Oral Health Locus of Control Scale

Abstract

The Oral Health Locus of Control Scale (often operationalized as the Locus of Control for Oral Health [LOCOH] scale alongside the complementary Oral Health Value [OHV] scale) is a multidimensional psychometric instrument designed to evaluate an individual’s causal attributions and generalized expectancies regarding oral health outcomes. Developed within the psychometric traditions of Julian B. Rotter’s Social Learning Theory and adapted from Kenneth Wallston and colleagues’ Multidimensional Health Locus of Control (MHLC) paradigm, the LOCOH addresses the domain-specific nature of dental beliefs. While generalized health locus of control scales provide an overarching view of systemic wellness beliefs, condition-specific instruments like the LOCOH account for the unique preventative behaviors, treatment anxieties, and clinical interactions inherent to oral pathology, such as periodontal disease and dental caries.

The standard battery formulated by Rosita Brown Long (2006) incorporates an initial comprehensive dental history and behavioral inventory followed by psychometrically validated core dimensions: Internal Oral Health Locus of Control (10 items), Chance Oral Health Locus of Control (11 items), Powerful Others Oral Health Locus of Control (10 items), and the Oral Health Value Scale (3 items). Responses are captured using a 6-point Likert format ranging from 1 (Strongly Agree) to 6 (Strongly Disagree). Psychometric evaluations demonstrate robust internal consistency across subscales, with Cronbach’s alpha coefficients typically ranging from .70 to .86. Factor analytic solutions confirm the empirical independence of internal agency, fatalistic/chance beliefs, and reliance on dental professionals. The scale exhibits strong convergent validity with documented oral hygiene adherence, preventive dental checkups, and self-reported symptomatology, serving as an essential behavioral diagnostic tool in dental public health, behavioral dentistry, and clinical psychology.

Keywords

Oral Health Locus of Control, LOCOH, Multidimensional Health Locus of Control, Behavioral Dentistry, Dental Psychology, Oral Health Value, Dental Health Beliefs, Health Attribution, Dental Adherence, Psychometrics

Authors

The formal multidimensional instrument and its comprehensive psychometric validation were developed and documented by Rosita Brown Long, Ph.D., as part of her doctoral research in Health, Leisures, and Human Performance at Oklahoma State University (2006). Her work synthesized and substantially expanded upon early dental locus of control conceptualizations (such as those by Duke and Cohen, 1975, and Wolfe et al., 1996), establishing rigorous item-reduction protocols, factor-structure validations, and direct empirical associations with both general health locus of control and self-reported dental self-care practices.

Purpose

The primary clinical and empirical objective of the Oral Health Locus of Control Scale is to quantify the cognitive attributions that guide how individuals perceive their ability to prevent, manage, and recover from oral diseases. In dental medicine, preventive behaviors—such as interdental flossing, mechanical plaque removal via toothbrushing, sugar restriction, and routine attendance at professional prophylaxis appointments—are predominantly under the direct volitional control of the patient. However, epidemiologists and dental clinicians have long observed significant variance in patient compliance that cannot be accounted for by socioeconomic status or dental knowledge alone. The LOCOH scale was constructed to measure the underlying cognitive-behavioral expectancy constructs that moderate this gap between knowledge and clinical action.

In clinical practice, the tool functions as an assessment for identifying maladaptive belief systems before initiating complex periodontic, prosthodontic, or orthodontic interventions. Patients exhibiting high Chance locus of control frequently hold fatalistic perceptions regarding tooth loss (e.g., viewing edentulism as an inevitable consequence of chronological aging or pure genetic destiny). Such beliefs are directly associated with treatment non-adherence, sporadic emergency-only dental visits, and poor plaque control. Conversely, patients with high Powerful Others beliefs place disproportionate responsibility upon the dental surgeon or hygienist, expecting clinical interventions to compensate fully for personal hygiene neglect. Identifying these profiles allows clinicians to deploy targeted psychoeducational interventions, motivational interviewing (MI), and cognitive reframing techniques designed to cultivate internal agency.

In behavioral and public health research, the LOCOH facilitates empirical modeling of oral health disparities. Researchers utilize the instrument to evaluate the efficacy of community water fluoridation initiatives, educational outreach programs, and school-based oral hygiene curricula. Furthermore, when combined with the Oral Health Value (OHV) scale, the instrument allows investigators to test Rotter’s classic postulate: that expectancies (locus of control) predict deliberate behavior most powerfully when the reinforcement value of the specific behavioral outcome (valuing dental health) is exceptionally high.

