Spiritual Health Locus of Control Scales

Abstract

The Spiritual Health Locus of Control Scales (SHLOC) represent an influential psychometric instrument developed by Dr. Cheryl L. Holt and colleagues to capture the multidimensional ways individuals integrate religious and spiritual beliefs into their subjective attributions of health, illness, and recovery. Expanding upon classical social learning theory and established health locus of control paradigms, the SHLOC addresses critical limitations inherent in standard measurement models that traditionally operationalize divine attribution as a monolithic, external, and passive psychological mechanism. The instrument differentiates between two distinct operational dimensions: an Active Spiritual locus of control, wherein individuals view their relationship with God as an empowering partnership that motivates proactive self-care, health behaviors, and adherence to medical regimens; and a Passive Spiritual locus of control, characterized by spiritual deferral, fatalistic surrender of personal agency, and the potential relinquishment or avoidance of conventional medical intervention. Consisting of 14 items evaluated along a five-point Likert response format ranging from Strongly Disagree to Strongly Agree (with an intermediate neutral midpoint), the SHLOC has demonstrated robust psychometric properties across diverse demographic cohorts, most notably within African American faith-based communities and populations navigating chronic disease management. Validation studies utilizing exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) have consistently substantiated its dual-factor construct structure, establishing high internal consistency (Cronbach’s alpha values ranging from .80 to .91 for Active Spiritual and .65 to .78 for Passive Spiritual dimensions), stable test-retest reliability, and divergent validity against conventional measures of internal and external health locus of control. The SHLOC serves as an essential tool in behavioral medicine, health psychology, and public health disparities research, clarifying how spiritual worldviews systematically influence preventive health screenings, cancer surveillance, treatment compliance, and psychosocial well-being.

Keywords

Spiritual Health Locus of Control, SHLOC, Cheryl L. Holt, Health Locus of Control, Religious Coping, Active Spiritual, Passive Spiritual, Health Disparities, Multidimensional Health Locus of Control, Behavioral Medicine, Psychometrics

Authors

The Spiritual Health Locus of Control Scales were conceptualized and validated by Dr. Cheryl L. Holt in collaboration with multidisciplinary research teams specializing in behavioral oncology, community health, and health disparities. Dr. Holt is a renowned Professor in the Department of Behavioral and Community Health at the University of Maryland, School of Public Health, College Park, Maryland, United States. She also holds affiliations with the University of Maryland Greenebaum Comprehensive Cancer Center. Dr. Holt received her Ph.D. in Social and Health Psychology from Saint Louis University and completed advanced postdoctoral training in behavioral oncology. Her programmatic body of research focuses primarily on cancer communication, community-based participatory research (CBPR), church-based health interventions, and the psychosocial mechanisms through which religiosity and spirituality moderate or mediate health behaviors among racial and ethnic minority populations, particularly African American communities.

Throughout the continuous refinement and cross-validation of the SHLOC and its related iterations, Dr. Holt collaborated with notable researchers in public health, including Matthew W. Clark, David B. Lukwago, Eddie M. Clark, and Ralph J. DiClemente. Inquiries regarding scale usage, validation histories, and collaborative projects are typically directed to Dr. Cheryl L. Holt at the Department of Behavioral and Community Health, University of Maryland School of Public Health.

Purpose

The primary purpose of the Spiritual Health Locus of Control Scales is to operationalize, quantify, and delineate the attributional beliefs that individuals hold regarding the divine or spiritual determination of their physical health. In standard health psychology literature, the locus of control construct—derived from Julian Rotter’s social learning framework and operationalized by Kenneth Wallston and colleagues via the Multidimensional Health Locus of Control (MHLC) scales—segmented health attributions into Internal (self-determination), Powerful Others (reliance on medical professionals), and Chance (luck or fate). While subsequent iterations (such as Form C of the MHLC) attempted to measure “God Locus of Control,” they frequently treated divine attribution as a singular, external vector.

This traditional paradigm proved deeply problematic when applied to highly religious populations, particularly African American faith communities, where spiritual commitment is neither homogeneous nor inherently passive. By collapsing all spiritual attributions into an external locus of control, classical instruments erroneously conflated healthy spiritual empowerment with fatalistic passivity. The SHLOC was purposefully designed to resolve this conceptual conflation by distinguishing between two divergent psychological pathways:

• Active Spiritual Attribution: An intrinsic theological schema where faith in God reinforces personal responsibility, provides psychological resilience, promotes healthy behaviors, and views medical providers as biological instruments through which divine healing operates.
• Passive Spiritual Attribution: A fatalistic or deferent theological schema wherein individuals relinquish human agency entirely, believing that personal self-care is futile or that seeking professional medical care reflects a deficiency of faith.

