Multidimensional Health Locus of Control (MHLC)

1. Abstract

The Multidimensional Health Locus of Control (MHLC) scales, developed by Kenneth A. Wallston, Barbara Strudler Wallston, and Robert F. DeVellis in 1978, represent the gold standard psychometric instrument designed to measure domain-specific control beliefs regarding personal health status and medical outcomes. Rooted in Julian Rotter’s social learning theory and expanding upon Hanna Levenson’s conceptualization of multidimensional locus of control, the instrument measures an individual’s dispositional expectations across three distinct, orthogonal dimensions: Internal Health Locus of Control (IHLC), which assesses the degree to which an individual attributes health status to personal behaviors and choices; Powerful Others Health Locus of Control (PHLC), which evaluates the belief that health is primarily determined by medical personnel, family members, or caregivers; and Chance Health Locus of Control (CHLC), which captures the conviction that health outcomes are governed by luck, fate, chance, or unpredictable circumstances.

Comprising two equivalent 18-item parallel general forms (Form A and Form B), each scale presents six items per subscale scored on an authentic 6-point Likert response format ranging from 1 (Strongly Disagree) to 6 (Strongly Agree). Subscale raw scores range from 6 to 36, without reverse scoring, producing a multidimensional profile rather than a single continuous composite score. Psychometric investigations across diverse healthy and clinical populations demonstrate acceptable to good internal consistency (Cronbach’s alpha coefficients routinely ranging between .67 and .77 for initial validation studies, and frequently exceeding .80 in tailored clinical samples) alongside robust construct, convergent, discriminant, and predictive validities. The MHLC serves as a critical predictive instrument in behavioral medicine, health psychology, adherence research, and chronic disease management.

2. Keywords

Multidimensional Health Locus of Control, MHLC, internal health locus of control, powerful others, chance locus of control, health behavior, psychometrics, social learning theory, health expectancies, treatment adherence, health psychology

3. Authors

The MHLC scales were developed through a collaborative research program conducted in the late 1970s by a team of prominent health psychologists:

• Kenneth A. Wallston, Ph.D. — Professor Emeritus of Psychology in Nursing at Vanderbilt University School of Nursing, Nashville, Tennessee, USA. A pioneering figure in health psychology and behavioral science who led foundational research on patient empowerment, perceived control, and chronic disease adaptation.
• Barbara Strudler Wallston, Ph.D. — Late Professor of Psychology at George Peabody College for Teachers and Vanderbilt University, Nashville, Tennessee, USA. Highly influential for her methodological rigor in social psychology, feminist theory, and health-related social learning applications.
• Robert F. DeVellis, Ph.D. — Professor Emeritus of Health Behavior at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, USA. Renowned international authority on scale development methodology and psychometric measurement in health sciences.

4. Purpose

The primary purpose of the Multidimensional Health Locus of Control (MHLC) scales is to provide an empirical, domain-specific measurement tool to assess the perceived source of control over personal health. Prior to the publication of the MHLC, research examining perceived control predominantly utilized generalized locus of control instruments, most notably Rotter’s Internal-External (I-E) scale, or the unidimensional Health Locus of Control (HLC) scale introduced by Wallston and colleagues in 1976. However, generalized instruments frequently failed to account for significant variance in health-specific behaviors, such as seeking preventive screening, adhering to complex medication regimens, adopting dietary modifications, or executing smoking cessation protocols.

Clinical and empirical experience demonstrated that health is a distinct life domain characterized by unique emotional, physiological, and social contingencies. An individual might exhibit a marked generalized internal locus of control regarding career trajectory or academic performance while simultaneously harboring strong external beliefs regarding biomedical outcomes, such as viewing oncological or cardiovascular diagnoses as purely capricious or entirely in the hands of specialized medical providers. The MHLC was formulated to capture these health-specific expectancies with greater predictive power.

