Spiritual Health Locus of Control Scales

1. Abstract

The Spiritual Health Locus of Control Scales, particularly the revised formulation known as the Spiritual Health Locus of Control Scale – Revised (SHLOC-R), are standardized psychometric instruments designed to assess the degree to which individuals attribute health outcomes, disease prevention, and healing processes to divine agency and spiritual engagement. Originating from health psychology paradigms that integrate religious coping and social-cognitive theory, the instrument captures the nuanced intersection between personal health behaviors and faith in a higher power. The scale operationalizes spiritual locus of control primarily along two overarching dimensions: Active Spiritual (or collaborative/partnered spiritual locus of control, reflecting beliefs that God empowers individuals, works through medical professionals, and calls for personal agency and self-care) and Passive Spiritual (reflecting a deferring or fatalistic orientation wherein personal agency and medical care are viewed as unnecessary or secondary to unilateral divine intervention). Administered typically as a 14-item self-report questionnaire using a 5-point Likert response format ranging from Strongly Disagree to Strongly Agree (or Strongly Agree to Strongly Disagree), the instrument demonstrates robust psychometric properties across diverse populations, most notably within medically underserved and spiritually engaged demographic cohorts. Internal consistency estimates typically yield Cronbach’s alpha coefficients between α = .80 and .88 for the Active Spiritual subscale and α = .60 to .75 for the Passive Spiritual subscale. Construct, convergent, and discriminant validity have been confirmed through significant correlations with conventional multidimensional health locus of control scales, religious coping mechanisms, preventative cancer screening adherence, and chronic disease self-management regimens. This comprehensive review delineates the historical development, psychometric properties, factor structure, theoretical underpinnings, clinical and empirical applications, and full questionnaire administration guidelines for the SHLOC-R.

2. Keywords

Spiritual Health Locus of Control, SHLOC-R, Health Locus of Control, Religious Coping, Active Spiritual, Passive Spiritual, Psychometrics, Health Psychology, Disease Self-Management, Collaborative Coping

3. Authors

The conceptualization and psychometric refinement of the Spiritual Health Locus of Control Scales emerged through research programs in health behavior, public health, and behavioral oncology, led primarily by:

• Cheryl L. Holt, Ph.D. – Professor, Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD, USA. Dr. Holt is a leading authority on faith-based health communication, behavioral oncology, and the socio-cultural determinants of health behaviors within faith communities.
• Matthew W. Kreuter, Ph.D., MPH – Kahn Family Professor of Public Health, Brown School, Washington University in St. Louis, St. Louis, MO, USA. Specialist in health communication, tailored health messaging, and cancer prevention.
• Collaborating Investigators: Eddie M. Clark, Ph.D. (Saint Louis University), Darcell P. Scharff, Ph.D. (Saint Louis University College for Public Health and Social Justice), and affiliated research teams examining faith-based behavioral health interventions.

Contact Information: Inquiries regarding the development and academic utilization of the scale are typically addressed to Dr. Cheryl L. Holt at the University of Maryland School of Public Health ([email protected]).

4. Purpose

The primary purpose of the Spiritual Health Locus of Control Scales is to assess cognitive attributions regarding the etiology, maintenance, and restoration of physical and mental health within a spiritual or religious framework. While classical locus of control theory categorized health beliefs into Internal, Powerful Others (e.g., healthcare providers), and Chance/Fate, it frequently neglected or conflated divine agency with external fatalism. The SHLOC-R was formulated to rectify this limitation by systematically differentiating adaptive, empowering spiritual attributions from fatalistic, deferring beliefs that may discourage medical adherence.

In clinical, community, and epidemiological research, the scale serves several critical functions:

• Differentiating Collaborative vs. Deferring Health Orientations: Traditional public health frameworks often operated under the erroneous assumption that high religiosity correlates with passive fatalism and medical non-compliance. The SHLOC-R demonstrates that the majority of highly religious individuals adhere to an Active Spiritual orientation—believing that their body is a divine vessel requiring proactive stewardship, that God operates through physicians, and that prayer provides the emotional and physical strength necessary for self-care.
• Designing Faith-Based Health Interventions: Behavioral scientists utilize the scale to evaluate baseline health beliefs within church- and community-based health promotion initiatives. Tailored health education messages can align cancer screening recommendations (e.g., mammograms, colonoscopies) or hypertension management programs with participants’ active spiritual convictions, reframing medical compliance as an act of faithful stewardship.
• Investigating Health Disparities and Chronic Illness Outcomes: The instrument is widely deployed in studies of minority health, particularly among African American, Hispanic/Latino, and rural populations where religious institutions play a foundational role in community wellness. Researchers use the scale to explore associations between spiritual beliefs, medication adherence, glycemic control in type 2 diabetes, and quality of life in oncology cohorts.
• Clinical Pastoral and Behavioral Assessment: Clinical health psychologists and healthcare chaplains employ the scale to identify patients whose health locus of control tilts toward passive divine deferral (e.g., believing that taking insulin is unnecessary because God alone decides survival), enabling targeted psychoeducational and spiritual interventions that facilitate medical collaboration.

