, and recovery are predominantly determined by uncontrollable, external, and unpredictable forces such as luck, fate, destiny, or random coincidence. High CHLC individuals maintain a fatalistic perspective, believing that preventative measures or behavioral adaptations are largely futile because disease occurrence is arbitrary. In psychometric research, elevated CHLC scores systematically correlate with depressive symptomatology, low self-efficacy, and reduced engagement in screening or preventative behaviors.

Theoretical Framework

The theoretical architecture of the MHLC is rooted in Social Learning Theory, formulated by Julian B. Rotter (1954, 1966). Rotter posited that the potential for a given behavior to occur in a specific psychological situation is a function of the individual’s expectancy that the behavior will lead to a particular reinforcement, multiplied by the subjective value placed on that reinforcement (Behavior Potential = f(Expectancy & Reinforcement Value)).

Rotter initially conceptualized locus of control as a generalized, bipolar unidimensional continuum ranging from internal control (reinforcements are contingent on one’s own actions) to external control (reinforcements are contingent on external forces, chance, or powerful others). In 1976, Wallston and colleagues developed the unidimensional Health Locus of Control (HLC) scale to adapt Rotter’s construct to health behaviors. However, empirical findings revealed that the unidimensional model oversimplified the cognitive attribution process; individuals frequently endorse beliefs in medical expertise simultaneously with beliefs in personal self-care responsibility.

To overcome these conceptual limitations, Wallston, Wallston, and DeVellis (1978) integrated the theoretical modifications introduced by Hanna Levenson (1973). Levenson demonstrated that external control is not a monolithic dimension, but rather consists of two psychologically independent orientations: belief in ordered, predictable control by “powerful others” versus belief in chaotic, unpredictable control governed by “chance or fate.” By synthesizing Rotter’s social learning framework with Levenson’s tripartite differentiation, the developers constructed the MHLC as an orthogonal, multidimensional model where Internal, Powerful Others, and Chance beliefs operate as distinct, co-occurring cognitive dimensions rather than opposing poles of a single axis.

Validity

The psychometric validity of the Multidimensional Health Locus of Control scales has been established through decades of rigorous empirical research spanning normative community cohorts, university samples, and diverse patient populations:

Construct and Factorial Validity

In the seminal validation study by Wallston, Wallston, and DeVellis (1978), the three-factor structure was confirmed via orthogonal factor analysis. Factor loadings for individual items consistently exceeded the standard .40 threshold on their assigned dimensions, with negligible cross-loadings across alternative factors. Later confirmatory factor analytic (CFA) studies using structural equation modeling have repeatedly corroborated the three-factor model across multiple languages, yielding comparative fit index (CFI) values typically exceeding .90 and root mean square error of approximation (RMSEA) values below .06.

Convergent and Discriminant Validity

Convergent validity has been established by correlating MHLC subscales with generalized locus of control and health-related constructs:

• Levenson’s IPC Scales: The IHLC subscale correlates positively with Levenson’s Internal (I) scale (r = .56 to .67); the PHLC subscale correlates with the Powerful Others (P) scale (r = .60 to .74); and the CHLC subscale correlates with the Chance (C) scale (r = .55 to .71).
• General Health Motivation and Knowledge: IHLC demonstrates significant positive correlations with health information-seeking behaviors, nutritional awareness, and physical fitness adherence, while demonstrating no meaningful correlation with generalized social desirability scales (such as the Marlowe-Crowne Social Desirability Scale, r < .15), demonstrating solid discriminant validity.
• Health Value Interaction: In accordance with social learning theory, Wallston et al. demonstrated that IHLC predicts health-related behavior most robustly when health is held as a high personal value, validating the interaction term between expectancy and reinforcement value.

Predictive and Criterion Validity

The MHLC displays predictive validity across clinical outcomes. High IHLC scores predict successful smoking cessation, weight management, and post-cardiac rehabilitation adherence. High PHLC scores predict strict adherence to hemodialysis and antiretroviral regimens. Conversely, high CHLC scores correlate with delayed medical consultation for ambiguous symptoms and elevated mortality risk in long-term longitudinal studies of chronic illness.

Reliability

The Multidimensional Health Locus of Control scales demonstrate solid internal consistency and temporal stability across clinical and non-clinical populations:

Internal Consistency

In the initial normative development samples (Wallston et al., 1978), the internal consistency reliability coefficients (Cronbach’s alpha) for Form A and Form B demonstrated moderate to high reliability across all three subscales:

• Form A: Internal Health Locus of Control (IHLC) α = .77; Powerful Others Health Locus of Control (PHLC) α = .67; Chance Health Locus of Control (CHLC) α = .75.
• Form B: Internal Health Locus of Control (IHLC) α = .71; Powerful Others Health Locus of Control (PHLC) α = .72; Chance Health Locus of Control (CHLC) α = .69.

When Form A and Form B are combined into single 12-item subscales (yielding a 36-item instrument), internal consistency coefficients increase substantially: IHLC α = .86, PHLC α = .83, and CHLC α = .84. Subsequent international adaptations (including German, Spanish, Turkish, and Chinese translations) have confirmed alpha coefficients generally falling between .70 and .85.

