Role of Health Locus of Control Beliefs in Cancer Screening of Elderly Hispanic Women

8/11/2019 Role of Health Locus of Control Beliefs in Cancer Screening of Elderly Hispanic Women

1/7

HealthPsychology

1993, Vol.12,

No .

3,193-199

Copyright1993by theAmerican Psychological Association, Inc.,and

the Division of Health

Psychology/0278-6133/93/$3.00

RoleofHealth LocusofControl

Beliefs

inCancer ScreeningofElderly

Hispanic

Women

Nancy

I. Bund ek,GaryMarks, andJeanL.Richardson

This

study

examined the

health locus

of control

beliefs

of

elderly

Hispanic women and relation

between

frequency

of

breast

self-examination

(BSE),attention

to

health-relatedinformation,

and

recency

of Pap

smear

and physician breast examination. As

hypothesized,

holding a belief that

health outcomes are controlled by oneself (internal control) was positively related to screening

behaviors overwhich

one has a

high

degree of

personal control, such

as

frequency

of BSE and

attention to health-related

information.

Belief

that

medical professionals

control

healthoutcomes

waspositively related

to physician-dependent screening

activities, such

as

recency

of Pap smear

and

physician breast

exam. The findings confirm the

specificity

of association between

health

control beliefs and preventive behaviors and

demonstrate

the importance of these

beliefs

in

medical

screening

by

Hispanic

women.

Understanding

people's

beliefs about

the

factors that con-

trol health outcomes

may be

critical

to

understanding

people's

health-related behaviors. Early work by B. S. Wallston,

Wall-

ston, Kaplan, and Maides

(1976)

focused on internal and

external dimensions of health locus of control, an outgrowth of

Rotter's(1954,1966)distinction between internal

and

external

expectancies

of

reinforcement.

The

early two-dimensional

scale

was

later expanded

to the

Multidimensional Health

Locus

of

Control (MHLOC) scale

(K. A.

Wallston, Wallston,

&

DeVellis,

1978).

Internal control refers to the belief that

health outcomes

are

determined

byone's own

actions

and

decisions. Control by powerful others refers to the belief that

the actions ofdoctors and

other

health professionals deter-

mine

health outcomes through the instructions, recommenda-

tions, and medications they provide. Chance control refers to

the belief that health and illness are largely a matter of chance

or fate.

These

beliefs generally

form

earlyin life as aresultofearly

childhood experiences wi th illness inone's family, and may

remain

relatively stable across time (Lau, 1982). The three

health control dimensions are relatively independent of one

another. The strongest correlation has been

found

between

chance control

and

control

bypowerful

others(rs

= .20 to

.35;

Marks, Richardson, Graham, & Levine, 1986; K. A. Wallston

et al.,

1978),

presumably reflecting a common component of

external

control.

Initial

research focused

on the

relationship between locus

of

control

and people's

interest

in

health-related information

Nancy

I.

Bundek, Gary

Marks, and

Jean

L. Richardson, Institute for

Health Promotion and Disease Prevention Research,D epartment of

Preventive

Medicine, University ofSouthernCalifornia.

This research w assupported by National Cancer

Institute

Grant

CA3566.W egratefully acknowledgeJohnC .Hisserich,JuliaM. Solis,

Lourdes Birba,

Fernando

Torres-Gil, and Linda Collins for their

contributions tothis project.

Correspondence concerning

this article

should be

addressed

to

Nancy I.

Bundek, University

of

Southern

California,

Institute

for

Prevention

Research, 1000

South Fremont, Suite

641,

Alhambra,

California91803-1358.

(see

K. A.

Wallston

&

Wallston, 1982). Using

the

early

two-dimensional scale, K. A. Wallston, Maides, and Wallston

(1976)

found

that college students

who

valued health highly

and had an internal orientation requested more pamphlets on

hypertension than

did

those

who

were internal

w i thlow

health

values

or

those

who

were external. Among older non-Hispanic

men and women (mean age = 57 years), Toner and Manuck

(1979)

found

that internals requested more information on

heart disease than did externals. No

effects,

however, were

found

for younger participants (mean age = 25 years).These

results are consistentwi ththose of K. A. Wallston et al.(1976)

ifone

assumes that

the

elderly place greater value

on

health

than

do

younger people

(K. A.

