Locus of Control Theory: Internal versus External Health Locus of Control as a Moderator of Treatment Adherence in Hypertension and Diabetes Mellitus

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The goal of medicine is to avoid the onset or delay the progression of multiple disease states. As the rate of chronic disease is on the rise, general practitioners are challenged to identify disease states and implement treatment regimens in order to avoid progressive medical sequaelle. Healthcare providers and patients work together to develop treatment plans which may include medication, diet modification, weight loss, smoking cessation, etc in order to avoid secondary health problems. However, treatment plans are only effective when patients consistently comply with healthcare suggestions. Of interest to current review is the psychosocial variable of health locus of control (LOC) and how it moderates patient adherence in hypertensive and type 1 and type 2 diabetic patients. Hypertension and diabetes mellitus are two chronic disease states requiring medication and lifestyle changes to maintain health and delay disease progression. Research reveals that patients exhibit poor adherence in both disease states which may lead to more severe health concerns if unmodified. Research has shown that the psychosocial variable of health LOC plays a role in medication adherence; a relationship deserving more attention to further understand noncompliance. Health LOC is measured using the Multidimensional Health Locus of Control (MHLC) Scale. The MHLC Scale used in research has demonstrated that an internal LOC is positively correlated with higher medication adherence as well as certain modes of behavior modification. Even when barriers to medication compliance are present, a high internal LOC mediates compliance until barriers become too numerous for coping. Administering the MHLC Scale in inpatient/outpatient settings allows the practitioner to individualize patient education in an effort to increase medicinal adherence. Knowledge of internal versus external LOC in regards to health maintenance allows physicians to predict noncompliance, monitor patient progression more closely, and continue educating and encouraging patients who have difficulties adhering to provider treatment plans.

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Introduction In times of modern medicine, it is of no surprise that people are enjoying high quality lifestyles with longer life expectancies. Technology has allowed healthcare providers to identify and diagnose disease states earlier, perform invasive surgeries with limited hospital stay, and treat illnesses with self-administered pharmaceutical therapies. Maintenance of health status requires patient responsibility with the advancement of medicine. In chronic disease states or illnesses, the key to health improvement is patient compliance with treatment plans. According to Haynes et al, patient compliance is defined as “the extent to which a person‟s behavior (in terms of taking medication, following a diet, modifying habits or attending clinics) coincides with medical or health advice” [1]. The term compliance is oftentimes used interchangeably with adherence; although compliance oftentimes suggests a paternalistic relationship between healthcare provider and patient [1]. In this review of literature, the terms will be used interchangeably. Depending on the disease state, healthcare providers may prescribe multiple drug therapies, weight loss, smoking cessation, regular office visits, increase exercise, to maintain health. Willingness to adhere with treatment plans varies between individuals and may include the following reasons: co-morbidities, multiple medications, adverse effects of drugs, cost of therapy, beliefs regarding health outcomes, patient education [1]. In general, patient noncompliance results in a mismatch of the provider‟s treatment goals with patient willingness to follow a treatment plan. As healthcare providers, it is important to recognize that patients may not adhere to treatment plans aimed at health improvement. In fact, research shows that certain disease processes maintain higher rates of patient adherence than others. Briesacher et al conducted a study to determine drug adherence rates among patients with chronic disease entities including gout, hyperlipidemia, hypertension, hypothyroidism, osteoporosis, seizure disorder, and type 2 Page 3

diabetes mellitus [2]. Complete data included year long medication compliance rates for 706,032 newly diagnosed adult patients with one of the listed chronic diseases [2]. Medication adherence was measured in terms of a medication possession ratio (MPR); the number of days‟ drug supply dispensed divided by the total number of days in a year [2]. Results suggest that 8090% of patients maintained the following MPRs: gout (36.8%), hyperlipidemia (54.6%), hypertension (72.3%), hypothyroidism (68.4%), osteoporosis (51.2%), seizure disorder (60.8%), and type 2 diabetes mellitus (65.4%) [2]. This study addressed adherence rates to medication only; lifestyle modifications were not included as measures of patient adherence. Treatment plans involving medication and lifestyle modification provide anticipated results when implemented consistently. Therefore, understanding patient noncompliance to treatment plans is crucial, especially involving chronic disease states. Chronic disease is the leading cause of death in the United States [3]. Stroke, heart disease, diabetes, cancer, and arthritis are common chronic diseases that are costly and preventable [3]. Treatment plan noncompliance allows these diseases to become severely debilitating while decreasing quality of life. Theoretical approaches, grounded in behavioral psychology and social learning theory, have been employed to study patient adherence in various chronic disease states. Of interest to current review is the Locus of Control (LOC) theory and how it applies to adherence in two chronic disease states: hypertension and diabetes mellitus. Background How does LOC theory affect adherence in patients with hypertension and diabetes mellitus? In order to understand the research surrounding this question, it is important to have a working knowledge of LOC theory, hypertension, and diabetes mellitus. The theory of LOC was developed in 1954 by Julian B. Rotter [4]. Individuals are labeled based on two belief systems:

