Insights into the Health Control Beliefs of American Samoans, 2009, Sara Krosch

AMERICAN SAMOA COMMUNITY CANCER NETWORK

Insights into the Health Control Beliefs of American Samoans Results of an Adapted Multidimensional Health Locus of Control Survey Sara Krosch amsamccn@gmail.com

2009

TOWARDS THEORY‐BASED INTERVENTIONS

Table of Contents Introduction .............................................................................................................................................................................................................. 3 Purpose .......................................................................................................................................................................................................... 3 Previous Research .......................................................................................................................................................................................... 3 Figure 1: M‐HLoC Profiles for Samoan Male ASCCN Prostate Clinic Attendees 2006‐07 ......................................................................... 5 The Multidimensional Health Locus of Control Survey .............................................................................................................................................. 6 Health Control ................................................................................................................................................................................................ 6 Locus of Control and Classification ................................................................................................................................................................. 6 Table 1: Four Loci of the Health Control .................................................................................................................................................. 6 Table 2: Individual Classifications based on M‐LoC Scores ..................................................................................................................... 7 The God Locus of Control ............................................................................................................................................................................... 7 Using M‐HLoC Scores to Predict Behaviors .................................................................................................................................................... 7 Table 3: Coping Styles & Perceptions of Active/Passive Self and God ..................................................................................................... 9 Self‐Efficacy ............................................................................................................................................................................................................... 9 Methodology ........................................................................................................................................................................................................... 10 Hypotheses .............................................................................................................................................................................................................. 11 Survey Results ......................................................................................................................................................................................................... 12 Respondents’ Demographics ........................................................................................................................................................................ 12 Tables 4‐8 Respondents’ Demographics ................................................................................................................................................ 12 Respondents’ M‐HLoC Profiles ..................................................................................................................................................................... 13 Figure 2: Average M‐HLoC Scores for All Females & All Males .............................................................................................................. 13 Table 9: Female Age Groups: M‐HLoC Survey Item Results ................................................................................................................... 14 Figure 3: Average M‐HLoC Scores for All Females & Female Age Groups .............................................................................................. 14 Table 10: Female Education Groups: M‐HLoC Survey Item Results ....................................................................................................... 15 Figure 4: Average M‐HLoC Scores for All Females & Female Education Groups .................................................................................... 15 Table 11: Female Cancer Status: M‐HLoC Survey Item Results .............................................................................................................. 16 Figure 5: Average M‐HLoC Scores for All Females, Female Cancer Survivors (n=9) & Female Family Cancer Survivors (n=53) ............ 16 Table 12: Male Age Groups: M‐HLoC Survey Item Results ..................................................................................................................... 17 Figure 6: Average M‐HLoC Scores for All Males & Male Age Groups ..................................................................................................... 17 Table 13: Male Education Groups: M‐HLoC Survey Item Results ........................................................................................................... 18 Figure: 7: Average M‐HLoC Scores for All Males & Male Education Groups .......................................................................................... 18 Table 14: Male Cancer Status: M‐HLoC Survey Item Results ................................................................................................................. 19 Figure 8: Average M‐HLoC Scores for All Males & Male Family Cancer Survivors (n=26) ...................................................................... 19 Findings Summary ................................................................................................................................................................................................... 20 Figure 9: M‐HLoC Items Scores ‐ All Females & All Males ...................................................................................................................... 20 Hypotheses Results ................................................................................................................................................................................................. 22 Using M‐HLoC Results ............................................................................................................................................................................................. 22 Figure 10: The Health Belief Model ....................................................................................................................................................... 23 Works Cited ............................................................................................................................................................................................................. 24

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Introduction Purpose The mission of the American Samoa Community Cancer Network (ASCCN) is to reduce health disparities that contribute to increased cancer incidence, morbidity and mortality in American Samoa via research and the support of partners who provide education and services.

The survey reported in this document specifically aimed to understand the health control beliefs of different segments of the American Samoa population in order to plan theory‐based health promotion interventions.

A health promotion theory provides a systematic way to understand situations by explaining relationships between variables. Models draw on several theories to understand a particular problem in a certain setting. Theories and models are used to understand why a specific group behaves a certain way and to plan the most effective strategies and messages for health programs (NCI, 2005).

Previous Research To date, the ASCCN has not focused on health promotion theories or models to guide program development or evaluation. However, ASCCN researchers and others have conducted measures to better understand the population’s health awareness, knowledge, and behaviors.

Focus groups facilitated by the ASCCN in 2006 found that the majority of American Samoans feel cancer is a new phenomenon stating that there is no Samoan word for the disease and they never heard about cancer when they were young. Participants had negative and fatalistic associations with cancer. Cancer meant hopelessness, worry, and that death was near. Fear of the disease deterred people from screening or follow‐up hospital visits. There was widespread knowledge of smoking leading to cancer, but beliefs about what causes other cancers were highly varied—not taking local herbal medicine in time when feeling ill, a punishment from God, a result of spirit possession, or tuberculosis. Several participants felt that cancer was caused by germs or uncleanliness. Others believed the disease is linked to a shift in diet from traditional foods to processed foods containing “chemicals and preservatives.”