In clinical practice and behavioral health interventions, the MHLC serves multiple essential purposes:

• Predicting Preventive and Protective Health Behaviors: When combined with assessments of health value (the importance an individual places on maintaining good health), the MHLC reliably differentiates individuals likely to engage in active wellness behaviors from those who are passive or fatalistic.
• Tailoring Educational and Treatment Interventions: Clinicians and psychoeducational programs utilize MHLC profiles to design personalized behavioral strategies. For example, high IHLC patients thrive under self-monitoring and collaborative decision-making regimens, whereas high PHLC patients demonstrate optimal adherence when given direct, structured, and authoritative instructions by healthcare professionals.
• Understanding Coping Mechanisms in Chronic Illness: Across conditions such as type 1 and type 2 diabetes mellitus, end-stage renal disease, rheumatoid arthritis, hypertension, and cancer, the MHLC clarifies why certain patients develop learned helplessness or medical fatalism (high CHLC), while others actively cultivate adaptive self-management routines (high IHLC).
• Evaluating Psychoeducational Program Efficacy: The scales are extensively utilized as pre- and post-intervention outcome measures to assess whether rehabilitative programs successfully empower patients to shift away from chance attributions toward constructive internal or cooperative external frameworks.

5. Psychological Construct

The psychological construct underlying the MHLC is health locus of control, defined as a generalized expectancy regarding whether one’s health status, wellness, and recovery from illness are contingent upon one’s own behavioral actions, the intervention of influential external individuals, or arbitrary, random factors. Expanding upon unidimensional paradigms that treated internal and external control as mutually exclusive poles of a single continuum, the MHLC operationalizes control beliefs across three distinct, independently varying dimensions:

Internal Health Locus of Control (IHLC)

The IHLC dimension reflects the extent to which an individual believes that personal behavior, lifestyle choices, self-regulation, and internal agency directly dictate their health outcomes. Individuals scoring high on this subscale endorse statements such as “If I take the right actions, I can stay healthy” and “The main thing which affects my health is what I myself do.” They operate under the assumption that sickness and wellness are self-determined consequences of personal efficacy, diet, exercise, and vigilance. In contrast, low IHLC scorers perceive their personal actions as essentially decoupled from their biological state, viewing bodily wellness as occurring independently of their daily choices.

Powerful Others Health Locus of Control (PHLC)

The PHLC dimension gauges the degree to which an individual attributes health status to the intervention, expertise, and authority of significant social actors, primarily medical doctors, nurses, and allied healthcare professionals, but secondarily spouses, family members, and caregivers. High PHLC scorers endorse items such as “Having regular contact with my physician is the best way for me to avoid illness” and “Regarding my health, I can only do what my doctor tells me to do.” This dimension does not inherently represent pathological dependency; rather, in medical contexts requiring rigorous therapeutic compliance, a moderate to high PHLC orientation often facilitates exceptional adherence to pharmacotherapy and scheduled clinical visits. Low PHLC individuals exhibit skepticism or detachment from medical authority, relying little on institutional healthcare advice.

Chance Health Locus of Control (CHLC)

The CHLC dimension measures fatalistic expectancies, capturing the belief that health and illness are the products of serendipity, fortune, divine intervention, environmental randomness, or unavoidable destiny. Prototypical items include “Luck plays a big part in determining how soon I recover from an illness” and “No matter what I do, if I am going to get sick, I will get sick.” High CHLC beliefs are frequently associated with fatalism, passive coping, elevated anxiety, and reduced engagement in prophylactic screening or lifestyle modification, as individuals view the body as an unpredictable system immune to deliberate human effort. Low CHLC scorers reject the idea that health is an arbitrary gamble, expecting logical causal relationships between actions or treatments and physical outcomes.

Typological Profiles

Because the three subscales are structurally orthogonal rather than mutually exclusive, researchers commonly configure them into distinctive clinical profiles:

• The Pure Internal: High IHLC, Low PHLC, Low CHLC. Manifests high autonomy, proactive health information seeking, and potential resistance to rigid medical authority.
• The Double External: Low IHLC, High PHLC, High CHLC. Relies entirely on outside systems while maintaining underlying fatalistic anxiety.
• The Believer in Control: High IHLC, High PHLC, Low CHLC. A highly adaptive medical profile where the individual takes personal responsibility for daily habits while actively adhering to expert medical guidance.
• The Pure Chance / Fatalist: Low IHLC, Low PHLC, High CHLC. Poses the highest behavioral risk due to pervasive learned helplessness and disregard for both lifestyle modification and medical counsel.