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external control versus internal control [4]. According to Connolly, LOC theory involves a “key link…between behavior and its consequence, and the relationship between outcomes and personal effort” [5]. Individuals maintaining an external LOC believe the consequences of their behaviors are “a direct consequence of luck, chance, or fate” [4]. Regardless of the consequence following behavior, positive or negative, behavior modification is unlikely due to attribution of consequences to bad luck or fate [4]. Persons with an internal LOC believe the consequences of their actions are a result of hard work, effort, or ability [4]. Negative consequences following behavior are more likely to result in behavioral modification [4]. The individual with internal LOC is prone to repeat behaviors resulting in positive outcomes [4]. The positive reinforcement maintaining behavior is derived from the belief that hard work and ability leads to desired positive outcomes [4]. LOC theory underlies patient adherence in terms of an individual‟s health care beliefs and attitudes towards health maintenance [6]. A patient‟s perception of personal ability to control future health may act as a predictor of adherence to treatment recommendations [6]. For example, an individual with external LOC may be less likely to comply with medical treatment as he or she believes the course of disease is uncontrollable. This individual would attribute advances or declines in health to natural remission or progression of disease. In contrast, an individual with internal LOC may be more willing to follow treatment recommendations as he or she believes the path of disease progression may be controlled via personal ability and action; action in this sense referring to adherence. LOC is measured using one of three versions of the Multidimensional Health Locus of Control (MHLC) Scale; Form A, B, or C [7]. Forms A and B have been used since the mid1970‟s and assess attitudes or beliefs towards health in general [7]. Both questionnaires require

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responses to 18 statements; 6 statements devoted to each of the following types of LOC: internal (IHLC), powerful others (PHLC), and chance (CHLC) [7]. PHLC and CHLC are measures of external LOC in regards to who or what controls behavior choices [7]. Form C of the MHLC is composed of 18 statements used to assess LOC in regards to specific diseases or illnesses [7]. Table 1 is a sample of the MHLC Form C questionnaire. Forms A, B, and C each measure IHLC, CHLC, and PHLC; with Form C splitting the 6 PHLC to assess the influence of specific persons: doctors versus others [7]. Participants completing any version of the MHLC respond on a 1 to 6 Likert Scale grading opinions from 1= strongly disagree to 6= strongly agree [7]. As each category of LOC is independent of the others, there is not a total score for LOC [7]. IHLC, PHLC (doctor and others), and CHLC have their own scores ranging from 6 to 36 with higher scores indicative of patient alignment with the specific LOC in question [7]. Table 2 illustrates the scoring schema of Forms A, B, and C with regards to which statements reflect opinions of each LOC subtype [7]. Hypertension affects 1 of 3 adults in the United States [8]. A blood pressure reading consists of two numbers: systolic and diastolic pressures [8]. Systolic blood pressure refers to the force of blood exerted against arterial walls while the heart is contracting [8]. Diastolic blood pressure is the force of blood exerted against arterial walls while the heart is at rest [8]. Hypertension may present with few or no symptoms, and is oftentimes referred to as the “silent killer” when the end result is heart disease or stroke [8]. The Center for Disease Control (CDC) recommends the following guidelines for patients diagnosed with hypertension: 1) balanced diet including fruits, vegetables, and fiber; 2) limited sodium and alcohol intake; 3) maintain a healthy weight; 4) exercise for 30 minutes on most days; 5) discontinue tobacco product use; 6) medication adherence; and 7) blood pressure journaling [8]. As healthcare providers, it is