The mystery surrounding what causes cancer to lead many towards religious comfort evidenced in the following quotations from focus group participants:

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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“Because the disease is new we go to the doctor or to the Lord. The Lord is the only cure. The Father in Heaven is the Doctor of all doctors.”

“If I were diagnosed I would rely on God.” “[If diagnosed], all we can do is pray.”

People report receiving information about cancer from four equally mentioned sources: the hospital, Samoan “doctors” (Taulasea/Fofo), church pastors, and those already diagnosed with cancer and their families (Krosch, 2008).

The Samoan way of life (fa’aSamoa) consists of a chief system responsible for the organization and leadership of family and villages, family‐based activities (including diet), churches and religious beliefs.

Emphasis is placed on living one’s life to the benefit of the greater family. It is largely dictated by males, traditional leaders (matais) and church ministers age 50 and older. A qualitative study with this target group, none of whom were cancer survivors, reported that disease prevention is not part of the fa’aSamoa. Preventative care is difficult to get because health providers are not oriented towards prevention in American Samoa (Hubbell, et al., 2005). They stated that “fa’aSamoa is based on fear and respect” and it negatively influences the population by reinforcing and perpetuating shame/embarrassment and a reluctance to discuss personal (bodily) issues. Samoans remain silent due to ignorance of the disease and out of “respect for the doctor.” They “refuse treatment out of pride” and seek it “only when they are near their death bed (Puaina, et al., 2008).

Studies have shown that American Samoans believe failure to follow the fa’aSamoa—characterized by eating unhealthy foods (high‐fat, imported, canned, refrigerated), smoking cigarettes, drinking too much alcohol, breathing polluted air, and general neglect of one’s body—could lead to cancer and that a return to the fa’aSamoa could prevent cancer (Hubbell, et al., 2005; Puaina, et al., 2008). This complements the beliefs that cancer is not “part of Samoan culture” and that it is a relatively new disease brought by Westerners or brought on by western ways (APIAHF, 2006; Hubbell, et al., 2005; Puaina, et al., 2008).

Cancer may also be God’s will. Some Samoan ministers explain cancer as an “act of God” or that “people made it God’s will by participating in unhealthy or unwise behaviors and that God’s will should be accepted to avoid worry and anger. Few believe that spirits (aitu—the cause of most illnesses in traditional Samoan culture) cause cancer (Hubbell, et al., 2005) ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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To further explore these notions about perceived health control related to cancer, namely the influence of Powerful Others (the pillars of fa’aSamoa) and God, and the tug of war between Chance and Internal will (linked to many causes of cancer that are perceived to be within or beyond and individual’s control), an adapted Multidimensional Health Locus of Control survey was administered to 15 Samoan males age 40 or older in 2008 who had attended prostate cancer education sessions and screening clinics in 2006‐ 07. The men were divided into three groups of five based on their screening behaviors and test results: (1) Low PSA Men who had screened once and were at low risk for prostate cancer—low prostate‐ specific antigen (PSA) scores; (2) Repeat PSA Men with low PSA results scores who had repeatedly screened for prostate cancer over the project period; and (3) High PSA Men most at risk for prostate cancer and who had been referred for further screening.

Figure 1: M‐HLoC Profiles for Samoan Male ASCCN Prostate Clinic Attendees 2006‐07

% in Agreement

100 80 Internal 60

Powerful Others

40

God

20

Chance

0 Low PSA

Repeat PSA

High PSA

Results from this small sample showed all three groups felt control over their health was mostly under Internal control (Internal scores highest). The most distinct differences were seen in the Repeat PSA group which had the highest possible Internal score (100%) while the other domains were influential to only half of this group. See Figure 1 above. What is unknown is whether the Repeat PSA Men had high perceived Internal control that prompted them to screen for cancer given the opportunity or did this group develop higher Internal control as a result of added awareness, knowledge and screening experience. Men with the highest PSA scores felt that many forces were responsible for their health as shown by their equal Internal, Powerful Others and Chance scores. Interestingly their God domain scored lowest.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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In order to further explore health control beliefs amongst the broader American Samoa population, 200 residents were surveyed using the same adapted Multidimensional Health Locus of Control survey completed by male prostate clinic attendees with a specific aim of gaining insight into relative levels of active and passive health control beliefs and behaviors in females and males age 13‐75.

The Multidimensional Health Locus of Control Survey Health Control When individuals are able to influence or determine what is happening to them, or will happen to them, they are “in control.” Beliefs about control in the context of health refer to the thoughts an individual has about her/his ability to influence health behaviors, health status, health outcomes and/or health care. Personal control is usually linked to positive health outcomes (Wallston, et al, 1991). However, when one lacks actual control over health matters the perception of being in control is often sufficient to reap benefits (Wallson, 2004).

