1. Abstract
The Multidimensional Health Locus of Control (MHLC) scales represent one of the most widely utilized psychometric instruments in health psychology, behavioral medicine, and public health research. Developed by Kenneth A. Wallston, Barbara Strudler Wallston, and Robert DeVellis in 1978, the instrument was formulated to address the conceptual and empirical limitations of unidimensional generalized locus of control measures when applied to health-specific behavioral outcomes. Rooted in Julian B. Rotter’s social learning theory and Albert Bandura’s conceptualizations of expectancies, the MHLC assesses an individual’s dispositional beliefs regarding the primary agents or mechanisms governing their physical health and recovery from illness. The instrument comprises 18 self-report items partitioned equally into three distinct, orthogonal 6-item subscales: Internal Health Locus of Control (IHLC), reflecting beliefs that one’s personal behaviors directly dictate health status; Powerful Others Health Locus of Control (PHLC), reflecting beliefs that health outcomes depend primarily upon healthcare providers, family members, or external authorities; and Chance Health Locus of Control (CHLC), reflecting beliefs that health status is primarily determined by luck, fate, chance, or uncontrollable external circumstances. Items are scored on a fully anchored 6-point Likert scale ranging from 1 (Strongly Disagree) to 6 (Strongly Agree), yielding subscale scores from 6 to 36 without reverse scoring. Decades of psychometric evaluation have demonstrated satisfactory internal consistency (Cronbach’s alpha coefficients routinely ranging from .67 to .86 across normative and clinical samples), acceptable test-retest reliability, robust three-factor orthogonal structures confirmed via exploratory and confirmatory factor analyses, and sound convergent, discriminant, and predictive validity across diverse medical conditions, preventive health behaviors, and treatment adherence paradigms.
2. Keywords
Multidimensional Health Locus of Control, MHLC, health locus of control, internal health locus of control, powerful others, chance locus of control, health psychology, psychometrics, health behavior, medical adherence
3. Authors
The original Multidimensional Health Locus of Control (MHLC) scale was developed and psychometrically validated by:
- Kenneth A. Wallston, Ph.D. — Professor Emeritus of Psychology in Nursing at Vanderbilt University School of Nursing, Nashville, Tennessee, USA. Dr. Wallston was a pioneering behavioral scientist whose research focused extensively on the interface between perceived control, adaptation to chronic illness, and health behavior change.
- Barbara Strudler Wallston, Ph.D. (1943–1987) — Professor of Psychology and Human Development at Peabody College of Vanderbilt University, Nashville, Tennessee, USA. A prominent social psychologist whose empirical work advanced the understanding of gender roles, health attitudes, and locus of control constructs.
- Robert F. DeVellis, Ph.D. (1947–2020) — Professor Emeritus of Health Behavior at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, USA. Renowned psychometrician and author of classical treatises on scale development and measurement theory in the social and behavioral sciences.
4. Purpose
The primary purpose of the Multidimensional Health Locus of Control (MHLC) scales is to operationalize and quantify the specific generalized expectancies individuals maintain regarding the determinants of their health status, recovery from disease, and overall physical well-being. Prior to the publication of the MHLC in 1978, investigators seeking to measure control expectancies in clinical and health behavior contexts relied either on generalized locus of control instruments—most notably Julian Rotter’s I-E Scale (1966)—or on the preliminary unidimensional Health Locus of Control (HLC) scale introduced by Wallston et al. in 1976. However, generalized control instruments exhibited weak predictive utility when correlated with domain-specific health actions such as dietary modifications, smoking cessation, and medical adherence. Furthermore, treating locus of control as a strictly bipolar continuum (Internal vs. External) obscured critical distinctions between external control exerted by organized human agency (e.g., physicians and nurses) versus external control exerted by stochastic, unpredictable forces (e.g., luck, fate, or chance).