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important to encourage hypertensive patients to incorporate the above guidelines into a treatment plan. Diabetes mellitus is a chronic disease identified by an elevated serum glucose level [9]. Diabetes is divided into two subtypes, type 1 and type 2, which differ in the mechanism causing elevated serum glucose levels [9]. Type 1 diabetes mellitus is oftentimes diagnosed during childhood or adolescence [9]. This disease is a result of an autoimmune attack of pancreatic beta islet cells which are responsible for insulin secretion [9]. After food is properly digested, insulin is responsible for the transfer of glucose from the blood stream into body cells for future use [9]. Type 1 diabetics must receive exogenous insulin injections in order to process glucose molecules effectively [9]. Type 2 diabetes is a disease that can affect individuals of any age [9]. The disease occurs as fat, muscle, and liver cells become less sensitive to the effects of insulin [9]. The pancreas of the type 2 diabetic initially secretes more insulin in order to counteract decreased insulin sensitivity exhibited by body tissues; however, the pancreas fails to keep up with the daily demand [9]. Signs and symptoms of type 1 and type 2 diabetes mellitus include increased micturation and thirst, peripheral neuropathy, and increased serum glucose levels [9]. Treatment plans for diabetics include oral medications or insulin injections, multiple daily finger sticks for serum glucose monitoring, diet modification, exercise, regular foot inspection, and monitoring of blood pressure and cholesterol levels [9]. Patients diagnosed with hypertension or diabetes mellitus have been informed of bodily malfunction. Fortunately, treatment plans have been developed to maintain health or slow progression of chronic disease. Patients also have the ability to monitor hypertension and diabetes mellitus daily. Automatic sphygmomanometers provide accurate systolic and diastolic

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blood pressure readings within minutes, and blood glucose monitors provide serum glucose readings with a single finger stick. Medicines, diet recommendations, exercise plans, and disease state monitoring technologies are available; however, these interventions are not efficacious if the patient is noncompliant. Review of Literature: LOC and Hypertension Medication Adherence A study conducted by Hong et al sought to illustrate the role of LOC as a moderating factor between medication barriers and anti-hypertensive medication adherence [10]. Medication barriers, such as adverse side effects, medication forgetfulness, and multiple daily medicinal administrations, are associated with poor medication adherence [10]. LOC also mediates patient adherence; individuals maintaining high internal health LOC have been associated with greater medication adherence [10]. The underlying hypothesis of research suggests high internal health LOC mediates medication adherence regardless of medication barriers present [10]. In this study 588 hypertensive U.S. veterans were surveyed regarding medication adherence, medication barriers, and LOC [10]. Medication adherence was self reported using the four item Morisky Self-reported Medication-Taking Scale [10]. A nine item medication barrier survey rated patient responses from 1 (“definitely false”) to 4 (“definitely true”) in reference to personal experience of adverse side effects, forgetting to take medications, misunderstanding how to take pills, etc [10]. Higher scores represented the presence of multiple medication barriers. Internal LOC was assessed with three questions requiring an “agree” or “disagree” response. Internal locus of control was measured with the following statements: “ „The main thing which affects my high blood pressure is what I myself do,‟ „If I take the right actions, I can

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maintain my blood pressure control,‟ and „I have control over lowering my blood pressure.‟” [10]. Regression analysis was used to analyze the data. Initial regression analyses revealed that LOC and medication barriers have an effect on medication adherence; specifically, higher internal LOC and lower medication barriers were associated with increased scores of medication adherence [10]. In attempt to illustrate medication adherence as a function of LOC, the sample was divided into three groups based on LOC score [10]. The three internal locus of control groups were high (mean score + 1 standard deviation), medium (mean score), and low (mean score - 1 standard deviation) [10]. Separation into groups revealed significant differences in medication adherence as the number of perceived barriers increased [10]. High internal control subjects had significantly increased medication adherence with low medication barriers [10]. However, this group achieved lowest adherence rates as the number of barriers increased [10]. In comparison, low internal control subjects maintained low medication adherence with few barriers, but with an increase in barriers, medication adherence also increased [10]. Medium internal control subjects maintained average adherence regardless of the number of medication barriers [10]. Although it was expected that high internal control subjects maintain adherence despite medication barriers, Hong et al. suggest individuals discontinue medication usage when overwhelmed with numerous stressors and feelings of lack of control [10]. With discontinued medication use, drug adverse side effects are no longer experienced and further encourage drug abstinence [10]. Based on these findings, Hong et al. suggest that specific levels of internal control may be more or less adaptive depending on the number of medication barriers as a function of medication adherence [10]. Review of Literature- LOC and Diabetes Medication Adherence