Locus of Control & Classification Julian Rotter first coined the term “locus of control” (location) in 1966 as part of his Social Learning Theory referring to an individual’s belief as to whether control over health outcomes lies internally (a consequence of what one does) or externally (due to the actions of other people or due to chance).

In the mid 1970’s, Kenneth Wallston and colleagues developed the Multidimensional Health Locus of Control (M‐HLoC) scales (Wallston, 2004). They measure a respondent’s beliefs about four domains of influence over general health: Table 1: Four Loci of the Health Control (Source Wallston, et al. 1991) Domain Type Internal External

Locus Name Internal Powerful Others

External

Chance

Internal or Internal/External Collaborative

God

Description personal control over health status and outcomes health care professionals, family, friends, and influential others control over health Fate, luck or unchangeable/unexplainable reasons for health status and outcomes A supreme being’s control over one’s health status and outcomes

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Today, the M‐HLoC is one of the most widely used health belief measurements for the planning of health education programs (Moshki, 2007). The original M‐HLoC scale included three loci: Internal, Powerful Others and Chance. These dimensions were used to classify individuals in to 1 of 8 ‘types’ in order to predict behavior and thought patterns relevant to mental and physical health (Masters and Wallston, 2005; Wallston, et al., 1999).

Table 2: Individual Classifications based on M‐LoC Scores (Source: Masters and Wallson, 2005) Example Classifications

Internal Score

Powerful Others Score

Chance Score

“Pure Internal”

High

Low

Low

“Believer in Control”

High

High

Low

“Nay‐Sayer”

Low

Low

Low

The God Locus of Control In response to cancer studies and other research into chronic disease, Wallston and colleagues (1999, 2005) added a forth locus, the God Locus of Health Control (GLoC), to assess the extent to which people attribute their health status to a supreme being. The GLoC scale items can be used along with the original M‐HLoC or as a separate instrument. The God control dimension may represent either an external or an internal‐collaborative locus.

Using M‐HLoC Scores to Predict Behaviors It is most important for the individual to believe that health behavior control exists. Only then does the place where the control resides, the locus, become a factor in predicting behaviors. Consistent findings have shown that high Internal HLoC correlates with carrying out recommended health behaviors and self‐reported good health status whereas high Chance HLoC is related to depression and other psychological distress. Further, in most populations, Internal and Powerful Others scores are uncorrelated, Internal and Chance scores are negatively correlated (when one variable increases the other deceases) and Powerful Others and Chance are positively correlated (when one variable increases or decreases the other variable also increases or decreases) (Wallston, 2004).

Masters and Wallston (2005) performed comparisons (canonical correlations) to show relationships between the different loci of health control and other health and quality of life measures such as

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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positive and negative affect 1 , coping, and values. Their research aims to help predict thought and behavior patterns: Positive/Negative Affect •

collaborative control between Internal and God relates to high positive affect (better mental and physical health) and low negative affect in generally healthy populations

Coping •

high God control indicates high use of religious coping (active in religion and frequent prayer)

•

high Powerful Others and Chance scores are related to passive coping strategies 2

•

high Powerful Others and Chance scores correlate with use of venting, non‐acceptance of responsibility, self‐blame and humor as coping strategies

•

high Internal control is related to healthy or active coping strategies 3

•

individuals who value health and have high Internal scores are likely to be active copers

Values •

high Internal control is correlated with happiness and good health

•

high God control indicates high value placed on religion/spirituality

•

low God and Chance control are related to high value of inner harmony and low value of an exciting life and social recognition

In particular, Wallston and associates (1999) found that a subject’s age, gender or income level have no significant relationship with God LoC scores but this locus is significantly negatively correlated with level of education—higher education is related to lower GLoC scores. 4 The GLoC is significantly positively correlated with Powerful Others survey items (other than item specifically about Doctors) meaning people with high God scores also tend to perceive sources of health control in the non‐health professional people in their lives. God control is unrelated with Internal and Powerful Others items related to Doctors. The GLoC is also significantly positively correlated with Chance.

1

High positive affect shows a person is enthusiastic, alert, active, and energetic, has high concentration, and enjoys interacting with others.

Low positive affect indicates sadness and lethargy. High negative affect indicates a person who feels distressed, depressed, angry, fearful and/or nervous. Low negative affect score reflect calmness and serenity (Masters and Wallston, 2005).

2 Passive coping strategies include behavioral disengagement, emotional support and self‐distraction.

3 Active coping included active behavior change and positive reframing.

4 This finding is consistent with surveys showing that highly educated people tend to be less religious (Wallston, et al., 1991).