By decomposing the external control domain into “Powerful Others” and “Chance” dimensions, the MHLC affords clinicians and researchers a nuanced diagnostic profile. In clinical and medical settings, identifying a patient’s MHLC profile informs personalized psychoeducational interventions, shared decision-making models, and tailored treatment adherence plans. For instance, individuals exhibiting high Powerful Others Health Locus of Control (PHLC) scores often thrive under structured, practitioner-directed regimens, exhibiting high adherence to pharmacological recommendations and routine appointments. Conversely, patients presenting with elevated Internal Health Locus of Control (IHLC) scores typically respond more favorably to collaborative care models, self-management education, and behavioral autonomy, experiencing frustration when confronted with authoritarian medical approaches. Patients exhibiting dominant Chance Health Locus of Control (CHLC) scores frequently display behavioral fatalism, low adherence to screening protocols, and passive coping mechanisms, signaling the need for cognitive-behavioral strategies aimed at establishing perceived contingency between personal self-care actions and disease management.
In empirical research, the MHLC serves as a critical independent, mediating, or moderating variable across epidemiological investigations, health promotion trials, and behavioral medicine protocols. It has been extensively utilized to predict engagement in preventive behaviors (such as mammography, immunizations, and physical exercise), psychological adaptation to life-threatening or chronic medical conditions (including oncology, cardiovascular diseases, diabetes mellitus, end-stage renal disease, and chronic pain syndromes), and health-related quality of life. Moreover, the MHLC provided the psychometric foundation for subsequent specialized instruments, including Form C for condition-specific populations and the Multidimensional God Locus of Health Control (MGLHC) scales.
5. Psychological Construct
The psychological construct assessed by the Multidimensional Health Locus of Control (MHLC) scales centers on health-specific locus of control expectancies. Locus of control refers to a stable cognitive orientation regarding whether the outcomes of one’s actions are contingent upon what one does (internal control) or upon events outside one’s personal control (external control). In the context of health, the MHLC operationalizes this construct across three independent, multidimensional dimensions:
Internal Health Locus of Control (IHLC)
The IHLC subscale measures the degree to which an individual believes that personal behavior, lifestyle habits, and self-directed actions are the primary determinants of their health status and recovery from illness. Individuals who score high on IHLC perceive a strong contingency between their own self-regulatory health behaviors (e.g., nutrition, physical activity, medication adherence, stress reduction) and positive somatic outcomes. For example, an individual endorsing items such as “If I take care of myself, I can avoid illness” or “The main thing which affects my health is what I myself do” views health not as a passive endowment or a matter of random fortune, but as an ongoing consequence of personal agency. In contrast, individuals scoring low on IHLC experience a diminished sense of bodily autonomy and personal accountability regarding physical health, rarely linking somatic changes to their own preceding behavioral choices.
Powerful Others Health Locus of Control (PHLC)
The PHLC subscale captures the extent to which an individual believes that their health, illness severity, and recovery trajectory are governed by external human agents who possess specialized knowledge, authority, or interpersonal influence. The primary external agents referenced within this dimension are medical practitioners (physicians, nurses, specialists), followed by family members, close relatives, and social support systems. An endorsement of items such as “Having regular contact with my physician is the best way for me to avoid illness” and “Whenever I recover from an illness, it’s usually because other people… have been taking good care of me” reflects a high PHLC orientation. Crucially, high PHLC does not imply passive helplessness; rather, it reflects a socially mediated pathway of control wherein the individual derives security and positive health expectations through active alignment with institutional healthcare authorities and trusted caregivers.
Chance Health Locus of Control (CHLC)
The CHLC subscale quantifies an individual’s conviction that health outcomes are fundamentally governed by fate, serendipity, fortune, luck, or uncontrollable biological and environmental vagaries. High scorers on CHLC endorse statements such as “No matter what I do, if I am going to get sick, I will get sick” and “My good health is largely a matter of good fortune.” This cognitive profile embodies health fatalism, wherein the individual perceives little to no functional relationship between behavioral inputs (e.g., smoking cessation, dietary restriction) and systemic clinical endpoints. Elevating CHLC often correlates with psychological distress, learned helplessness, avoidant coping styles, and delayed healthcare seeking, as individuals perceive bodily outcomes as intrinsically random and impervious to human intervention.