Test-Retest Stability

Temporal stability assessments reveal that the MHLC reflects stable cognitive dispositions over moderate time frames. Test-retest correlation coefficients over a six-week interval have ranged from r = .66 to .73 across subscales in healthy adult samples. Over shorter intervals (two to three weeks), test-retest coefficients consistently exceed .75, indicating that while health control beliefs are sensitive to major life events (e.g., the acute onset of a debilitating condition), they remain stable personality expectancies in baseline environments.

Factor Analysis

The structural composition of the MHLC was initially determined through exploratory factor analysis (EFA) utilizing principal components analysis with varimax orthogonal rotation on a pool of 81 preliminary items administered to 115 healthy adults. The final 18 items for Form A and Form B were selected based on their salient loadings on the intended factor (≥ .40) and minimal cross-loadings (≤ .25) on the remaining factors.

Modern psychometric evaluations using Confirmatory Factor Analysis (CFA) have rigorously scrutinized both orthogonal and oblique structural configurations. The consensus from extensive structural equation modeling indicates that an oblique three-factor model provides superior fit compared to a unidimensional or two-factor external-internal model. While the orthogonal model was originally theorized, empirical studies show modest inter-factor correlations: IHLC typically shares a slight negative or non-significant correlation with CHLC (r = -.10 to -.25), whereas PHLC occasionally exhibits modest positive correlations with IHLC or CHLC depending on cultural norms and healthcare delivery models.

Standard CFA fit indices reported across multiple validation studies demonstrate excellent model adequacy:

• Goodness of Fit Index (GFI): .91 to .95
• Comparative Fit Index (CFI): .92 to .96
• Tucker-Lewis Index (TLI): .90 to .94
• Root Mean Square Error of Approximation (RMSEA): .042 to .058 (90% CI [.035, .064])
• Standardized Root Mean Square Residual (SRMR): .048 to .061

Item-to-factor loadings in contemporary CFA replications consistently range between .52 and .81 for IHLC items, .45 and .78 for PHLC items, and .50 and .84 for CHLC items, validating the stability of the tripartite model across demographic strata.

Instrument / Measurement Tool

The structural characteristics, administration parameters, and scoring protocols of the Multidimensional Health Locus of Control are detailed below:

• Test Type: Self-administered psychometric rating scale / self-report inventory.
• Target Population: Adults and adolescents aged 16 and older across general, community, and clinical medical populations.
• Item Count: 18 items per standardized form (Form A, Form B, and condition-specific Form C).
• Time to Complete: Approximately 5 to 10 minutes.
• Authentic Response Scale: 6-point Likert scale without a neutral midpoint:
  • 1 = Strongly Disagree (SD)
  • 2 = Moderately Disagree (MD)
  • 3 = Slightly Disagree (D)
  • 4 = Slightly Agree (A)
  • 5 = Moderately Agree (MA)
  • 6 = Strongly Agree (SA)
• Subscale Item Distribution (Form A):
  • Internal Health Locus of Control (IHLC): Items 1, 6, 8, 12, 13, 17
  • Chance Health Locus of Control (CHLC): Items 2, 4, 9, 11, 15, 16
  • Powerful Others Health Locus of Control (PHLC): Items 3, 5, 7, 10, 14, 18
• Scoring Instructions:
  • Each item is scored from 1 to 6 corresponding directly to the chosen numeric response.
  • There are no reverse-coded items on the standard MHLC instruments.
  • Scores for each subscale are calculated by summing the raw scores of the 6 constituent items.
  • The possible score range for each subscale is 6 to 36.
  • Crucial Clinical Rule: Subscale scores must never be summed into a total composite score. The three dimensions are statistically independent and must be analyzed and interpreted as separate continuous variables or converted into behavioral typology profiles (e.g., “pure internal,” “pure powerful others,” or “system believers”).

Permissions & Fee and Test Year

The Multidimensional Health Locus of Control scales were initially published in 1978 by Kenneth A. Wallston, Barbara S. Wallston, and Robert F. DeVellis in the journal Health Education Monographs (now Health Education & Behavior). The condition-specific Form C was subsequently published in 1994 in the Journal of Health Psychology.

Licensing and Fee Policy: The developers placed the MHLC scales in the public domain to facilitate academic, educational, and clinical research. The instruments may be utilized, reproduced, and translated without royalty fees or formal written permission, provided that proper bibliographic citation is given to the authors and original publications. Vanderbilt University maintains public access to the scale texts and scoring keys for scholarly investigation.

References

• Levenson, H. (1973). Multidimensional locus of control in psychiatric patients. Journal of Consulting and Clinical Psychology, 41(3), 397–404. https://doi.org/10.1037/h0035357
• Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall. https://doi.org/10.1037/11388-000
• Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1–28. https://doi.org/10.1037/h0092976
• 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. https://doi.org/10.1037/0022-006X.44.4.580
• Wallston, K. A., Stein, J. A., & Smith, C. A. (1994). Form C of the MHLC Scales: A condition-specific measure of locus of control. Journal of Personality Assessment, 63(3), 534–553. https://doi.org/10.1207/s15327752jpa6303_11
• Wallston, K. A., & Wallston, B. S. (1981). Health locus of control scales. In H. M. Lefcourt (Ed.), Research with the locus of control construct (Vol. 1, pp. 189–243). Academic Press. https://doi.org/10.1016/B978-0-12-443201-7.50010-5
• Wallston, K. A., Wallston, B. S., & DeVellis, R. F. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6(2), 160–170. https://doi.org/10.1177/109019817800600107

Items of the Scale