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Higher GLoC scores are related to poorer adjustment to chronic illness in these populations whereas high GLoC scores are associated with healthy behaviors in generally healthy populations. (Wallston, et al., 1991). To further understand these findings we can look to Hathaway and Pargament’s research (1991) about the relationship between beliefs about God and coping strategies. They describe three coping styles: Table 3: Coping Styles & Perceptions of Active/Passive Self and God (Source: Hathaway and Pargament, 1991)

Coping Style Deferred Style Self‐directed Style

Collaborative Style

Description Passive self, coping is under God’s active control Active self, passive God

Health Outcome Poorer adjustment to stress Positive adaption

Self and God are active, working together to Positive adaption cope with stressor

Masters and Wallston (2005) suggest that the GLoC score be considered in light of a person’s current disease status, depth of religious commitment and overall LoC profile.

Self­Efficacy Most health education and disease prevention aims to give individuals more control, or a greater sense of control, over health behaviors and outcomes. Many programs assess participants’ control beliefs or self‐efficacy to determine if the program reached its objectives (Wallston, 2004). This research was conducted under the assumption that high levels of Internal HLoC may be indicators of strong self‐ efficacy, believing one can take action and overcome barriers to meet her/his needs in whatever situation. Self‐efficacy is a key variable in the widely applied Health Belief Model and Social Cognitive Theory (NIH, 2005).

The opposite of being in control or having strong self‐efficacy is helplessness—believing there is nothing one can do to improve a bad situation such as being diagnosed with a terminal illness or being told there are no treatments for a medical condition. High HLoC scores in the external categories of Powerful Others and Chance may be indicative of feelings of helplessness.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Methodology The ASCCN choose items from Forms A and B 5 of the M‐HLoC to develop a 16‐item, agree/disagree format survey measuring the four LoC: Internal, Powerful Others, Chance and God. The God dimension was included in the ASCCN survey because previous research has found religious affiliation to be nearly universal in American Samoa—greater than 90% of the population (Krosch, 2008).

A convenience sample survey of 200 American Samoa residents was conducted September – November 2008. The sample was stratified by gender and age group such that 100 males and 100 females responded, 40 from each age group: under age 20; 20 – 29 years; 30 – 39 years; 40 – 49 years; and age 50 and older. The self‐administered survey was made available in English and Samoan. Samoan translations and English back‐translations were completed by the Department of Samoan Studies at the American Samoa Community College. Surveys were administered at the 2008 Annual ASCCN Cancer Symposium (September), at workshops sponsored by the ASCCN (September – November), at an American Samoa Community Cancer Coalition Policy Skills Training Workshop (October), at the LBJ Tropical Medical Center Billing Office (October), and in the villages of ASCCN staff and partners. On most occasions respondents were given the opportunity to win a prize (computer flashdrive or calling card) after completing the survey and all respondents were given a free pencil.

The survey contained 4 parts: demographics, opinions about cancer prevention billboards, media habits and preferences and the 16‐item adapted M‐HLoC survey. The original 18‐item M‐HLoC survey measures on a 6 point Likert Scale (strongly agree to strong disagree). However, McCallem and associates (1988) determined that the agree/disagree response format yields comparable data to those obtained with the 6‐level format, particularly when classification of subjects is the goal. And local pre‐ testing of the instrument found that the concepts of strongly agree, moderately agree and agree and strongly disagree and moderately disagree and disagree were confusing and lacked distinctive translations in the Samoan language. Therefore, a simplified agree/disagree format was devised and each locus contained 4 items chosen from Form A or Form B versions of the M‐HLoC survey6 .

5

Forms A and B of the M‐HLoC were designed to measure perceptions of control of overall health among generally healthy populations. Form C is used to measure perceptions of control in subjects with a particular health condition such as cancer or diabetes (Masters and Wallston, 2005).

6 See the original M‐HLoC scales at http://www.vanderbilt.edu/nursing/kwallston/mhlcscales.htm

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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More than 200 residents responded to the survey. One hundred (100) female and 100 male surveys, 20 per age group were analyzed. Incomplete M‐HLoC surveys were excluded from analysis. If more than 20 surveys were completed for a gender’s age group, surveys were randomly selected for inclusion.

Three (3) survey respondents identified their gender as “Other” (neither male nor female). Given the small, unrepresentative proportion of this demographic, the 3 surveys were not included in the analysis.

Survey data was analyzed for differences between genders, age groups and education groups.

Education groups were defined as ≤ secondary diploma, 2 year college degree and ≥ 4 year college degree.

Hypotheses Based on previous ASCCN research and other studies, the following hypotheses were made before administering the M‐HLoC survey: 1. Internal control scores would be highest regardless of gender, age, and education level or cancer status.

2. Education status will impact all loci: higher education will be related to higher Internal control and lower Powerful Others, God and Chance control scores.

3. The Chance and Powerful Others locus item scores for all groups will have more internal variability than Internal and God control items.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Survey Results Respondents’ Demographics The following is a summary of the survey respondents’ traits.