6. Theoretical Framework

The conceptual foundation of the MHLC is firmly anchored 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 situation ($BP$) is a joint function of the individual’s expectancy ($E$) that the behavior will lead to a particular reinforcement, and the subjective reinforcement value ($RV$) of that outcome, expressed mathematically as:

BP = f(E, RV)

In Rotter’s framework, expectancies are categorized along a continuum of generalizability. When individuals confront novel, ambiguous, or complex situations, they rely heavily on generalized expectancies derived from cumulative historical learning. Rotter operationalized one primary generalized expectancy as the internal versus external locus of control of reinforcement. Individuals with an internal locus perceive reinforcements as contingent upon their own characteristics or behaviors, whereas those with an external locus perceive reinforcements as controlled by forces outside themselves, such as chance, fate, or powerful social structures.

While Rotter’s generalized I-E scale yielded immense heuristic value across social and personality psychology, its predictive utility within specific situational domains was limited. Social learning theory explicitly dictates that as an individual gains familiarity with a specific situational domain (such as personal physical health), domain-specific expectancies increasingly account for the variance in behavior, superseding broad, generalized expectancies.

The second major theoretical pillar of the MHLC is Hanna Levenson’s (1973, 1974) Tripartite Model of Locus of Control. Levenson critiqued Rotter’s external dimension for confounding two qualitatively distinct worldviews: the belief that the world is chaotic, random, and unpredictable (Chance), versus the belief that the world is orderly, predictable, but controlled by powerful other persons (Powerful Others). Levenson demonstrated that individuals who believe their lives are governed by powerful human agents behave very differently from those who view outcomes as a roulette wheel; the former often display purposeful, adaptive cognitive processing when navigating authority structures, whereas the latter succumb to apathy and helplessness.

Wallston, Wallston, and DeVellis (1978) synthesized Rotter’s domain-specific social learning theory with Levenson’s tripartite structural model. They hypothesized that health behaviors cannot be accurately forecasted without simultaneously modeling domain-specific expectancies alongside the reinforcement value of health. Consequently, social learning theory dictates that a high internal health locus of control (IHLC) will predict healthy behavioral choices (such as smoking cessation, exercise adherence, or glycemic monitoring) primarily among individuals who place a high subjective value on health relative to other competing life goals.

7. Validity

The validity of the MHLC has been substantiated through extensive empirical research spanning more than four decades across healthy populations, community samples, and numerous chronic illness cohorts.

Construct Validity

Construct validity was initially established during the scale’s development by administering the experimental MHLC items alongside Levenson’s generalized Internal, Powerful Others, and Chance (I, P, and C) scales. In the initial validation sample of 115 healthy adults, Wallston et al. (1978) documented statistically significant, theoretically consistent correlations between the corresponding subscales:

• The IHLC correlated moderately and positively with Levenson’s generalized I scale ($r = .567, p < .001$), confirming that health-specific internal beliefs share variance with generalized self-agency while retaining substantial unique variance.
• The PHLC correlated significantly with Levenson’s generalized P scale ($r = .275, p < .01$).
• The CHLC demonstrated strong positive correlation with Levenson’s generalized C scale ($r = .551, p < .001$).

Importantly, the correlations between divergent dimensions were minimal or non-significant, corroborating the tripartite orthogonality postulated by the authors.

Convergent and Predictive Validity

Convergent and predictive validity have been documented across hundreds of clinical trials and epidemiological studies:

• Health-Promoting Behaviors: In adherence to Rotter’s theoretical paradigm, studies routinely confirm that when health value is high, IHLC scores correlate positively with regular physical activity, balanced nutritional intake, routine dental prophylaxis, and adherence to preventive cancer screenings (such as mammography and colonoscopy).
• Medication and Treatment Adherence: PHLC scores consistently predict high treatment adherence in clinical environments characterized by active medical management, such as oncological chemotherapy protocols, hemodialysis schedules, and antihypertensive pharmacotherapy. Patients who trust in powerful medical others demonstrate superior appointment compliance.
• Psychological Distress and Quality of Life: CHLC scores consistently correlate positively with measures of illness anxiety, somatic depression, generalized helplessness, and poorer physical health-related quality of life (SF-36 bodily pain and mental health scales), confirming that fatalism impairs psychological adaptation to chronic illness.