The clinical and research applications of the SHLOC are extensive. In community-based and clinical oncology settings, researchers use the scale to predict adherence to cancer screening guidelines (e.g., mammography, colonoscopy, and Pap tests). In chronic disease management—such as hypertension, Type 2 diabetes mellitus, and cardiovascular disease—the SHLOC helps clinicians identify individuals who may be at risk for non-adherence due to passive religious deferral. Conversely, identifying high levels of Active Spiritual locus of control allows behavioral scientists and clinical health psychologists to develop culturally competent, faith-placed interventions that harness an individual’s religious faith as a cognitive catalyst for health promotion rather than a barrier to medical compliance.

Psychological Construct

The psychological construct assessed by the SHLOC lies at the intersection of cognitive attribution theory, religious coping theory, and health psychology. At its core, Health Locus of Control refers to a person’s generalized expectancy concerning whether their health outcomes are determined by their own actions, by powerful external agents, or by unpredictable chance factors. When spirituality is introduced into this cognitive calculus, attribution patterns diverge into complex psychological mechanisms.

1. The Active Spiritual Dimension

The Active Spiritual subscale captures a collaborative, reciprocal, and empowering dynamic between the individual and the divine. Within this construct, God is not conceptualized as a detached entity who arbitrarily dispenses wellness or disease, nor is God viewed as an excuse for human neglect. Instead, faith serves as an internal psychological resource that enhances self-efficacy, moral imperative, and physical vitality. Specifically, this dimension reflects several interrelated cognitive themes:

• Spiritual Self-Care Mandate: The theological conviction that the human body is a sacred vessel or divine trust, creating a moral obligation to practice healthy lifestyles, exercise, maintain a balanced diet, and seek preventive medical care (e.g., “Living the way the Lord says I’m supposed to live means I have to take care of myself”).
• Divine Empowerment and Self-Agency: The belief that God endows the individual with internal strength, cognitive resolve, and executive functioning required to overcome behavioral obstacles and manage health conditions (e.g., “God gives me the strength to take care of myself”).
• Collaborative Partnership: An explicit cognitive attribution of shared responsibility between human effort and divine providence (e.g., “God and I share responsibility for my health”).
• Integration of Medicine and Faith: The cognitive assimilation of modern medicine into a theological framework, viewing healthcare professionals and pharmacological therapies as instruments of divine grace (e.g., “God works through doctors to heal us”).

2. The Passive Spiritual Dimension

In stark contrast, the Passive Spiritual subscale measures a fatalistic, deferring, and externally dependent attributional style. Individuals scoring high on this dimension abdicate personal agency, projecting all accountability for health and illness onto divine omnipotence. This construct manifests through two primary maladaptive mechanisms:

• Abdication of Behavioral Responsibility: The belief that personal health behaviors, disease prevention, and self-management are meaningless or unnecessary because divine sovereignty dictates all physiological outcomes (e.g., “There is no point in taking care of myself when it’s all up to God anyway”).
• Avoidance or Rejection of Medical Intervention: The hazardous attribution that seeking medical attention or taking prescribed medications demonstrates a lack of faith in God’s miraculous healing power (e.g., “It’s ok not to seek medical attention because I feel that God will heal me”).

Psychologically, the passive spiritual orientation closely aligns with external locus of control, learned helplessness, and avoidant coping mechanisms. In contrast, the active spiritual orientation exhibits robust positive correlations with perceived self-efficacy, intrinsic motivation, and proactive problem-focused coping.

Theoretical Framework

The theoretical architecture of the SHLOC integrates foundational paradigms from social learning theory, cognitive appraisal models, and the psychology of religion.

Social Learning Theory and Locus of Control

The conceptual origin of locus of control stems from Julian B. Rotter’s (1954, 1966) Social Learning Theory. Rotter postulated that the potential for a behavior to occur in a specific situation is a function of the individual’s expectancy that the behavior will lead to a particular reinforcement, and the subjective value placed on that reinforcement. Rotter conceptualized locus of control as a generalized expectancy across situations: internal locus of control represents the conviction that reinforcements are contingent upon one’s own behavior, skills, or internal characteristics, whereas external locus of control represents the belief that outcomes are mediated by external forces such as chance, luck, fate, or powerful others.