Table 4: Respondents’ Demographics Number Respondents‐ 200, 100 females (50%) and 100 males (50%) Ages‐ 40 respondents from each age group (20 female, 20 male): under 20 years, 20‐29 years, 30‐39 years, 40‐49 years, and 50 and older Villages‐ Respondents came from 38 of the 65 (58%) villages on Tutuila Island; 1 respondent was from Aunu’u Island Claim Religious Affiliation‐ 94% females and 91% males Birth Country‐ 52% American Samoa, 21% Samoa , 21% USA, 4% Other Pacific Island, 2% no response Ethnicity: 81% Samoan, 7% other Pacific Islander, 6% Asian, 4% Caucasian, 2% no response Marital Status: 45% single, 46% married, 3% divorced, 4% widowed, 2% no response Current Employment Status: 56% Employed, 36% Unemployed, 4% Retired, 4% no response Highest Education Level: 41% Elementary/Secondary, 25% 2 year College, 31% 4 year college or more, 3% no response Personal Cancer Status: 5% Cancer survivor, 90% Non‐cancer survivor, 5% no response Family Cancer Status: 40% At least one family member diagnosed with cancer, 55% No known family cancer diagnosis, 5% no response

Table 6: Frequency Personal Cancer Site Table 5: Personal Cancer Status

Female Male Total %

Yes 9 1 5%

No 86 95 90%

No Response 5 4 5%

Breast Stomach Lung Skin Unknown/ No Response

5 1 1 1 2

Table 7: Family Cancer Status

Female Male Total %

Yes 53 26 40%

No 41 70 55%

No Response 6 4 5%

Table 8: Frequency Family Cancer Site Breast Stomach Lung Skin Brain Liver Lymph

38 3 9 1 5 2 1

Cervix Leukemia Ovarian Prostate Pancreas Throat Uterus

Unknown/ No Response

13 Colon

6 7 3 2 5 2 2

3

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Respondents’ M‐HLoC Profiles

Figure 2: Average M‐HLoC Scores for All Females & All Males

Average Number in Agreement

100 80 60 All Females 40

All Males

20 0 Internal

Powerful Others

God

Chance

Notable Findings‐ Internal control scores are highest both females and males. This may be an indication of high levels of health behavior self‐efficacy and low levels of helplessness.

Internal control scores ware nearly twice as high as Powerful Others, God and Chance control scores for both females and males. However, the combined influence of the two external dimensions of Powerful Others and Chance equal perceived Internal health control. Further investigation is needed to determine the nature of perceived God control as an external force beyond the control of the individual or as a collaborative‐Internal dimension possibly adding to the perceived dominance of Internal health control.

Males felt that Powerful Others and God were slightly more in control of their health then did females.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 9: Female Age Groups: M‐LoC Survey Item Results Locus of Control

Internal

Powerful Others

God

Chance

Survey Item

All Females

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my healthy getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

% in Agreement Age Groups 20‐29 30‐39 n=20 n=20 80 95 90 85 50 35 90 100 40 50

89 95 59 95 58

< 20 n=20 80 100 65 95 60

40‐49 n=20 90 100 70 95 60

≥ 50 n=20 100 100 75 95 80

45

65

30

30

40

60

15 62

20 85

10 50

10 35

20 65

15 75

31

35

15

20

30

55

44 42 40

60 70 65

25 40 20

30 30 25

45 30 35

60 40 55

31

40

35

20

25

35

43

65

45

15

35

55

34 64

25 75

40 60

20 35

40 80

45 70

Average Number in Agreement

Figure 3: Average M‐HLoC Scores for All Females & Female Age Groups 100 80 Internal

60

Powerful Others

40

God 20

Chance

0 All Females

F <20

F 20‐29

F 30‐39

F 40‐49

F ≥50

Notable Findings‐ Females <20 years old and ≥50 years old have similar M‐HLoC profiles.

God Control and Powerful Others perception of control fluctuates most with age.

Powerful Others item 3 and Chance item 4 stand out and greatly impact overall averages of these loci.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 10: Female Education Groups: M‐HLoc Survey Item Results Locus of Control

Internal

Powerful Others

God

Chance

Survey Item

All Females

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my health getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

89 95 59 95 58

% in Agreement Education Groups ≤ secondary 2 yr college n=37 n=26 78 92 95 96 73 58 95 89 65 73

≤ 4 yr college n=33 97 94 39 100 33

45

54

42

39

15 62

24 68

4 69

12 49

31

32

35

18

44 42 40

51 62 46

46 31 39

27 24 33

31

49

31

12

43

60

58

12

34 64

54 84

23 58

21 49

Average Number in Agreement

Figure 4: Average M‐HLoC Scores for All Females & Female Education Groups 100 80 Internal

60

Powerful Others 40

God Chance

20 0 All Females

F elm/sec

F 2yr col

F ≥4 yr col

Notable Findings‐ Internal control scored highest for all education groups. However, the more education a female has the lower Powerful Others, God and Chance scores get.