Wallston

&

Wallston,

1982).

A few studies have examined the extent to which health

control beliefs are associated

wi th

medical screening practices.

Redeker

(1989)

administered

the

MHLOC scale

to a

sample

of

non-Hispanic women and

found

that those who had never

practiced breast self-examination (BSE) tended

to

have lower

internal controlscoresthan did those who had performed BSE

three or more times a year. Beliefs about

powerful

others were

not examined. Hallal

(1982)

sampled English-speaking women

and

found

a

significant

negative correlation between control by

powerfulothers and ever practicing BSE and a nonsignificant

positive relationship between internal control and ever perform-

ingBSE.

Methodological limitations, however, raise concern about

HallaPs

(1982) findings. First,

frequency

of BSE was measured

dichotomously: those who ever practiced BSE (80%) versus

those who never practiced BSE (20%). Such unbalanced

groups

may

produce

highly

unstable results. Moreover,

the

former

group included women

who

performed

BSE

monthly

as

well

as those who performed it less than once a year. Thus,

Hallal's results may not

reflect

the precise manner in which

frequency

of BSE relates to a particular health control

dimension.

One purpose of the present study was to test the idea that a

specificMHLOC belief promotes a specific health practice. In

other words,

we

tested

the specificity of

association between

beliefs and

behaviors (Fishbein

& Ajzen,

1975).

We

were

193


2/7

194

N . B U N D E K , G . MA R K S , A N D J . R IC H A R D S O N

especially

interested

in the

manner

in

which beliefs

relate to

frequencyof performingBSE, recencyof gynecologicalscreen-

ing, and attentiveness tohealth-related

information.

We

wouldexpect

peoplehighininternalcontrolto perform

screeningbehaviors tha t havea strong personal control compo-

nent, such

as BSE and payingattention to

information

about

health

issues

(Redeker, 1989;

Toner

&

Manuck,

1979; K. A.

Wallston

et al., 1976). Although gynecological screening in-

volves some

degree

of

personal control

in setting up an

appointment,thistype of

screening

behavior

stronglyempha-

sizes the role of adoctoras thecontrollerof health

outcomes.

Thus,it should berelated

more

strongly to

belief

incontrolby

powerful

others

than to

belief

ininternal

control.

Accordingly,

wetested

the

following

three

hypotheses:

(1) The

frequency

of

performing

BSEcorrelatesdirectly with internal control be-

liefs.

(2) Attentiveness to health-related information

corre-

lates directly with internal control beliefs. (3) Recency of

gynecological

screeningcorrelatesdirectly with belief

in con-

trol

by

powerful

others.

A

second purpose

of the

study

was to

examine these

hypotheseswi th

a

sample

of

Hispanic

women.

Previous studies

of

health

control beliefs

have

been performed

almost

exclu-

sivelyw i t h non-Hispanicsamples.Infact,K. A.

Wallston

et al.

(1978)identifiedand validated the multidimensionalnatureof

these beliefs

with

a predominantly

White

sample.

Thus,

it is

reasonable to ask whether

MHLOC

beliefs are

relevant

to

medicalscreening behaviorsinother

cultural

groups.

Hispanic

women

in the

United States

represent one such

important

group.

They

are

diagnosedwithbreast

and

cervical

cancers at a

more

advanced stage ofdisease than are non-

HispanicWhite

women

(Richardsonet al.,

1992;

Samet,Hunt,

Lerchen, &Goodwin, 1988;

Westbrook,

Brown, & McBride,

1975). This has prompted concern about the cancer screening

practices

of Hispanic women. Indeed, compared

with

other

groups, they

are screened

irregularly, thus contributing

to

later-stagediagnosis andreducedchances ofsurvival(Ander-

son,

Lewis,

Giachello,

Aday, &

Chiu, 1981).