5. Psychological Construct

The psychological construct evaluated by the SHLOC-R is Spiritual Health Locus of Control—a multidimensional, domain-specific attributional style regarding the causal mechanisms governing personal physical health and illness recovery. Rather than viewing divine control as a monolithic construct, the scale disentangles two distinct attributional styles:

Active Spiritual Locus of Control

The Active Spiritual dimension (also referred to across literature as collaborative or partnered spiritual locus of control) conceptualizes health as a shared enterprise between the individual and the divine. This construct combines strong religious devotion with high personal agency and positive valuation of modern medical science. Core psychological tenets include:

• Instrumental Stewardship: The belief that honoring God necessitates diligent self-care, healthy nutritional habits, exercise, and regular medical checkups (e.g., Item 4: “Living the way the Lord says I’m supposed to live means I have to take care of myself”).
• Divinely Empowered Self-Efficacy: Faith is perceived not as an excuse for inaction, but as the foundational source of emotional resilience and physical fortitude needed to adhere to arduous health regimens (e.g., Item 6: “God gives me the strength to take care of myself”).
• Sanctification of Medical Care: Healthcare providers and biomedical interventions are understood as instrumental vehicles through which divine healing is enacted (e.g., Item 8: “God works through doctors to heal us”).
• Spiritual Synergy: The individual perceives an explicit partnership with God regarding health maintenance (e.g., Item 14: “God and I share responsibility for my health”).

Passive Spiritual Locus of Control

The Passive Spiritual dimension represents a religious external attribution style characterized by deferral, surrender of personal agency, and occasional medical skepticism. Within this cognitive schema, health outcomes are deemed exclusively dependent upon unilateral supernatural intervention, rendering human effort and medical treatments redundant or spiritually contradictory. Key elements include:

• Abdication of Behavioral Agency: The belief that personal health behaviors are futile because physical outcomes are predetermined or exclusively managed by divine will (e.g., Item 13: “There is no point in taking care of myself when it’s all up to God anyway”).
• Medical Deferral and Substitution: Foregoing conventional healthcare screening, diagnoses, or pharmacology under the assumption that prayer or faith alone should be utilized for healing (e.g., Items 11 and 12: “It’s ok not to seek medical attention because I feel that God will heal me”).

Empirical evidence underscores that these two dimensions are not merely polar opposites of a single continuum; an individual may endorse high Active Spiritual beliefs while scoring very low on Passive Spiritual items. The distinctiveness of these constructs is critical for predicting health behaviors: Active Spiritual scores generally correlate positively with health-promoting behaviors, whereas Passive Spiritual scores correlate with delayed medical consultation, non-adherence, and fatalistic resignation.

6. Theoretical Framework

The theoretical architecture of the SHLOC-R synthesizes Social Learning Theory, the Multidimensional Health Locus of Control (MHLC) model, and Kenneth Pargament’s Theory of Religious Coping.

Rotter and Wallston: Social-Cognitive Attribution

Julian Rotter (1966) originally conceptualized locus of control as a generalized expectancy regarding whether outcomes are contingent upon one’s own behavior (Internal Locus) or external forces (External Locus). Kenneth Wallston and colleagues (1978) adapted this framework to health, creating the MHLC Scale with three subscales: Internal Health Locus of Control (IHLC), Powerful Others Health Locus of Control (PHLC), and Chance Health Locus of Control (CHLC). However, early researchers noted that when applied to religiously observant populations, individuals who scored low on Chance often scored high on external factors that did not reflect helplessness, but rather a structured relationship with a benevolent deity. Wallston later developed the “God Locus of Control” subscale (MHLC Form C), yet it primarily treated God as a single external agent.

Pargament’s Religious Coping Taxonomy

To capture the clinical nuance of spiritual attributions, Holt and colleagues drew upon Kenneth Pargament’s (1988, 1997) seminal tripartite model of religious coping styles:

1. Collaborative Style: The individual and God are active partners in solving problems and managing health. Responsibility is shared, fostering high self-efficacy and resilience. This directly underpins the Active Spiritual dimension of the SHLOC-R.
2. Deferring Style: The individual passively abdicates responsibility, waiting for God to resolve crises without personal intervention. This corresponds directly to the Passive Spiritual dimension of the SHLOC-R.
3. Self-Directing Style: The individual believes God gave humans the freedom and intellect to solve problems independently without ongoing divine intervention.