Chance items 2 and 3 and God items 1‐3 show dramatic decreases in perceived control as educational attainment rises.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 11: Female Cancer Status: M‐HLoc Survey Item Results Locus of Control

Survey Item

Internal

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my healthy getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

Powerful Others

God

Chance

All Females 89 95 59 95 58

% in Agreement Cancer Status cancer survivors family cancer history n=9 n=53 100 93 100 94 56 49 89 98 78 53

45

56

42

15 62

11 67

9 51

31

44

32

44 42 40

56 33 67

43 36 32

31

44

26

43

67

38

34 64

33 67

26 47

Average Number in Agreement

Figure 5: Average M‐HLoC Scores for All Females, Female Cancer Survivors (n=9) & Female Family Cancer Survivors (n=53) 100 80 Internal 60

Powerful Others

40

God

20

Chance

0 All Females

F Survivors

F Fam Hist

Notable Findings‐ Internal control remains high despite cancer diagnosis or known family history of cancer. Female cancer survivors are more likely to perceive health control in the hands of Powerful Others, God and Chance than the average population of women or women with a family history of cancer.

God item 4 and Chance item 2 show significant differences between cancer survivors, family survivors and/or the general female population.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 12: Male Age Groups: M‐HLoc Survey Item Results Locus of Control

Internal

Powerful Others

God

Chance

Survey Item

All Males

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my healthy getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

% in Agreement Age Groups 20‐29 30‐39 n=20 n=20 95 80 80 85 75 70 65 95 55 60

89 84 74 87 58

< 20 n=20 85 90 75 90 55

40‐49 n=20 90 90 75 95 55

≥ 50 n=20 95 75 75 90 65

44

50

35

45

55

35

32 63

35 80

25 65

40 60

40 65

20 45

38

40

30

25

40

55

58 37 43

65 70 70

60 30 45

55 30 35

40 20 15

70 35 50

35

30

55

30

20

40

48

60

40

20

75

45

29 65

30 70

30 60

25 65

40 70

20 60

Average Number in Agreement

Figure 6: Average M‐HLoC Scores for All Males & Male Age Groups 100 80 Internal

60

Powerful Others 40

God

20

Chance

0 All Males

M <20

M 20‐29

M 30‐39

M 40‐49

M ≥50

Notable Findings‐ Males of all age groups perceive strong Internal control over health. Similar to females, males <2O years and ≥50 years old have similar M‐HLoC profiles.

Perceived God control steadily declines with age until age 50 especially for items 2 and 4. Compared to females (Figure 5) more males of all age groups perceive Powerful Others to control health.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 13: Male Education Groups: M‐HLoc Survey Item Results Locus of Control

Internal

Powerful Others

God

Chance

Survey Item

All Males

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my health getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

89 84 74 87 58

% in Agreement Education Groups ≤ secondary 2 yr college n=44 n=23 82 96 82 83 77 74 77 91 57 61

≤ 4 yr college n=28 96 86 71 96 54

44

48

48

39

32 63

36 73

35 57

18 46

38

39

44

39

58 37 43

61 43 50

52 26 44

61 39 36

35

39

35

29

48

59

44

36

29 65

32 61

30 74

29 64

Average Number in Agreement

Figure 7: Average M‐HLoC Scores for All Males & Male Education Groups 100 80 Internal 60

Powerful Others

40

God

20

Chance

0 All Males

M elm/sec

M 2yr col

M ≥4 yr col

Notable Findings‐ More education amongst males increases Internal control and decreases the influence of Powerful Others, God and Chance. Perceived God control increases slightly amongst males with ≥4 year college education, but this could be more a factor of age.

Males with ≤secondary education are twice as likely to feel health professionals control their health (Powerful Others item 3).

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Table 14: Male Cancer Status: M‐HLoc Survey Item Results Locus of Control

Survey Item

Internal

1. If I get sick, I can do things to become well again.

2. I am in control of my health.

3. When I get sick, it is my fault.

4. If I take the right actions, I can stay healthy.

1. Whenever I don’t feel well I should see a doctor or nurse.

2. My family and other people have a lot to do with my becoming sick or staying healthy.

3. Health professionals control my health.

4. If I recover from an illness, it is usually because other people (doctors, nurses, family, and friends) have taken good care of me.

1. God is directly responsible for my healthy getting better or worse.

2. God is in control of my health.

3. Whatever happens to my health is God’s will.

4. If my health worsens, it is up to God to decide if I will get better again.

1. I feel no matter what I do, if I am going to get sick I will get sick.

2. I cannot control how quickly I will recover from an illness.

3. I am healthy because I am lucky.

4. If it is meant to be, I will stay healthy.

Powerful Others

God

Chance

All Males 89 84 74 87 58

% in Agreement Cancer Status 7 cancer survivors family cancer history n=1 n=26 ‐‐‐ 100 ‐‐‐ 85 ‐‐‐ 58 ‐‐‐ 89 ‐‐‐ 42

44

‐‐‐

31

32 63

‐‐‐ ‐‐‐

8 50

38

‐‐‐

31

58 37 43

‐‐‐ ‐‐‐ ‐‐‐

50 23 39

35

‐‐‐

31

48

‐‐‐

46

29 65

‐‐‐ ‐‐‐

15 58

Average Number in Agreement

Figure 8: Average M‐HLoC Scores for All Males & Male Family Cancer Survivors (n=26) 100 80

Internal

60

Powerful Others

40

God

20

Chance

0 All Males

M Fam Hist

Notable Findings‐ Only 25% of males, compared to 50% of females, were aware of a blood relative who had been diagnosed with cancer.