Most of the

past

research

on screening

practices

of Hispanic

women

(and men)

has focused on the rolesof acculturation (Chavez,Cornelius,

&Jones, 1985;

Chesney,

Chavira, Hall, & Gary, 1982; Deyo,

Diehl, Hazuda,

&

Stern, 1985; Marks

et

al., 1987; Wells,

Hough,Golding,Burnam, & Karno, 1987) and accessto care

(Anderson et al., 1981; Richardson et al., 1987; Solis, Marks,

Garcia,

&

Shelton,

1990). Our

focus

was on the role

that

psychological variablesplay

in

preventivehealthbehaviors.

Method

Sample

O ur data were part of Proyecto a Su Salud (Project to Your

Health),

a

longitudinal study

of

cancer symptom knowledge

an d

screening practices of elderly Hispanic wo men. Pa rticipants lived in 17

publicly

subsidized housing projects

in Los

Angeles.

These

projects

we re selected because they had a very high percentage of Hispanic

residents.

A ll

w o m en

55

years

of age or

older received

a

mailed

solicitationto participate a nd then werecontactedi n

person

by a study

representative. Hispanic ethnicity (i.e., family origin from a Latin

Am erican country, including Cuba and Puerto Rico) was confirmed by

the

interviewer. Of the 890 Hispanic womencontacted, 603(67.8%)

agreed

to be in the

study.

T he

study involved

an

intake assessment

of

he alth knowledge

an d

screening behaviors. Following

th e

intake, housing projects w ere

randomly

assigned

to one of threeconditions (comprehensive health

education program,

min ima l - in forma t ion

control group,

or no-

information

control group).

The

comprehensive program consisted

of

four 2-hr group educational programs pertaining to breast, cervical,

colorectal,

an d

oral cancers.

The minimal-information

control pro-

gram

consisted

o f a

45-min presentation about

warning

signs

of

cancer,

risk

factors, screening recommendations,

and the

importance

of

early

detection.

A

follow-upquestionnaire

was

administered

to all

subjects

approximately 1year

after

the intervention.

The p resent d ata involve wom en in eithe r of the two control

conditions ( = 429).These groups were combined because the two

conditions

did not

produce

an y m a i n or

interaction effects

on any

outcome measure. W e omitted women who received the comprehen-

sive

education program

(n =

174) because

it was

designed

to

improve

medical

screening practices.

A ll

variablesusedin the

analysis,

except measures of demographics

an d acculturation, were taken from

th e

follow-up questionnaire.

O f

the 429 women in the two control conditions, 270 provided complete

data on the

study

variables and constituted our analytic sample. To

check for possible attrition bias, we compared women who dropped

out of the study (n = 159) with our analytic sample on several variables

measured at intake: demographics, dateof last physical examination,

frequency

w ith wh ich they did BSE, nervousness a bout BSE, physician

breast exam and Pap smear, and recency of these screening proce-

dures. Dropouts

differed from

participants p < .05) only in the

frequency

with which they ha d performed BSE. T he primary

differ-

ence was tha t 27.4% of the participants reported that they never

practiced BSE, compared with41.2% ofthosewh o dropped out. Thus,

generalizations

from ou r

study

m ay be

more applicable

to

w o m en

w ho

practice

BS E with at least some regularity.

Questionnaire Design an d

Administration

The questionnaire was written in English, translated into Spanish,

and then back-translated to

identify ambiguity

of meaning. Both

versions were pilot-tested

w i t ha

sm all sample

o f

Hispanic women

from

the housing projects. In the main study, the questionnaire was

administered

at

each participant's home

by

Spanish-speaking women

trained

in

interviewing techniques.

T he

interview

w as

conducted

in the

languageof the participant's choice(75.9%chose Spanish).

Independent

Variables

Demographics and acculturation. W e measured several demo-

graphic factors, including age, education, marital status, monthly

income,

an d

health insurance coverage. Acculturation

w as

measured

with

18 items from the Acculturation Rating Scale fo r Mexican

Americans (Cuellar, Harris,

& Jasso,

1980), focusing primarily

on

language preference andusage,country of birth, and years residing in

the United

States.

In tern al reliability was very high

(Cronbach's

alpha = .95). Responses were standardized to a mean ofzero and a

variance

of one and

then averaged

to form on e

overall acculturation

scorefo r

each subject. Standardizing

the rawscores

gave equal weig ht

to

each item

in thescale.