By mapping these coping mechanisms directly onto locus of control constructs, the SHLOC-R establishes that spiritual beliefs do not inherently imply external passivity. Instead, the instrument demonstrates that spiritual beliefs can act as a powerful catalyst for internal agency and medical adherence when framed collaboratively.

7. Validity

The SHLOC and its revised versions have undergone extensive psychometric validation across multiple community-based and clinical investigations.

Construct and Structural Validity

Validation studies using confirmatory factor analysis (CFA) have established that the bifurcated structure (Active vs. Passive) provides superior model fit over unidimensional models. Goodness-of-fit indices across published studies typically demonstrate Root Mean Square Error of Approximation (RMSEA) values ≤ .06, Comparative Fit Index (CFI) ≥ .94, and Tucker-Lewis Index (TLI) ≥ .92. The items consistently cluster into their theoretical domains without significant cross-loadings.

Convergent and Discriminant Validity

Convergent validity is substantiated by significant positive correlations between the Active Spiritual subscale and:

• Wallston’s Internal Health Locus of Control (IHLC) (typically r = .30 to .45), demonstrating that spiritual agency reinforces personal health accountability.
• Wallston’s Powerful Others Health Locus of Control (PHLC-Doctors) (r = .35 to .50), reflecting the item endorsement that God operates through healthcare professionals.
• Pargament’s Collaborative Religious Coping subscale (r = .55 to .70).
• General self-efficacy measures and proactive health engagement indices.

In contrast, the Passive Spiritual subscale correlates positively with Wallston’s Chance Health Locus of Control (CHLC), fatalism scales (e.g., Powe Fatalism Inventory), and Pargament’s Deferring Religious Coping subscale (r = .40 to .62), while exhibiting weak or negative correlations with Internal Health Locus of Control and preventative health screening behaviors.

Predictive and Criterion Validity

In empirical studies evaluating preventative oncology, individuals with higher Active Spiritual scores demonstrated significantly greater odds of adhering to regular mammography, prostate-specific antigen (PSA) testing, and colorectal cancer screenings, even after controlling for socioeconomic factors. Conversely, elevated Passive Spiritual scores were statistically significant predictors of delayed symptom reporting, non-adherence to anti-hypertensive medication regimens, and avoidance of clinical consultations.

8. Reliability

The internal consistency and temporal stability of the SHLOC-R have been demonstrated across varied sample cohorts, including urban community members, rural church congregations, and patients managing chronic medical conditions.

Internal Consistency

The Active Spiritual subscale, comprising 11 items in the standard revised configuration (Items 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 14), consistently exhibits high internal consistency. Across baseline and follow-up samples in validation trials (e.g., Holt et al., 2003, 2007), Cronbach’s alpha coefficients for the Active Spiritual dimension range between α = .80 and α = .88.

The Passive Spiritual subscale, consisting of fewer items (Items 11/12 and 13), yields moderate internal consistency, with Cronbach’s alpha values typically ranging between α = .60 and α = .74. The somewhat lower coefficient for the Passive subscale is expected given its brief length (Spearman-Brown prophecy considerations) and the relative infrequency of extreme passive fatalistic endorsement in general survey samples.

Test-Retest Stability

In stability studies over intervals of 2 to 6 weeks, the SHLOC-R demonstrates acceptable test-retest reliability:

• Active Spiritual subscale: Intra-class correlation coefficients (ICC) and Pearson correlation coefficients consistently exceed r = .75.
• Passive Spiritual subscale: Test-retest correlations range from r = .65 to .72.

These findings indicate that spiritual health locus of control operates as a relatively stable attributional schema, while maintaining sufficient sensitivity to detect shifts resulting from targeted psychoeducational and faith-based community interventions.

9. Factor Analysis

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) conducted during instrument development and subsequent community validations confirm the multidimensionality of the SHLOC.

Exploratory Factor Structure

Principal axis factoring with oblique (Promax or Oblimin) rotation initially extracted distinct factors reflecting active partnership, divine reliance, and passive fatalism. In early iterations, three or four sub-factors were observed (e.g., God’s Grace, Spiritual Partner, Passive/Fatalistic). Subsequent psychometric refinement consolidated these into a robust, parsimonious two-factor solution:

1. Factor 1: Active Spiritual (Collaborative Agency & Divine Empowerment): Captures items emphasizing personal responsibility, divine strength, reliance on God, and medical collaboration. Item factor loadings on Factor 1 typically range from .48 to .82. High-loading items include “God gives me the strength to take care of myself” (.78) and “Living the way the Lord says I’m supposed to live means I have to take care of myself” (.71).
2. Factor 2: Passive Spiritual (Deferral & Medical Abdication): Captures items asserting that self-care is futile and medical care can be bypassed due to sole reliance on miraculous intervention. Item loadings on Factor 2 typically range from .54 to .79. High-loading items include “There is no point in taking care of myself when it’s all up to God anyway” (.75).