Psychological Construct

The psychological construct assessed by the LOCOH scale is rooted in attribution theory and locus of control constructs within health psychology. Rather than conceptualizing locus of control as a unidimensional bipolar continuum (internal vs. external), modern psychometrics operationalizes health-related expectancies across three distinct orthogonal dimensions, supplemented by a value construct:

1. Internal Oral Health Locus of Control (LOCOH-I)

The Internal subscale measures the degree to which an individual attributes oral wellness, periodontal integrity, and dental disease prevention to their personal habits, volitional choices, and self-care efficacy. Exemplified by statements such as “I am directly responsible for keeping my teeth and gums healthy” and “My oral health depends solely on the way I take care of myself,” high scores on this dimension reflect an internal cognitive orientation. Individuals with high internality recognize that dental caries and gingival inflammation are biologically mediated by biofilm accumulation that can be controlled via daily plaque disruption. Consequently, these individuals exhibit higher frequencies of interdental cleaning, proactive inquiries regarding preventive sealants, and higher resilience when confronted with minor dental setbacks.

2. Chance Oral Health Locus of Control (LOCOH-C)

The Chance subscale captures external fatalism, luck, predestination, and biological determinism. Represented by items such as “Most things that affect my dental health happen because of luck” and “I think just about everybody loses teeth as they get older,” this construct taps into an individual’s sense of helplessness regarding oral disease. High scorers tend to view tooth decay and periodontal breakdown as random biological misadventures or unavoidable ancestral inheritances against which individual prophylaxis is largely futile. This construct often correlates positively with high dental anxiety, procedural avoidance, and acute-phase-only clinic utilization.

3. Powerful Others Oral Health Locus of Control (LOCOH-PO)

The Powerful Others dimension delineates external attributions directed toward authoritative figures, notably dental surgeons, hygienists, and to a secondary degree, immediate familial support networks. Items such as “Dental professionals are responsible for keeping my teeth and gums healthy” and “The care I receive from dental professionals is the main reason for how well I recover from dental problems” reflect this orientation. While an appreciation of professional skill is necessary for regular attendance, an extreme Powerful Others orientation can become maladaptive if it fosters clinical passivity—wherein the patient abdicates personal responsibility for day-to-day plaque control under the assumption that biannual dental scaling will fully mitigate their behavioral neglect.

4. Oral Health Value (OHV)

In accordance with social learning formulations, generalized expectancies cannot reliably predict behavior in isolation from the subjective reinforcement value ascribed to the outcome. The Oral Health Value subscale measures the relative salience, prestige, and personal priority assigned to natural dentition relative to other life goals (e.g., “My dental health is highly important compared to other things in my life”). A high internal locus of control only translates into rigorous twice-daily flossing if the patient inherently values retaining their natural dentition, preventing halitosis, and maintaining aesthetic appearance.

Theoretical Framework

The psychometric architecture of the LOCOH scale is grounded in Julian Rotter’s (1954, 1966) Social Learning Theory. Rotter formulated the basic predictive formula for human behavior as:

BP_x,s1,Ra = f(E_x,Ra,s1 & RV_a,s1)

where the Behavior Potential (BP) of engaging in a specific action (e.g., flossing before sleep) in a given situation (s1) in relation to a specific reinforcement (Ra) is a joint function of the individual’s Expectancy (E) that the behavior will yield that reinforcement, and the subjective Reinforcement Value (RV) of that outcome. Rotter emphasized that while generalized expectancies govern behavior in novel, unstructured situations, domain-specific expectancies progressively assume greater predictive power as an individual acquires direct, experiential feedback within a concrete behavioral setting.

In the late 1970s, Kenneth Wallston, Barbara Wallston, and Robert DeVellis (1978) extended Rotter’s unidimensional framework by demonstrating that external control is bifurcated into distinct environmental forces: unpredictable chance occurrences versus structured actions executed by powerful societal agents (physicians, nurses). This resulted in the Multidimensional Health Locus of Control (MHLC) scale. Although the MHLC proved revolutionary across chronic disease research, researchers subsequently identified significant limitations when applying general health attributions to the unique anatomical, aesthetic, and functional realities of oral medicine.

Oral health constitutes a unique psychological domain: systemic health failure is frequently viewed as insidious or unpredictable, whereas oral diseases (caries and periodontitis) are largely non-communicable, chronic, highly visible, and almost entirely preventable through non-invasive self-care. Moreover, dental interventions frequently invoke acute physical discomfort, procedural phobias, and immediate out-of-pocket financial expenditures. Consequently, generalized health locus of control scales routinely fail to explain significant portions of variance in dental hygiene behaviors. The LOCOH framework resolves this domain-specificity limitation by embedding the tripartite locus of control structure (Internal, Chance, Powerful Others) directly into the behavioral phenomenology of oral self-care and professional dental consultation.