Discriminant Validity

The MHLC exhibits excellent discriminant validity against potential confounding psychometric constructs:

• Social Desirability: Correlations with the Marlowe-Crowne Social Desirability Scale are consistently low across all three subscales ($r$ values typically falling between $-.10$ and $.15$, non-significant), demonstrating that participant responses reflect genuine health attitudes rather than a desire to present a socially acceptable image.
• General Cognitive Ability: Investigations evaluating cognitive functioning and intelligence report negligible correlations with MHLC dimensions, confirming that the tool assesses cognitive belief structures rather than cognitive capacity.

8. Reliability

The psychometric reliability of the MHLC has been scrutinized across varied populations, establishing robust internal consistency and temporal stability.

Internal Consistency

In the original scale development study, Wallston et al. (1978) administered Forms A and B to a diverse norming sample of 115 adult subjects recruited from airport terminals and public venues. The calculated Cronbach’s alpha coefficients across the 6-item subscales demonstrated satisfactory reliability for brief behavioral scales:

• Form A:
  • Internal Health Locus of Control (IHLC): $\alpha = .767$
  • Powerful Others Health Locus of Control (PHLC): $\alpha = .673$
  • Chance Health Locus of Control (CHLC): $\alpha = .753$
• Form B:
  • Internal Health Locus of Control (IHLC): $\alpha = .768$
  • Powerful Others Health Locus of Control (PHLC): $\alpha = .710$
  • Chance Health Locus of Control (CHLC): $\alpha = .691$

When researchers combine the parallel forms (Form A + Form B) to create 12-item subscales, internal consistency coefficients consistently increase to between $.83$ and $.86$. Subsequent psychometric evaluations in clinical populations (e.g., individuals with diabetes, coronary artery disease, chronic pain) have yielded alpha coefficients routinely ranging from $.70$ to $.84$, exceeding standard psychometric thresholds for research use.

Test-Retest Stability

Temporal stability reflects the conceptualization of health locus of control as a relatively stable generalized disposition in the absence of major life events. In the developmental cohort, Wallston et al. obtained test-retest reliability coefficients over a brief interval ranging from $.60$ to $.71$. Longitudinal investigations in stable chronic disease cohorts have documented test-retest coefficients between $.65$ and $.78$ over intervals of six months to one year, indicating substantial stability over time while retaining sufficient sensitivity to register true cognitive shifts following major educational or therapeutic interventions.

9. Factor Analysis

The structural integrity of the MHLC has been evaluated through extensive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) across numerous linguistic and cultural adaptations.

Exploratory Factor Analysis (EFA)

During scale construction, Wallston, Wallston, and DeVellis (1978) conducted principal components analysis (PCA) with orthogonal varimax rotation on a pooled item pool. The empirical analyses yielded a distinct three-factor solution matching the theoretical expectations:

• Factor I (Internal): Items 1, 6, 8, 12, 13, and 17 loaded strongly onto this factor (loadings ranging from $.52$ to $.74$), accounting for the largest proportion of total common variance, with negligible cross-loadings onto the other two factors.
• Factor II (Chance): Items 2, 4, 9, 11, 15, and 16 loaded specifically on this dimension (loadings ranging from $.49$ to $.72$).
• Factor III (Powerful Others): Items 3, 5, 7, 10, 14, and 18 demonstrated strong, unambiguous loadings (loadings ranging from $.48$ to $.69$).

The three-factor solution accounted for approximately 42% to 48% of the total variance across Form A and Form B, validating the multidimensional conceptualization over a single-factor internal-external axis.