6. Theoretical Framework
The theoretical architecture of the Multidimensional Health Locus of Control scale is situated at the intersection of Julian B. Rotter’s Social Learning Theory (1954, 1966) and the broader expectancy-value paradigms developed within cognitive psychology and behavioral medicine. Rotter conceptualized behavior as a function of both an individual’s expectancy that a given behavior will lead to a particular outcome and the reinforcement value that the individual places on that outcome within a specific psychological situation, formally represented as:
Behavior Potential = f(Expectancy, Reinforcement Value)
In Rotter’s framework, generalized expectancies emerge across an individual’s developmental trajectory as generalized abstractions derived from specific past learning histories. When confronted with ambiguous, novel, or complex situations, people rely heavily on generalized expectancies concerning internal versus external control of reinforcement. However, Rotter noted that as situations become more familiar, domain-specific expectancies exert far stronger predictive control over overt behavior than generalized expectancies. Wallston et al. (1976, 1978) extended this proposition specifically to health-related contexts, establishing that an individual’s beliefs about the locus of control over health outcomes operate as domain-specific expectancies that predict health behaviors far more accurately than generalized personality measures.
A critical theoretical refinement incorporated into the MHLC was the departure from a unidimensional, bipolar continuum of internal versus external control. Drawing upon the theoretical insights of Hanna Levenson (1973, 1974), who demonstrated that generalized locus of control among psychiatric and college populations comprised three distinct, non-overlapping dimensions (Internal, Powerful Others, and Chance), Wallston, Wallston, and DeVellis asserted that external health beliefs were inherently heterogeneous. Believing that one’s health is entrusted to expert medical practitioners represents an active, organized reliance on human agency, whereas believing that health is ruled by luck or fate represents perceived randomness and uncontrollability. Treating external control as a unitary construct had historically obscured empirical findings, as positive correlations with medical compliance (driven by Powerful Others) were cancelled out by negative correlations with compliance (driven by Chance).
Furthermore, the theoretical framework dictates that health locus of control expectancies do not operate in a cognitive vacuum; their predictive power over health-protective or illness-management behavior is moderated by the subjective value the individual assigns to physical health (Health Value). According to the MHLC expectancy-value paradigm, high internal health expectancies will only motivate proactive health behaviors if health is deeply valued by the individual. If health value is negligible, even an individual who strongly believes they have absolute control over their health will exhibit little inclination to initiate preventative or therapeutic regimens.
7. Validity
The validity of the Multidimensional Health Locus of Control scales has been extensively documented through construct, convergent, discriminant, and criterion-related predictive validity studies across hundreds of diverse clinical and non-clinical populations over four decades.
Construct and Convergent Validity
In the seminal psychometric validation study by Wallston, Wallston, and DeVellis (1978), construct and convergent validity were established by correlating the three MHLC subscales (Forms A and B) with Levenson’s generalized Internal, Powerful Others, and Chance (I, P, and C) scales. As theoretically hypothesized, the MHLC subscales exhibited statistically significant, moderate convergent correlations with their generalized counterparts. Across a validation sample of 115 adults, the IHLC subscale correlated positively with Levenson’s Internal scale (r = .56, p < .001). The PHLC subscale correlated significantly with Levenson’s Powerful Others scale (r = .27, p < .01), and the CHLC subscale demonstrated a substantial positive correlation with Levenson’s Chance scale (r = .79, p < .001). These robust positive associations confirmed that the MHLC successfully captures specific manifestations of generalized control beliefs within health settings.
Discriminant Validity
Discriminant validity was verified through low to negligible correlations between the MHLC subscales and measures of general intellectual ability, socioeconomic status, and social desirability. In the initial validation cohorts, correlations between MHLC subscales and the Marlowe-Crowne Social Desirability Scale hovered between -.11 and .09, confirming that endorsement of IHLC, PHLC, or CHLC items is largely unconfounded by the need for social approval. Furthermore, the intercorrelations among the three MHLC subscales themselves demonstrated empirical independence: IHLC correlated weakly and non-significantly with PHLC (r = .05 to .10) and correlated negatively with CHLC (r = -.15 to -.30), while PHLC and CHLC maintained modest, non-overlapping associations (r = .15 to .25), affirming that the subscales capture orthogonal constructs.