In the late 1970s, Kenneth A. Wallston, Barbara Strudler Wallston, and Robert DeVellis adapted Rotter’s generalized construct to health-specific contexts by developing the Multidimensional Health Locus of Control (MHLC) scale. The MHLC split external control into “Powerful Others Health Locus of Control” (PHLC) and “Chance Health Locus of Control” (CHLC). However, when researchers attempted to fit religious and spiritual beliefs into this tripartite model, they found that believers often endorsed items reflecting high internal control simultaneously with high divine control. This theoretical anomaly revealed that spiritual attribution does not operate on a simple zero-sum continuum between human and external agency.

Pargament’s Theory of Religious Coping

To accurately capture the nuance of spiritual attribution, Holt and colleagues grounded the SHLOC in Kenneth I. Pargament’s seminal framework of religious coping styles (Pargament et al., 1988). Pargament delineated three primary models through which individuals negotiate problem-solving with God:

1. The Collaborative Style: The individual and God are viewed as active partners who share responsibility for problem-solving. This style maintains human agency while drawing emotional, cognitive, and spiritual strength from God.
2. The Deferring Style: The individual passively waits for God to solve the problem, abdicating personal responsibility, decision-making, and proactive action.
3. The Self-Directing Style: The individual relies entirely on their own abilities without expecting or seeking divine intervention, viewing God as having provided the freedom and capacity for autonomous action.

The SHLOC directly operationalizes this distinction within the domain of physical health: the Active Spiritual dimension embodies Pargament’s Collaborative style (with elements of proactive self-direction grounded in spiritual mandate), while the Passive Spiritual dimension directly operationalizes the maladaptive aspects of the Deferring style.

Bandura’s Social Cognitive Theory and Self-Efficacy

The SHLOC also draws upon Albert Bandura’s Social Cognitive Theory, particularly the construct of self-efficacy. In classical models, an external attribution is assumed to diminish self-efficacy. However, the Active Spiritual subscale of the SHLOC operationalizes a phenomenon termed “the proxy agency of God,” wherein an individual’s belief in God’s omnipotence actually enhances their own perceived self-efficacy to initiate and maintain challenging health behaviors (e.g., smoking cessation, dietary restriction, or managing complex cancer therapies).

Validity

The validity of the Spiritual Health Locus of Control Scales has been extensively evaluated through construct, convergent, discriminant, and predictive validation studies across diverse community and clinical samples.

Construct and Structural Validity

Construct validity has been established through repeated factor analyses demonstrating that the items reliably load onto two independent, theoretically congruent dimensions rather than a single bipolar continuum. Studies by Holt and colleagues (2001, 2003, 2007) across multiple cohorts totaling over 1,500 African American and diverse church-going adults showed that Active and Passive Spiritual subscales display weak or non-significant inter-correlations (typically ranging from r = -.08 to r = .15). This empirical orthogonality confirms that endorsing an active spiritual partnership does not simply represent the mathematical absence of passive deferral; rather, they represent separate cognitive schemata that can co-exist or vary independently within an individual’s psychological architecture.

Convergent and Discriminant Validity

Convergent validity has been established by examining the relationships between SHLOC subscales and established measures of religiosity, spirituality, and general health locus of control:

• Religiosity and Spiritual Well-Being: The Active Spiritual subscale correlates moderately to strongly with measures of intrinsic religiosity (such as the Duke University Religion Index [DUREL]), religious coping (Brief RCOPE Collaborative subscale, r = .52 to .68), and spiritual well-being (FACIT-Sp). The Passive Spiritual subscale correlates moderately with negative religious coping, spiritual struggle, and deferring coping styles (r = .38 to .54).
• Health Locus of Control Dimensions: When compared against Wallston’s MHLC Form C (God Locus of Control), the Active Spiritual subscale demonstrates positive correlations with MHLC Internal scale (r = .31 to .45) and MHLC Doctors/Powerful Others scale (r = .40 to .55). In contrast, the Passive Spiritual subscale demonstrates significant negative or null correlations with MHLC Internal locus of control and strong positive correlations with MHLC Chance subscale (r = .35 to .48), confirming that passive spiritual attribution shares psychological variance with fatalism.
• Discriminant Validity: Both SHLOC subscales show low correlations with unrelated constructs such as social desirability, generalized intelligence, and baseline physical functional status, confirming that the instrument captures unique variance specific to health-related spiritual attributions.