Health

locus

of

control. Health locus

of

control

w as

m easured

with

nineitems from

th e

MHLOCscale

(K. A.

Wallston

et

al.,1978).

T he

original scale used

six

items

to

measure each dimension

of

control.

To

keep our questionnaire at a manageable length, we used the three

items that most strongly defined each subdimension in terms of the

highest

item-subscale correlations (Marks et

al.,

1986; C. H.

Wolk,

personalcomm unication, 1982).Theseitems

and the

responseformat

ar e

presented

in the

Append ix.


3/7

HISPANIC CANCER SCREENING

195

The internal reliability for each dim ension was quite high.

Cron-

bach's alpha

w as .82 for the

three internal control items,

.82 for the

powerful

others

items, and .72 for the

three chance control

items.

Responses

to the

items

within

each dimension were standardized

and

averaged

to

form three subscalescores

for

each participant.

D ep enden t

Variables

Frequency

of

BSE. It isgenerally accepted that once pe r m o n this

the optimal frequency for perform ing BSE (A lagna,

Morokoff,

Bevett,

&

Reddy,

1987).

Thisfrequency

enables

womento develop the most

sensitivity

to

detect breast lumps

and

changes

in

their breasts.

PerformingBSE

more frequently

may

diminish

one's

ability

to

detect

subtle changes. This recommendation governed our decision about

how

wecodedour BSEfrequency

data.

Each woman was asked whether she had performed BSE and how

often

she did it. Seventeen p ercent rep orted doing BSE on a m onthly

basis; for purposes of analysis, they were assigned a code of 4.

Thirty-seven

percent

reported that they performed BSE more fre-

quentlythanoncea mo nth; they were assigned a code of 3. Those w ho

reportedperforming

BSE

less th anonce

a

month (21,0%) were coded

2,

and

those

who

reported never doing

BSE

(25.0%) were coded

1.

Empirical

support

fo r

this coding scheme

is

provided

by the

women's demonstration of their ability to detect lumps in a

foam

breast model. During q uestionnaire adm inistration, they were pre-

sentedwitha life-size foam m odel of a breast t hat co ntained five lum ps

of

varyingsizes. They were asked to ex am ine it as they would their own

breastsand toreportthe number of lumps found.For the 72% who

agreed to examine the model

(n =

195), women who performed B SE

monthly

found

significantlym ore lumps than didthosewho performed

BSE

more than once

a

month

(Ms =

2.57

vs.

1.48,p


4/7

196

N . B U N D E K ,

G.

M A R K S ,

AND J.

R IC H A R D S O N

Table

2

Means an d Standard

Deviations

of

Study

Variables

Variable

Belief

i n

intern al control

Belief

in

control

by

powerful others

Belief inchance control

Frequency

of

breast self-examination

Recency of gynecological screening

Attention

to health-related information

M

3.44

3.27

2.08

2.45

3.90

3.37

SD

0.57

0.59

0.87

1.04

1.27

0.79

Note.

Entries

a re

based

on raw

scoremeans.

control, followedbypow erful others. Paired

t

tests indicated

that the means fo r internal control an d control bypowerful

others differed significantly,

t(269)

= 4.41, p < .01. Both

differed greatly

from

chance control: powerful others versus

chance, t(269) = 27.0,p < .001, and intern al versus chance,

t(269) =28.55,p < .001. In sum, our subjects had a stronger

tendency

to attribute health outcomes to their own actions or

to the efforts oftheir doctors th antochance.

Correlations

Among

Variables

Table 3 presents the Pearson correlations among the study

variables. Internal control

w as

related directly

to BSE

fre-

quency

and topaying attention tohealth-related inform ation,

supportingHypotheses 1 and 2. Attestof differences between

dependent

correlations (Cohen & Cohen, 1975, p. 53)indi-

cated that frequency

of BSE

correlated with internal control

more strongly than

it did

with control

by

powerful others,

f(267)

= 2 .11, p < .01. Sim ilarly, attention to h ealth-related

information correlated with

internal

control more strongly

thanit didwith

control

by

powerful others,

t(267) =

4.43,

p

Documents

Role of Health Locus of Control Beliefs in Cancer Screening of Elderly Hispanic Women