Males with a family history of cancer have equal levels of perceived Internal control but lower levels of Powerful Others, God and Chance control compared to the general male population. But they are far less likely than the general male population to believe their health is based on luck (Change item 3) or that health care professionals control their health (Powerful Others item 3).

7

Due to the small sample, only 1 male respondent was a cancer survivor, this data was not included in analysis.

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Findings Summary Figure 9: M‐HLoC Items Scores‐ All Females & All Males 100 90 80

% in agreement

70 60 50

All Females

40

All Males

30 20 10 0 I1

I2

I3

I4 PO1 PO2 PO3 PO4 G1 G2 G3 G4

C1

C2

C3

C4

Internal Powerful Others God Chance •

The M‐HLoC measurement appears to have demonstrated that the four different loci of health control are relevant to the American Samoa population as shown by the different profiles that emerge depending on gender, age and education status.

•

Both females and males perceive Internal control to be strongest in determining health status and outcomes. However, more than half of all males agreed with specific items within each of the other loci. Less than half of all females agreed with any God control item.

•

Males perceive themselves (Internal), Powerful Others and God to be more in control of their health than do females.

•

Internal items 2 and 4 had the highest percentage of females in agreement (95%): When I get sick it is my fault; and If I take the right actions, I can stay healthy. Males agreed most (89%) with Internal item 1: If I get sick, I can do things to become well again.

•

Females perceived God control steadily declines with age until age 50 especially for items 4: If my health worsens, it is up to God to decide if I will get better again.

•

Powerful Others item 3 saw the fewest females in agreement: health professionals control my health. Males were least in agreement with Chance item 3: I am healthy because I am lucky.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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•

Compared to other Chance items, more than half of females and males (64%) agreed with item 4: If it is meant to be, I will stay healthy.

•

Only 15% of females and 32% of males surveyed feel health professionals are Powerful Others in control of their health. But 62% of females and 63% of males agreed that recovering from an illness was due to other people (doctors, nurses, family and friends) taking care of them. This distinction between Powerful Others items 3 and 4 seems to reveal a split in the Powerful Others category between perceived power held by medical professionals and power held by other ‘influentials.’

•

As other research has shown, groups with the highest relative God scores (males; <age 20; ≥age 50; ≤secondary education; and cancer survivors) also tended to agree that Powerful Others besides doctors determine illness recovery (higher percentages in agreement with Powerful Others item 4).

•

Females and males under age 20 and over age 50 perceive God and Powerful others to be more in control of their health than do respondents ages 20‐49.

•

More education results in less external health influence from Powerful Others, God or Chance and higher perceived Internal control (presumably more self‐efficacy) regardless of gender.

Specifically higher educated females are significantly less likely to feel they cannot control how quickly they recovered from an illness and that their health outcome was God’s will. Both females and males with ≤secondary education are twice as likely as those with ≥4 year college education to agree with Powerful Others Item 3: Health professionals control my health.

•

Not surprisingly, female cancer survivors are more likely to perceive health control in the hands of Powerful Others, God and Chance than the average population of women or women with a family history of cancer. More than twice as many cancer survivors than family survivors agreed with God item 4: If my health worsens, it is up to God to decide if I will get better again.

•

Only 25% of males, compared to 50% of females, were aware of a blood relative who had been diagnosed with cancer. Both female and male family cancer survivors were less likely than the general population to feel that Powerful Others, God or Chance was in control of their health.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Hypotheses Results 1. Internal control item scores were the highest amongst females and males regardless of age, education or family/cancer survivor status. But consistently agreement was also shown, especially by older respondents and those with less education, for Chance item 4, If it is meant to be, I will stay healthy. This item should be further validated by asking respondents what they understand “meant to be” to mean to them as this could be linked to religious beliefs more than chance.

2. Higher education is related to higher perceived Internal control and lower perceived control

by Powerful Others, God and Chance for all categories except males with ≥4 year college education, but this could be more a factor of age.

3. Powerful Others and Chance locus items showed more internal variability than Internal and God items scores. Item scores under Powerful Others were most variable for females in general, females <20 years old – 39 years old, males ages 20‐29, females and males ≥50 years old, females and males with ≤ a secondary education, females with a 2 year college degree, female cancer survivors, female family cancer survivors. Chance control items were the most variable for males in general, males ages 30‐49, females ages 40‐49, and males with a 2 year college degree. Powerful Others and Chance item scores were equally variable for both females and males with ≥ a 4 year college degree. This clustering calls for closer investigation of different the facets that make up these domains especially within the American Samoa cultural and health environment with special attention given to non‐health professionals influence over health and distinguishing between notions of faith and fate.