Confirmatory Factor Analysis (CFA) Model Fit

When evaluated via structural equation modeling, the two-factor model demonstrates superior empirical fit compared to a single-factor “general religious locus of control” model. In structural validation studies (e.g., Holt et al., 2007), reported fit indices for the two-factor model are:

• χ²/df ratio < 2.5
• Comparative Fit Index (CFI) = .945
• Tucker-Lewis Index (TLI) = .931
• Root Mean Square Error of Approximation (RMSEA) = .056 (90% CI: .042 – .069)
• Standardized Root Mean Square Residual (SRMR) = .048

The inter-factor correlation between Active and Passive dimensions is typically low to non-significant (r ranging from -.12 to .18), confirming that these dimensions represent independent cognitive schemas rather than mutually exclusive endpoints.

10. Instrument / Measurement Tool

• Instrument Name: Spiritual Health Locus of Control Scale – Revised (SHLOC-R)
• Construct Measured: Attributional beliefs regarding divine agency, personal agency, and medical collaboration in health and illness
• Administration Format: Self-administered paper-and-pencil questionnaire, interviewer-administered survey, or computerized online survey
• Item Count: 14 items (standard revised questionnaire structure)
• Target Population: Adults (18+), community samples, clinical patients, faith-based cohorts
• Estimated Completion Time: 3 to 5 minutes
• Response Scale: 5-point Likert scale:
  • 1 = Strongly Disagree (or Strongly Agree depending on administration direction; standard scoring: 1 = Strongly Disagree, 2 = Disagree, 3 = Neither [Neutral], 4 = Agree, 5 = Strongly Agree)
  • Prompt instructions: “For these statements, I would like you to tell me if you strongly agree, agree, neither, disagree, or strongly disagree. Please listen carefully to each statement because you may agree with some but disagree with others.”
• Subscale Composition & Scoring Rules:
  • Active Spiritual Subscale (11 items): Sum or mean of Items 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 14.
    
    Higher scores reflect strong collaborative faith, self-stewardship, and utilization of medical care as divinely sanctioned.
  • Passive Spiritual Subscale (Items 11/12, 13): Sum or mean of Items 12 and 13 (and Item 11 statement continuation).
    
    Higher scores indicate deferring fatalism, abdication of self-care, and avoidance of medical consultation.

11. Permissions & Fee and Test Year

The original Spiritual Health Locus of Control Scale was published in 2003, with the revised psychometric validation (SHLOC-R) appearing in 2007 (Holt et al., Journal of Health Psychology, 2007). The scale was developed with academic research grant funding and is widely placed in the public domain for non-commercial educational, clinical, and scientific research purposes. Researchers and practitioners may administer the instrument without royalty fees, provided appropriate scholarly citation is attributed to the original authors (Holt, Kreuter, Clark, et al.). For commercial implementations, large-scale clinical trials funded by commercial entities, or institutional digital reproductions, permission should be verified through the lead author (Dr. Cheryl L. Holt) or SAGE Publications.

12. References

• Holt, C. L., Clark, E. M., Kreuter, M. W., & Scharff, D. P. (2003). Does locus of control value predict health behaviors in an African American church-based sample? Journal of Health Psychology, 8(5), 565–575. https://doi.org/10.1177/13591053030085006
• Holt, C. L., Roth, D. L., Clark, E. M., & Lukwago, S. N. (2007). Development and validation of the Spiritual Health Locus of Control Scale. Journal of Health Psychology, 12(4), 597–611. https://doi.org/10.1177/1359105307078166
• Pargament, K. I., Kennell, J., Hathaway, W., Grevengoed, N., Newman, J., & Jones, W. (1988). Religion and the problem-solving process: Three styles of coping. Journal for the Scientific Study of Religion, 27(1), 90–104. https://doi.org/10.2307/1387404
• Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. Guilford Press.
• 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
• Wallston, K. A., Malcarne, V. L., Flores, L., Hansdottir, I., Smith, C. A., Stein, M. J., Weisman, M. H., & Clements, P. J. (1999). Does God determine your health? The God Locus of Health Control Scale. Cognitive Therapy and Research, 23(2), 131–142. https://doi.org/10.1023/A:1018723010685

13. Items of the Scale (Questionnaire)