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A study conducted by O‟Hea et al. examined 109 medically underserved type 2 diabetics to determine if an interaction occurred between two social learning theories in predicting future health behavior [11]. Rotter‟s Locus of Control theory was integrated with Bandura‟s Social Congnitive Theory to determine if an interaction exists between the independent variables of locus of control, self-efficacy, and outcome expectancy in predicting glycosylated hemoglobin (HbA1c) levels, a measure of treatment adherence and diabetes control [11]. Hypothesized results included a three-way interaction between locus of control, self-efficacy and outcome expectancy, in regards to HbA1c levels in type 2 adult diabetics [11]. Greater predictive value of future HbA1c levels was expected when all three perceptions of control were integrated versus single factors alone. Participants in this study were diagnosed with type 2 diabetes for at least one year, and were maintained on oral diabetic medications for at least six months [11]. Measurements included perception of LOC, self efficacy, and outcome expectancies via two questionnaires [11]. The MHLC Scale was used to assess LOC perceptions. The Multiple Diabetes Questionnaire (MDQ) is a three sectioned survey assessing multiple aspects of diabetes perceptions and self care; of which, researchers were interested in self efficacy and outcome expectancy in regards to personal treatment [11]. The dependent variable of treatment plan adherence was measured via serum HbA1c levels [11]. HbA1c is a 3 month average of serum glucose and is affected by diet, exercise, and oral medication adherence [11]. Diabetics with HbA1c values between 4%-7% have demonstrated appropriate treatment adherence; while values greater than 7% are indicative of poorly managed diabetes [11]. Based on the results of each questionnaire, the participants averaged values indicative of high internal control, high outcome expectancy, and low self-efficacy [11]. This finding

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suggests that participants 1) believe they are in control of the progression and maintenance of their illness, 2) agree that following healthcare provider advice would lead to diabetes control, and 3) exhibit a lack of confidence which interferes with their ability to maintain treatment plans [11]. Results also indicate a moderate three-way interaction between LOC, self-efficacy, and outcome expectancy in regards to HbA1c levels [11]. Specifically, in individuals with high internal LOC (belief in ability to control health), low self-efficacy (lack of confidence in complying with treatment plan), and low outcome expectancy (following a treatment plan will not better the condition), HbA1c levels improve [11]. However, high internal control associated with low self-efficacy and high outcome expectancy revealed increased HbA1c, poor regimen adherence [11]. Although the average participant fell into the latter described category, knowledge regarding internal locus of control, self-efficacy, and outcome expectancy may be useful in predicting and encouraging treatment adherence in practice. Review of Literature- LOC and Lifestyle Modification Although medication adherence limits disease progression, treatment plans for hypertension and diabetes mellitus also involve lifestyle and behavior modification. A combination of drug therapy and lifestyle modification maximizes results in regards to health promotion and disease prevention. How does LOC theory apply to alterations in diet, exercise habits, sleep patterns, and smoking cessation? A study conducted by Bell et al. examined the relationship between health LOC and preventive behaviors in a sample of elderly rural Caucasian, African American, and Native Americans [12]. This study used three subscales of the MHLC Scale to assess level of adherence to weight loss, hypertension, diabetes, and exercise regimens [12]. Researchers hypothesized that subjects with greater internal LOC were more

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likely to participate in extra-medicinal measures of health maintenance, with a difference existing cross-culturally [12]. Over the course of one year, 76 participants completed three interviews and questionnaires required for complete data analysis [12]. The baseline interview collected general demographic information, mental and physical health scores, and information regarding eating habits and frequency [12]. Six months later, a second interview was administered to gather information regarding preventive health practices [12]. The following preventive practices were assessed: 1) diet (consumption of fat, sodium, fiber, cholesterol, and vitamins), 2) tobacco and alcohol use (amounts per day), 3) lifestyle (measures of stress, sleep, medication adherence), 4) accidents (steps taken to reduce falls in the home, use of smoke detectors and seatbelts), 5) activity and weight (maintenance of an exercise program and normal weight), and 6) overall health care (regular dental exams, blood pressure check, eye exam, and annual physical) [12]. After one year‟s time, the final interview measured health LOC with the MHLC questionnaire [12]. Responses to the 18 questions categorized subjects into one of the following subtypes of LOC; internal LOC, powerful others LOC, or chance LOC [12]. Data analysis was completed using hierarchical data regression to assess the predictive nature of LOC over twenty-two preventive health measures [12] Results of data collection suggest that individuals with an internal health LOC were more likely to be male, married, and had perceptions of being in good/excellent health [12]. An external LOC, associated with powerful others or chance, was found most commonly in women with less education and poor perceptions of health [12]. Interestingly, no significant differences in health LOC existed between Caucasians, African Americans, and Native Americans [12]. Preventive health measures associated with greater internal health LOC included limiting sugar