Validity

Empirical validation studies of the LOCOH and its constituent subscales confirm strong psychometric properties across construct, convergent, discriminant, and criterion-related domains:

Construct and Structural Validity

Construct validity has been established through structural modeling comparing the LOCOH subscales with general health locus of control batteries (Form A and Form B of the MHLC). In Long’s (2006) foundational psychometric validation involving community and collegiate adult cohorts, items specifically loaded onto their theoretically assigned oral dimensions without structural collapse into generalized health factors. The empirical separation of the Powerful Others dimension from the Internal dimension demonstrated that recognizing professional dental expertise does not imply an absence of personal self-efficacy; rather, adaptive dental patients often exhibit high concurrent levels of both Internality and Powerful Others orientation—a dynamic conceptualized in health psychology as “dual control.”

Convergent Validity

Convergent validity has been repeatedly demonstrated through statistically significant correlations with objective and self-reported behavioral indices:

• Oral Hygiene Behaviors: The Internal subscale correlates positively with weekly flossing frequency (r = .34 to .42, p < .001), tooth brushing duration, and tongue cleaning habits. Conversely, the Chance subscale exhibits significant negative correlations with routine flossing (r = -.38, p < .001).
• Professional Dental Attendance: Scores on the Powerful Others subscale correlate significantly with regular preventive dental visits (defined as attendance for cleanings, checkups, or fluoride treatments rather than acute emergency interventions; r = .31, p < .01).
• Systemic-to-Oral Congruence: Significant, moderate correlations emerge between corresponding dimensions of the general MHLC and the LOCOH (e.g., general Internal MHLC correlated with LOCOH Internal at r = .45 to .56), demonstrating that while the LOCOH taps into overarching personality traits, it captures substantial unique variance distinct to the dental setting.

Discriminant and Criterion Validity

Discriminant validity is supported by the absence of significant correlations between LOCOH dimensions and unrelated sociodemographic variables when controlling for education and healthcare access. Criterion-related validity is evident in the instrument’s capacity to discriminate between patients presenting with chronic untreated periodontal conditions versus those maintaining stable periodontal indices following active therapy. High Chance scores reliably predict histories of tooth loss, extensive untreated carious lesions, and emergency-room dental admissions, confirming the scale’s sensitivity to real-world clinical endpoints.

Reliability

The reliability of the LOCOH subscales has been corroborated via both internal consistency metrics and temporal stability evaluations across varied research samples:

Internal Consistency

During scale purification and validation (Long, 2006), Cronbach’s alpha coefficients across the primary final subscales consistently surpassed the accepted psychometric thresholds for behavioral science instruments (α ≥ .70):

• Internal Oral Health Locus of Control (10 items): Cronbach’s α ranges from .78 to .84, reflecting cohesive item covariance regarding self-responsibility, personal hygiene habits, and volitional control.
• Chance Oral Health Locus of Control (11 items): Cronbach’s α ranges from .80 to .86, indicating strong measurement precision in capturing fatalistic beliefs, bad luck, and age-related dental decline expectations.
• Powerful Others Oral Health Locus of Control (10 items): Cronbach’s α ranges from .75 to .81, reflecting reliable assessment of reliance on dental professionals and clinical oversight.
• Oral Health Value Scale (3 items): Demonstrates acceptable internal consistency for an ultra-short screening tool, with α ranging between .68 and .74.

Test-Retest Reliability

Temporal stability assessments conducted over two- to four-week intervals demonstrate intra-class correlation coefficients (ICCs) and Pearson stability coefficients exceeding r = .76 across the three locus of control subscales, confirming that the tool measures enduring cognitive-behavioral traits rather than transient emotional or psychological states.

Factor Analysis

The structural dimensionality of the LOCOH was established through iterative Exploratory Factor Analysis (EFA) followed by confirmatory structural models. In the primary psychometric development phase, candidate item pools assessing oral health control beliefs (items 8 through 50 in the developmental battery) were subjected to Principal Axis Factoring (PAF) and Principal Component Analysis (PCA) utilizing both orthogonal (Varimax) and oblique (Promax) rotations to account for potential theoretical intercorrelations among subdimensions.