Confirmatory Factor Analysis (CFA)

Subsequent modern structural equation modeling studies have tested competing structural models, comparing a unidimensional model, a two-factor model (Internal vs. External), and the theoretical three-factor oblique model. The three-factor model consistently demonstrates superior goodness-of-fit across adult populations:

• Model Fit Indices: Representative CFA studies report acceptable to good fit statistics: $\chi^2 / df < 2.5$; Comparative Fit Index (CFI) routinely between $.91$ and $.95$; Tucker-Lewis Index (TLI) $ge .90$; and Root Mean Square Error of Approximation (RMSEA) between $.045$ and $.065$ ($90% \text{ CI } [0.038, 0.071]$).
• Factor Intercorrelations: CFA models reveal that IHLC and CHLC exhibit a weak to moderate negative correlation (typically $r = -.20$ to $-.35$), IHLC and PHLC show near-zero to weak positive correlations (typically $r = .05$ to $.18$), and PHLC and CHLC share modest positive covariance (typically $r = .15$ to $.30$). These empirical relationships corroborate that while Powerful Others and Chance represent external orientations, they are psychometrically distinct constructs that must not be collapsed.

10. Instrument / Measurement Tool

• Tool Type: Domain-specific, multidimensional self-report psychological questionnaire.
• Administration Format: Standard paper-and-pencil questionnaire, computerized survey, or structured clinician-assisted interview.
• Target Population: Adults and adolescents aged 16 and older; typically requires an 8th-grade reading comprehension level. (Condition-specific variants, such as MHLC Form C, exist for chronic illness populations).
• Total Item Count: 18 items per form (Form A or Form B).
• Dimensions / Subscales:
  • Internal Health Locus of Control (IHLC): 6 items (Items 1, 6, 8, 12, 13, 17)
  • Powerful Others Health Locus of Control (PHLC): 6 items (Items 3, 5, 7, 10, 14, 18)
  • Chance Health Locus of Control (CHLC): 6 items (Items 2, 4, 9, 11, 15, 16)
• Response Scale: 6-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Moderately Disagree
  • 3 = Slightly Disagree
  • 4 = Slightly Agree
  • 5 = Moderately Agree
  • 6 = Strongly Agree
• Scoring Rules:
  • No reverse-scored items. Every item is scored in its direct recorded direction (1 to 6).
  • Each subscale score is computed by summing the numerical responses of its respective six items:
  • IHLC Sum: Items 1 + 6 + 8 + 12 + 13 + 17 (Possible range: 6 to 36).
  • PHLC Sum: Items 3 + 5 + 7 + 10 + 14 + 18 (Possible range: 6 to 36).
  • CHLC Sum: Items 2 + 4 + 9 + 11 + 15 + 16 (Possible range: 6 to 36).
  • No Total Composite Score: The MHLC does NOT yield an overall single score. Summing all 18 items into a single total is theoretically invalid and psychometrically prohibited.
• Completion Time: Approximately 5 to 10 minutes.

11. Permissions & Fee and Test Year

The Multidimensional Health Locus of Control (MHLC) scales were first published in 1978 by Kenneth A. Wallston, Barbara Strudler Wallston, and Robert F. DeVellis in the journal Health Education Monographs (Volume 6, Issue 2, pages 160–170).

Licensing and Accessibility: In accordance with the explicit wishes of the primary developer, Dr. Kenneth A. Wallston, the MHLC scales (Forms A, B, and the subsequent condition-specific Form C) are considered in the public domain for research and educational purposes. No permission fee or formal licensing agreement is required to reproduce or utilize the scales for academic, non-commercial clinical, or health promotion research. The authors made the instrument freely accessible to encourage rigorous measurement in health psychology and behavioral medicine. Researchers are requested only to properly cite the foundational 1978 publication in all resulting manuscripts, dissertations, and conference presentations.

12. 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
• Levenson, H. (1974). Activism and powerful others: Distinctions within the concept of internal-external control. Journal of Personality Assessment, 38(4), 377–383. https://doi.org/10.1080/00223891.1974.10119988
• Rotter, J. B. (1954). Social learning and clinical psychology. Prentice-Hall. https://doi.org/10.1037/11382-000
• 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., & DeVellis, R. (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, M. J., & 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., & DeVellis, R. (1978). Development of the Multidimensional Health Locus of Control (MHLC) Scales. Health Education Monographs, 6(2), 160–170. https://doi.org/10.1177/109019817800600207

13. Items of the Scale