role of health locus of control beliefs in cancer screening of elderly hispanic women
TRANSCRIPT
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8/11/2019 Role of Health Locus of Control Beliefs in Cancer Screening of Elderly Hispanic Women
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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
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8/11/2019 Role of Health Locus of Control Beliefs in Cancer Screening of Elderly Hispanic Women
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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.
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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
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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