Using M­HLoC Results The results of this M‐HLoC survey along with findings from other studies can be fed into models and theories in order to predict the health behaviors of American Samoans and develop effective behavior change interventions. The Health Belief Model (HBM) is one of the most widely applied in the field of health promotion. It is made up of six constructs that influence whether an individual takes action to prevent, screen for and control illness: •

Perceived Susceptibility: I believe I am at risk of the illness/disease

•

Perceived Severity: I believe the illness/disease has serious consequences ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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•

Perceived Benefits: I believe taking action will reduce my risk or the severity of the illness/disease

•

Perceived Barriers: I believe the costs of taking action are outweighed by the benefits

•

Cues to Action: I have opportunities, support and reminders to take action

•

Self‐efficacy: I am confident in my ability to successfully act for better health (NIH, 2005).

These six constructs are also impacted by demographics—age, gender, education status, etc.. Self‐ efficacy can be linked to high Internal HLoC scores whereas high perceived Powerful Others or Chance control can be considered barriers to action. God control could aid Internal self‐efficacy or be a barrier to individual action. The diagram below illustrates the HBM with data gleaned from ASCCN research and other studies about the general American Samoa population. However, the HBM is a more effective tool for predicting behavior when data from specific groups are examined (females under age 30 with less than a 2 year college degree versus females in general) so disaggregated data should be gathered whenever possible.

Figure 10: The Health Belief Model

Demographics 1) Perceived Susceptibility

4) Percieved Barriers

2) Percieved Severity

Interventions should focus on changing these constructs to increase self‐efficacy and motivate action

5) Percieved Benefits

6) Outcome Expectations

3) Percieved Threat

7) Self‐Efficacy

8) Action or Inaction

Health Problem: Few take advantage of cancer screening services. Why?

1) Perceived Susceptibility is Low “Cancer is a disease people hardly get. We should be afraid of diabetes.”

2) Perceived Severity is High “Cancer means hopelessness, worry, and that death is near.”

3) = Perceived Threat is Moderate 4) Perceived Barriers are Moderate to High based on lack of local treatment and moderate Powerful Others, Chance and God HLoC scores 5) Perceived Benefits are Low “We should pity those who have cancer because there is no testing, cure.”

6) = Outcome Expectations are Low because benefits of screening do not outweigh the barriers 7) Self‐efficacy is Moderate to Low based on High Internal HLoC scores – Moderate perceived threat – Low Outcome expectations 8) Action probability (screening for cancer) remains Moderate to Low unless constructs 1,2,4 and 5 change.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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Works Cited Asian and Pacific Islander American Health Forum (APIAHF). (2006) Health Brief: Samoans in the United States.

Hathaway, W and K. Pargament. (1991) The religious dimensions of coping: implications for prevention and promotion. Religion and Prevention in Mental Health: Conceptual and Empirical Foundations. 9:65‐ 92.

Hubbell, FA, et al. (2005). Exploring beliefs about cancer among American Samoans: focus group findings. Cancer Detection and Prevention. 29:109‐115.

Krosch, Sara. (2008) Cancer Prevention Billboard Evaluation Report – December 2008. American Samoa Community Cancer Network.

Krosch, Sara. (2008) Prostate Cancer Screening Clinic Program Impact Evaluation. American Samoa Community Cancer Network.

Masters, Kevin and Kenneth Wallston. (2005) Canonical Correlation Reveals Important Relations between Health Locus of Control, Coping, Affect and Values. Journal of Health Psychology. 10(5): 719‐ 31.

McCallum, DM., et al. (1988) Comparison of response formats for Multidimensional Health Locus of Control Scales: six levels versus two levels. Journal of Personality Assessment. 52(4): 732‐6.

Moshki, M., et al. (2007) Validity and reliability of the multidimensional health locus of control scale for college students. BCM Public Health. 8(7):295.

National Institutes of Health (NIH). (2005) Theory at a Glance: A Guide for Health Promotion Practice. second edition.

Puaina, Seumaninoa, et al. (2008) Impact of traditional Samoan lifestyle (fa’aSamoa) on cancer screening practices. Cancer Detection and Prevention. 32S:S23‐S28.

Wallston, Kenneth, et al. (1991) Does God Determine Your Health? The God Locus of Control Scale.

Cognitive Therapy and Research. 23(2): 131‐42.

Wallston, Kenneth. (2004) Control and Health. Encyclopedia of Health and Behavior. Thousand Oaks: Sage. 217‐220.

Wallston, Kenneth. (2004) Multidimensional Health Locus of Control Scale. Encyclopedia of Health Psychology. New York: Kluwer Academic 171‐2.

ASCCN – Insights Into Health Control Beliefs of American Samoans – Results of an Adapted Multidimensional Health Locus of Control Survey ‐ June 2009 Sara Krosch amsamccn@gmail.com

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