Predictive and Criterion-Related Validity

Criterion and predictive validity have been substantiated across numerous empirical health investigations:

• Preventive Health Screenings: In longitudinal and cross-sectional studies on cancer early detection, high scores on the Active Spiritual subscale prospectively predicted higher adherence to annual mammography screening among women (odds ratio [OR] = 1.42, p < .01) and greater rates of fecal occult blood testing (FOBT) and colonoscopy among adults over age 50. Conversely, high scores on the Passive Spiritual subscale were significantly associated with delayed screenings, non-adherence to diagnostic follow-ups, and avoidance of preventive health checkups (OR = 0.68, p < .05).
• Chronic Disease Management: In investigations involving African American adults with hypertension and diabetes, Active Spiritual scores were positively associated with medication adherence, regular home blood pressure monitoring, and physical exercise. Conversely, Passive Spiritual attributions predicted missed clinical appointments, lower medication compliance, and worse glycemic control (HbA1c levels).

Reliability

The reliability of the SHLOC has been verified across multiple psychometric investigations, demonstrating solid internal consistency, composite reliability, and temporal stability.

Internal Consistency

Internal consistency has been thoroughly documented across several validation cohorts using Cronbach’s alpha (α) and McDonald’s omega (ω):

• Active Spiritual Subscale: In the initial validation study by Holt (2001) comprising African American church members, the Active Spiritual subscale exhibited excellent internal consistency, with Cronbach’s α values ranging from .84 to .91 across subsamples. Subsequent cross-validation studies (e.g., Holt et al., 2003; Holt et al., 2007) reported alpha coefficients consistently between .81 and .88, confirming high item covariance and unidimensionality within this subscale. Corrected item-total correlations for Active items generally range between .48 and .74.
• Passive Spiritual Subscale: The Passive Spiritual subscale, consisting of fewer items, has yielded acceptable to good internal consistency coefficients, typically reporting Cronbach’s α values between .65 and .78. Given that alpha is sensitive to scale length (the Passive subscale contains 2 to 3 core items depending on specific structural editions), an alpha of .70+ reflects substantial item inter-relatedness. Mean inter-item correlations for this dimension remain robust (ranging from .45 to .60).

Temporal Stability (Test-Retest Reliability)

Test-retest reliability was established in longitudinal community cohorts with assessment intervals ranging from 2 weeks to 6 months:

• At a 2-week to 4-week re-administration interval, the intraclass correlation coefficient (ICC) for the Active Spiritual subscale was .82, and for the Passive Spiritual subscale was .76, indicating high measurement stability in the absence of major health crises.
• At a 6-month interval, stability coefficients remained moderate to high (r = .68 to .74 for Active; r = .59 to .67 for Passive), demonstrating that while spiritual health locus of control operates primarily as a stable cognitive disposition, it possesses sufficient sensitivity to capture cognitive shifts resulting from acute health events or targeted spiritual interventions.

Factor Analysis

The latent structure of the SHLOC has been scrutinized through extensive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to verify item dimensionality and structural invariance.

Exploratory Factor Analysis (EFA)

In the primary instrument development phases, Holt and colleagues conducted principal axis factoring and principal components analyses with both orthogonal (Varimax) and oblique (Promax) rotations to determine the underlying factor configuration. Eigenvalue-greater-than-one criteria and scree plot inspections consistently revealed a clear two-factor solution that accounted for over 52% to 58% of the total scale variance:

• Factor 1 (Active Spiritual): Captured items emphasizing self-care obligations, divine empowerment, medical collaboration, and shared responsibility. Factor loadings for items 1 through 10 and item 14 ranged robustly between .48 and .82, with negligible cross-loadings onto Factor 2 (all cross-loadings < .20).
• Factor 2 (Passive Spiritual): Captured items representing fatalistic deferral, denial of personal agency, and avoidance of medical intervention (notably items 12 and 13, along with item 11). Factor loadings on this component ranged from .62 to .86, demonstrating distinct statistical clustering.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analyses across subsequent independent samples have validated the superiority of the two-factor model over alternative single-factor or three-factor models. Structural equation modeling (SEM) indices consistently meet recognized standards for excellent model fit:

• Comparative Fit Index (CFI): .94 to .97
• Tucker-Lewis Index (TLI): .93 to .96
• Root Mean Square Error of Approximation (RMSEA): .042 to .058 (with 90% confidence intervals between .031 and .069)
• Standardized Root Mean Square Residual (SRMR): .041 to .052
• Chi-Square to Degrees of Freedom Ratio (χ²/df): Typically < 2.5

Alternative models, such as a unidimensional model loading all items onto a general spiritual control factor, demonstrated unacceptable fit (χ²/df > 6.8, CFI < .75, RMSEA > .12), confirming that active and passive spiritual attributions must be modeled as discrete, multifaceted constructs. Furthermore, multi-group CFA has demonstrated metric and scalar measurement invariance across sex and age groups in community samples.

Instrument / Measurement Tool

The Spiritual Health Locus of Control Scale is a brief, highly accessible self-report instrument designed for self-administration or interviewer-assisted administration in clinical, epidemiological, and community-based settings.

• Test Type: Psychometric Self-Report Questionnaire / Psychological Assessment Scale.
• Target Population: Adults (aged 18 and older); extensively validated in community, clinical, and faith-based populations, particularly African American churchgoers and individuals managing chronic health conditions.
• Administration Format: Paper-and-pencil questionnaire, interviewer-administered verbal protocol, or computerized/online survey interface.
• Number of Items: 14 items in the standard revised edition.
• Response Scale: 5-point Likert response format:
• Strongly Disagree
• Disagree
• Neither
• Agree
• Strongly Agree
• Subscale Composition:
  • Active Spiritual Subscale: Composed of items 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 14 (11 items total). Reflects collaborative partnership with God, spiritual self-care, and viewing medical professionals as instruments of divine healing.
  • Passive Spiritual Subscale: Composed of items 12 and 13 (with item 11 functioning as a qualifying stem or passive indicator; 2 to 3 items total). Reflects fatalistic relinquishment of agency and avoidance of healthcare.
• Scoring Instructions:
  • Each item is scored from 1 (Strongly Disagree) to 5 (Strongly Agree), or alternately 1 to 5 with 3 representing “Neither” (neutral).
  • Items are summed or averaged within each subscale to generate an Active Spiritual Score and a Passive Spiritual Score.
  • Higher scores on the Active Spiritual subscale indicate greater reliance on spiritual empowerment and collaborative self-care.
  • Higher scores on the Passive Spiritual subscale indicate elevated levels of spiritual fatalism and medical avoidance.
  • Subscales should be scored and interpreted separately; they should not be summed into a single composite total score.
• Completion Time: Approximately 3 to 5 minutes.

Permissions & Fee and Test Year

The Spiritual Health Locus of Control Scale was introduced in 2001 by Dr. Cheryl L. Holt, with subsequent revisions and validation expansions published in 2003 and 2007. The instrument is generally considered an academic instrument accessible for non-commercial research and educational applications without licensing fees, provided proper bibliographic citation is given to the primary validation publications. Researchers planning to utilize, translate, or adapt the SHLOC in clinical trials, large-scale epidemiological studies, or commercial healthcare settings should contact Dr. Cheryl L. Holt at the University of Maryland School of Public Health to request formal permission, obtain the most current administration guidelines, and ensure alignment with ongoing scale norms.

References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Holt, C. L., Clark, E. M., & Klem, P. R. (2007). Spiritual health locus of control and breast cancer beliefs among urban African American women. Health Education & Behavior, 34(2), 294–309. https://doi.org/10.1177/1090198106289002
• Holt, C. L., Clark, E. M., Kreuter, M. W., & Rubio, D. M. (2003). Spiritual health locus of control and health behaviors in African Americans: Conceptual framework and measure development. Journal of Health Psychology, 8(5), 503–516. https://doi.org/10.1177/13591053030085002
• Holt, C. L., Lukwago, S. N., & Kreuter, M. W. (2001). Spirituality, breast cancer beliefs and mammography utilization among urban African American women. Journal of Health Psychology, 6(4), 383–396. https://doi.org/10.1177/135910530100600403
• 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
• 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., Malcarne, V. L., Flores, L., Hansdottir, I., Smith, C. A., Stein, M. J., Weisman, M. H., & Clements, P. J. (1999). Does God warrant a serious look? A first look at the multidimensional health locus of control scale–God locus of control scale. Journal of Health Psychology, 4(4), 475–486. https://doi.org/10.1177/135910539900400402
• 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

13. Items of the Scale (Questionnaire)