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intake, consumption of adequate fiber, sleeping at least seven hours each night, and using smoke detectors in the home [12]. Inverse relationships existed between powerful others and chance LOC and included taking a multivitamin daily and participating in regular exercise [12]. Although the results were obtained from an elderly sample, the relationships demonstrated between health LOC and preventive health behaviors is useful in identifying patients likely to benefit from a combination of medicinal and behavioral treatment plans in controlling chronic disease. In a study conducted by Richard Shipley, the effects of follow-up letters and health locus of control were examined in regards to maintenance of smoking cessation [13]. At baseline, forty-three participants completed a MHLC Scale [13]. Subjects were separated into one of three categories of LOC: IHLC (internal), PHLC (powerful others), and CHLC (chance) [13]. PHLC is a category of external LOC where individuals believe powerful others have control over their health behaviors, whereas CHLC is an external LOC in which individuals believe chance or fate controls their health behaviors [13]. Anticipated results included: 1) greater smoking cessation maintenance in subjects with an internal LOC and 2) maintained smoking cessation in PHLC participants receiving motivational follow-up letters from providers [13]. All participants completed a week long smoking cessation program which included aversive stimuli to smoking, group discussion therapy, and relaxation technique training [13]. The experimental group received supportive follow-up letters for 3 months post-smoking cessation week [13]. Self-reported smoking behaviors were gathered at 3 and 6 months post treatment; additionally, participants reported number of weekly cigarettes at 6 months [13]. At the 6 month follow-up, a carbon monoxide breath test was performed on subjects which correlated well with self-reported smoking behaviors [13]. Six months after treatment, the

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experimental group smoked 49% of baseline number of cigarettes while the control group smoked 48% of baseline reported cigarettes [13]. Main effects were produced in the comparison of IHLC and CHLC individuals; internals versus chance were 47% as compared to 17% abstinent at 3 months [13]. The PHLC scale was shown to interact with letter receipt; individuals believing that powerful others do not control their behavior were more likely to smoke cigarettes as compared to high PHLC scorers receiving motivational letters [13]. Overall, internal LOC and low scorers on CHLC benefitted most from smoking cessation treatment, regardless of motivational letter receipt [13]. Discussion One of the most important qualities that a healthcare provider can possess is the ability to identify nonadherent patients in practice. According to Burke and Ockene, three simple strategies can be used to detect noncompliant patients: 1) missing appointments, 2) nonresponders to treatment therapies, and 3) simply asking patients about medicinal adherence [1]. Healthcare providers who identify nonadherent patients have the ability to intervene before secondary healthcare problems arise. After identifying a nonadherent patient, identify the underlying cause of poor treatment compliance. Administering Form C of the MHLC Scale provides insight as to the reinforcing motivators of health specific behavior maintenance. Nonadherent patients scoring high on internal health LOC may require further explanation of their particular disease state to motivate health behavior modification. Nonadherent patients scoring high on powerful others external LOC may require step-by-step specific instructions from a health care professional regarding the importance of recommended health maintenance behaviors. Nonadherent patients scoring high on chance external LOC may require stringent counseling to avoid poor health outcomes.

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Identifying a patient in regards to LOC guides patient counseling with the proposed result of increased patient compliance.

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References

1.

Burke, L.E. and I.S. Ockene, Compliance in healthcare and research. Compliance in healthcare and research. 2001, Armonk, NY US: Futura Publishing Co.

2.

Briesacher, B.A., et al., Comparison of Drug Adherence Rates Among Patients with Seven Different Medical Conditions. Pharmacotherapy, 2008. 28(4): p. 437-443.

3.

Chronic Diseases and Health Promotion. [website] 2009 December 17, 2009 [cited 2010 November 3, 2010]; Available from: http://www.cdc.gov/chronicdisease/overview/index.htm.

4.

Marks, L.I., Deconstructing Locus of Control: Implications for Practitioners. Journal of Counseling & Development, 1998. 76(3): p. 251.