Predictive and Criterion Validity
Substantial empirical literature supports the criterion-related and predictive validity of the MHLC in relation to preventative health actions, psychological adjustment to chronic disease, and medical regimen adherence. Studies evaluating preventive health screening behaviors (such as adherence to routine mammography, cervical cancer screening, and dental check-ups) have demonstrated that individuals exhibiting high IHLC scores paired with elevated health value engage in significantly higher rates of preventative behaviors compared to their low-IHLC counterparts. In medical adherence research, particularly among cohorts diagnosed with Type 2 diabetes mellitus, hypertension, and end-stage renal disease, elevated PHLC scores consistently predict rigorous adherence to complex pharmacotherapy and clinical follow-up schedules. Conversely, elevated CHLC scores have repeatedly emerged as predictive of treatment non-compliance, smoking persistence, delayed diagnostic presentation, and higher levels of depressive symptomatology and psychological distress in chronic illness management.
8. Reliability
The reliability of the Multidimensional Health Locus of Control scales has been established through both internal consistency metrics and temporal stability assessments across diverse geographical, cultural, and clinical cohorts.
Internal Consistency
In the original instrument development study conducted by Wallston, Wallston, and DeVellis (1978), Cronbach’s alpha coefficients were evaluated on an initial normative adult sample (N = 115) and subsequently cross-validated across multiple diverse samples (ranging from healthy university undergraduates to individuals enrolled in weight-loss clinics and chronic medical patients). Across the identical parallel forms (Form A and Form B), the 6-item subscales demonstrated satisfactory to good internal consistency coefficients:
- Internal Health Locus of Control (IHLC): Alpha coefficients ranged from .67 to .77 for Form A, and from .71 to .86 for Form B across normative cohorts.
- Powerful Others Health Locus of Control (PHLC): Alpha coefficients ranged from .67 to .74 for Form A, and from .69 to .72 for Form B.
- Chance Health Locus of Control (CHLC): Alpha coefficients ranged from .73 to .78 for Form A, and from .71 to .79 for Form B.
When the two parallel forms (Form A and Form B) are combined into 12-item subscales, the composite alpha reliabilities routinely exceed .83 to .87, providing elevated statistical precision for intensive individual assessment and longitudinal clinical trials.
Test-Retest Reliability and Temporal Stability
Test-retest reliability assessments have verified that while MHLC scores exhibit the requisite stability expected of generalized cognitive dispositions, they remain appropriately sensitive to major life events, educational interventions, and medical transitions. Wallston et al. (1978) reported stability coefficients across intervals of two to eight weeks ranging between .60 and .71 for IHLC, .58 and .74 for PHLC, and .62 and .76 for CHLC in healthy community samples. Subsequent investigations examining clinical cohorts before and after intensive patient empowerment and self-management programs have observed deliberate, statistically significant increases in IHLC and corresponding reductions in CHLC, confirming that the scale is sensitive to structured therapeutic change while preserving strong short-term psychometric stability.
9. Factor Analysis
The dimensional validity and factor structure of the Multidimensional Health Locus of Control scales have been subjected to extensive exploratory factor analyses (EFA) and confirmatory factor analyses (CFA) across numerous linguistic adaptations and diverse clinical populations.
Exploratory Factor Analysis (EFA)
In the foundational scale development protocol, Wallston, Wallston, and DeVellis (1978) generated an initial pool of 81 health-related control items, which were administered to adult samples. Principal components analysis (PCA) followed by orthogonal varimax rotation and oblique rotations consistently yielded a distinct, robust three-factor solution. The three emergent factors accounted for the vast majority of the common variance, corresponding cleanly to Internal, Powerful Others, and Chance dimensions. Items that loaded substantially (≥ .40) on their primary theoretical factor and demonstrated minimal cross-loadings (≤ .25) on secondary factors were retained. The final 18 items were divided into identical parallel 18-item forms (Form A and Form B). The factor loadings for the 18 items on their intended subscales routinely ranged from .45 to .75, with minimal cross-loadings, demonstrating clean structural integrity.