Factor Extraction and Eigenvalue Criteria

Inspection of Kaiser’s criterion (eigenvalues > 1.0) and Catell’s scree plot clearly indicated a dominant three-factor solution for the locus of control items, mirroring Wallston’s tripartite conceptualization:

• Factor 1 (Chance / External Fatalism): Accounted for the largest proportion of total variance (approximately 18.5% to 22.4% across samples), with primary loadings from items asserting that dental problems occur regardless of personal effort or are governed by luck and heredity.
• Factor 2 (Internal Agency / Self-Care): Accounted for approximately 14.2% to 17.1% of variance, characterized by high loadings from items emphasizing personal decision-making, oral hygiene diligence, and self-blame for dental neglect.
• Factor 3 (Powerful Others / Professional Reliance): Accounted for approximately 9.8% to 12.6% of variance, comprising items measuring reliance on dental professionals, regular clinic attendance, and clinical compliance.

Item purification retention rules dictated that items must achieve a primary factor loading of ≥ .40 with no significant cross-loadings (≥ .30 on secondary factors). Items failing to meet these strict psychometric cutoffs (such as complex hybrid statements concerning family dental histories or generalized dental modernism) were systematically excised, resulting in the streamlined, standardized final subscales (10 items for Internal, 11 for Chance, 10 for Powerful Others, and 3 for Value).

Instrument / Measurement Tool

The LOCOH assessment battery exists as an expansive survey containing clinical history screening items, behavioral tracking metrics, generalized health comparative items, and the validated domain-specific final subscales. Researchers and clinicians can administer either the comprehensive research inventory or the standalone final validated subscales.

Scale Structure & Administration Parameters

• Test Type: Self-report psychometric rating scale / behavioral inventory.
• Administration Format: Paper-and-pencil or secure digital survey administration. Self-administered or guided clinical interview.
• Target Population: Adolescents and adults (typically aged 15 years and older) across general, community, or clinical dental populations.
• Completion Time: Approximately 12 to 15 minutes for the full 68-item developmental inventory; 4 to 6 minutes for the final validated 34-item subscale battery (LOCOH-I, LOCOH-C, LOCOH-PO, and OHV).
• Response Format: Statements are rated on an authentic 6-point Likert agreement scale:
  • 1 = Strongly Agree
  • 2 = Moderately Agree
  • 3 = Agree
  • 4 = Disagree
  • 5 = Moderately Disagree
  • 6 = Strongly Disagree

Scoring Guidelines and Metric Interpretation

In scoring the finalized subscales, researchers typically calculate continuous summative or mean scores for each distinct dimension. Note that on the original 1-to-6 scoring continuum, lower numeric scores denote stronger agreement with that attributional style unless reverse-coded:

• LOCOH Internality Scale (10 items): Measures personal volitional responsibility. Sum ranges from 10 to 60. When reverse-scored (where 6 = Strongly Agree and 1 = Strongly Disagree), higher total scores indicate robust internal agency and self-care efficacy.
• LOCOH Chance Scale (11 items): Measures fatalistic and random expectations. Sum ranges from 11 to 66. Higher scores (under reverse scoring) reflect externalized fatalism, predicting avoidance of routine prophylaxis.
• LOCOH Powerful Others Scale (10 items): Measures reliance on dental healthcare providers and familial support. Sum ranges from 10 to 60. Elevated scores indicate strong deference to clinical authority.
• Oral Health Value Scale (OHV – 3 items): Evaluates the relative psychological importance of oral health compared to other life priorities. Sum ranges from 3 to 18 (with appropriate reversal of negative items, such as “There are many things I care about more than my dental health”).

Permissions & Fee and Test Year

The Oral Health Locus of Control Scale and its associated research instrument were formally developed and cataloged in 2006 by Dr. Rosita Brown Long at Oklahoma State University. The original psychometric scale was published within academic doctoral dissertation archives (Doctoral Dissertation, Oklahoma State University, Stillwater, OK). As an academic psychometric tool developed under university auspices, the instrument is widely accessible for non-commercial, scholarly research, public health investigations, and non-profit educational activities under standard fair-use academic guidelines. Commercial developers, proprietary clinical software vendors, or corporate entities seeking to integrate the scale into fee-for-service diagnostic platforms should obtain formal permission from the author or the intellectual property repository of Oklahoma State University.

References

• Duke, M. P., & Cohen, B. (1975). Locus of control as a biochemical and behavioral predictor of dental health. Journal of Clinical Psychology, 31(3), 497–500. http://digital.library.okstate.edu/etd/umi-okstate-2149.pdf
• Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall. https://doi.org/10.1037/10788-000
• 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, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6(2), 160–170. https://doi.org/10.1177/109019817800600107
• Wolfe, G. R., Stewart, J. M., & Hartz, G. W. (1996). Development of an oral health locus of control scale. Psychological Reports, 78(3), 779–788. https://doi.org/10.2466/pr0.1996.78.3.779

13. Items of the Scale (Questionnaire)