5.

Connolly, S.G., Changing Expectancies: A Counseling Model Based on Locus of Control. Personnel & Guidance Journal, 1980. 59(3): p. 176.

6.

Cameron, C., Patient compliance: recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. Journal of Advanced Nursing, 1996. 24(2): p. 244-250.

7.

Ken Wallston, P. Multidimensional Health Locus of Control (MHLC) Scales. [Website] June 15, 2007 [cited 2010 November 28]; Available from: http://www.vanderbilt.edu/nursing/kwallston/mhlcscales.htm.

8.

High Blood Pressure. [website] 2010 February 1, 2010 [cited 2010 November 6]; Available from: http://www.cdc.gov/bloodpressure/about.htm.

9.

Diabetes Overview. 2008 November 2008 [cited 2010 October 30]; Available from: http://www.diabetes.niddk.nih.gov/dm/pubs/overview/index.htm.

10.

Hong, T.B., et al., Medication barriers and anti-hypertensive medication adherence: The moderating role of locus of control. Psychology, Health & Medicine, 2006. 11(1): p. 20-28.

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11.

O'Hea, E.L., et al., The interaction of locus of control, self-efficacy, and outcome expectancy in relation to HbA1c in medically underserved individuals with type 2 diabetes. Journal of Behavioral Medicine, 2009. 32(1): p. 106-117.

12.

Bell, R.A., et al., Health Locus of Control Among Rural Older Adults: Associations with Demographic, Health and Preventive Health Characteristics. Gerontology & Geriatrics Education, 2002. 22(4): p. 69-89.

13.

Shipley, R.H., Maintenance of smoking cessation: Effect of follow-up letters, smoking motivation, muscle tension, and health locus of control. Journal of Consulting and Clinical Psychology, 1981. 49(6): p. 982-984.

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Table 1: Form C of the Multidimensional Health Locus of Control (MHLC) Scale [7]. 1=STRONGLY DISAGREE (SD) 2=MODERATELY DISAGREE (MD) 3=SLIGHTLY DISAGREE (D)

4=SLIGHTLY AGREE (A) 5=MODERATELY AGREE (MA) 6=STRONGLY AGREE (SA) SD MD D A MA SA

1

If my condition worsens, it is my own behavior which determines how soon I will feel better again.

1

2

3 4

5

6

1

2

3 4

5

6

1

2

3 4

5

6

1

2

3 4

5

6

Whenever my condition worsens, I should consult a medically trained 1 professional.

2

3 4

5

6

1

2

3 4

5

6

1

2

3 4

5

6

8 Whatever goes wrong with my condition is my own fault.

1

2

3 4

5

6

9 Luck plays a big part in determining how my condition improves.

1

2

3 4

5

6

2 As to my condition, what will be will be. 3

If I see my doctor regularly, I am less likely to have problems with my condition.

4 Most things that affect my condition happen to me by chance. 5

6 I am directly responsible for my condition getting better or worse. 7

Other people play a big role in whether my condition improves, stays the same, or gets worse.

10

In order for my condition to improve, it is up to other people to see that the right things happen.

1

2

3 4

5

6

11

Whatever improvement occurs with my condition is largely a matter of good fortune.

1

2

3 4

5

6

1

2

3 4

5

6

13

I deserve the credit when my condition improves and the blame when 1 it gets worse.

2

3 4

5

6

14

Following doctor's orders to the letter is the best way to keep my condition from getting any worse.

1

2

3 4

5

6

15 If my condition worsens, it's a matter of fate.

1

2

3 4

5

6

16 If I am lucky, my condition will get better.

1

2

3 4

5

6

12 The main thing which affects my condition is what I myself do.

17

If my condition takes a turn for the worse, it is because I have not been taking proper care of myself.

1

2

3 4

5

6

18

The type of help I receive from other people determines how soon my 1 condition improves.

2

3 4

5

6

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Table 2: Scoring schema for Forms A, B, and C of the MHLC Scales SUBSCALE Internal

FORM(s) A, B, C

POSSIBLE RANGE ITEMS 6 - 36 1, 6, 8, 12, 13, 17

Chance

A, B, C

6 - 36

2, 4, 9, 11, 15, 16

Powerful Others

A, B

6 - 36

3, 5, 7, 10, 14, 18 3, 5,

Doctors

C

3 - 18

Other People

C

3 - 18

14 7, 10,

18

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