Confirmatory Factor Analysis (CFA) and Model Fit
Subsequent modern psychometric evaluations utilizing Confirmatory Factor Analysis have systematically evaluated competing structural models, specifically contrasting a unidimensional model, a two-factor model (Internal vs. External), and the theoretical three-factor oblique model. Findings across international cohorts consistently demonstrate superior model fit indices for the three-factor model. Goodness-of-fit parameters reported in contemporary structural equation modeling literature typically document:
- Comparative Fit Index (CFI): .92 to .96, indicating good structural congruence.
- Tucker-Lewis Index (TLI): .91 to .95.
- Root Mean Square Error of Approximation (RMSEA): .042 to .058 (with 90% confidence intervals well below the .08 threshold for acceptable fit).
- Standardized Root Mean Square Residual (SRMR): .045 to .059.
Alternative structural configurations—such as collapsing Powerful Others and Chance into an overarching generic External factor—consistently result in catastrophic deterioration of model fit (CFI < .75, RMSEA > .11), reinforcing the absolute empirical and psychometric necessity of retaining three independent, differentiated dimensions.
10. Instrument / Measurement Tool
The Multidimensional Health Locus of Control (MHLC) scale is an objective, standardized self-report psychometric questionnaire designed for administration in both clinical and community research settings.
- Instrument Type: Standardized multi-item self-report questionnaire / psychometric rating scale.
- Format: Paper-and-pencil self-administered questionnaire, computerized electronic survey, or orally administered interview format for clinical populations with visual or motor limitations.
- Total Item Count: 18 items (divided into three equal 6-item subscales).
- Subscale Composition:
- Internal Health Locus of Control (IHLC): Items 1, 6, 8, 12, 13, and 17.
- Powerful Others Health Locus of Control (PHLC): Items 3, 5, 7, 10, 14, and 18.
- Chance Health Locus of Control (CHLC): Items 2, 4, 9, 11, 15, and 16.
- Parallel Forms: Form A (the primary standardized form presented herein) and Form B (an equivalent parallel form designed for longitudinal, pre-test/post-test experimental designs). Form C also exists as an 18-item condition-specific variant for individuals diagnosed with an existing chronic medical condition.
- Authentic 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 Protocol & Rules:
- There is no reverse scoring for any item on the MHLC.
- Subscale scores are obtained by calculating the sum of the numerical values assigned to the six items comprising each subscale.
- Possible score range for each subscale: 6 to 36 points.
- A total composite score across all 18 items is not psychometrically valid and should never be calculated, because the three dimensions are independent and orthogonal.
- Higher scores on a given subscale indicate a stronger endorsement of that specific health locus of control orientation.
- Average Administration Time: Approximately 5 to 10 minutes.
11. Permissions & Fee and Test Year
Publication Year: The Multidimensional Health Locus of Control (MHLC) scales were originally published in 1978 in Health Education Monographs (now known as Health Education & Behavior).
Licensing and Research Permissions: The authors, Kenneth A. Wallston, Barbara Strudler Wallston, and Robert DeVellis, placed the MHLC scales (Forms A, B, and C) into the public domain for open clinical and scholarly research use. No formal licensing fees, commercial royalties, or institutional purchase agreements are required to administer, adapt, or reproduce the instrument for academic, non-commercial, or clinical investigative purposes. Investigators utilizing the MHLC are requested only to cite the original 1978 instrument development article in resulting scientific presentations, theses, and peer-reviewed publications.
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/10.1037/10788-000
- 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, 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, 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
- Wallston, K. A. (2005). The validity of the Multidimensional Health Locus of Control scales. Journal of Health Psychology, 10(5), 623–631. https://doi.org/10.1177/1359105305055304