Angel, R.J., Angel, J.L., & Hill, T.D. (2009). Subjective control and health among mexican-origin elders in mexico and the united states: structural considerations in comparative research. Journal of
Gerontology: Social Sciences, 64B(3), 390–401, doi:10.1093/geronb/gbn029, Advance Access publication on March 30, 2009
Subjective Control and Health Among Mexican-Origin
Elders in Mexico and the United States: Structural
Considerations in Comparative Research
Ronald J. Angel,1 Jacqueline L. Angel,1,2 and Terrence D. Hill3
1Population
2LBJ
Research Center, University of Texas at Austin.
School of Public Affairs, Center for Health and Social Policy, University of Texas at Austin.
3Department of Sociology, University of Miami, Coral Gables, Florida.
Objectives. This study examines the joint impact of psychological and structural factors on Mexican and Mexican
American elders’ sense of personal control over important aspects of their lives and health in Mexico and the United
States.
Methods. We employ the Mexican Health and Aging Study (MHAS) and the Hispanic Established Populations for
Epidemiologic Studies of the Elderly (H-EPESE) to explore patterns of association among structural factors, personal
characteristics, indicators of material and physical vulnerability, and expressed locus of control.
Results. The results suggest that an older individual’s sense of personal control over important aspects of his or her
life, including health, reflects real material and social resources in addition to individual predispositions. In Mexico, only
the most privileged segment of the population has health insurance, and coverage increases one’s sense of personal control. In the United States, on the other hand, Medicare guarantees basic coverage to the vast majority of Mexican Americans over 65, reducing its impact on one’s sense of control.
Discussion. Psychological characteristics affect older individuals’ sense of personal control over aspects of their
health, but the effects are mediated by the economic and health services context in which they are expressed.
Key Words: Mexico—Mexican American—Locus of control—Health—Poverty—Health Systems.
D
URING the middle part of the previous century, the
humanistic psychologist Abraham Maslow developed
his theory of a hierarchy of human needs that posits that
each of us is confronted with a series of developmental tasks
that involve satisfying ever more complex social and personality needs beginning with the most basic of physiological needs and progressing through higher-level needs, such
as the need for safety and security, love and belonging, the
esteem and respect of others, and self-esteem. If, and only
if, these more basic needs are satisfied does one arrive at the
stage of self-actualization, which consists of a complex mix
of traits, attitudes, and behaviors that express one’s complete and engaged humanity (Maslow, 1962). As an ideal
goal, or even as a metaphor for the good life, Maslow’s
stage of self-actualization reflects the greatest possible generativity, social engagement, and emotional maturity that
the individual can achieve, and by extension, a stage at
which one has subjective control over important aspects of
one’s life.
Maslow’s theory remains appealing not because of its
ability to make specific empirical predictions but because of
its humanistic focus that draws attention to the major obstacles that marginalized and powerless individuals face in
their progress toward full material and psychological security. We employ Maslow’s theory rhetorically in order to
390
frame the objective of this study, which is to make the point
that successful aging and the potential for optimal development depends not only on individual characteristics but also
on the particular economic, political, and social contexts in
which an individual spends his or her life.
Our basic theoretical perspective views successful aging
as dependent both on agency and structure. Individual characteristics and behaviors are clearly important in determining one’s health, but health care system characteristics and
the ability to access high-quality care are essential if one is
to achieve optimal health in later life. Optimal physical and
mental health depends on adequate material resources, both
to prevent illness and to regain one’s health when one falls
ill. As part of our empirical analysis, we examine the extent
to which various health outcomes, as well as one’s sense of
control over important aspects of one’s life and health, reflect individual-level factors and structural factors related to
economics and the health care system in two very different
national contexts, Mexico and the United States. Rather than
focusing on specific scores or attempting to make specific
cardinal comparisons, which we find debatable in comparative research in general, our objective is to determine the extent of structural similarity among predictors of health and
one’s sense of control among older Mexicans and Mexicanorigin U.S. residents. Ultimately, the purpose of the study is
© The Author 2009. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: [email protected].
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
to theorize about and examine patterns of self-reported subjective health and individuals’ sense of personal control over
health in two very different socioeconomic contexts while
holding aspects of ethnicity and culture constant.
The Meaning and Social Context of Successful
Aging
The construct of “successful aging” was developed
primarily by psychologists and is largely defined in
psychological terms. In general, researchers identify several
functional domains as important components of successful aging (Havighurst, 1961; House, 2002; Neugarten,
Havighurst, & Tobin, 1961). Among the most important of
these are (a) a high level of cognitive functioning, (b)
resilience and the ability to adapt to the losses and physical
decline associated with aging, and (c) social integration
and engagement. The general concept often includes a
more general domain that taps (d) life satisfaction and
self-actualization. A major theoretical focus in this tradition
defines successful aging in terms of successful development,
adaptation, and coping, as well as the achievement of one’s
peak level of physical, social, and psychological well-being
(Berkman & Mullen, 1997; Fisher, 1992; Gibson, 1995;
Palmore, 1995; Ryff, 1989; Seeman et al., 1994). For purposes
of this discussion, we define successful aging broadly as
optimal physical functioning, emotional well-being, and
social engagement, but we also add a material dimension, as
we explain below.
Most conceptual models of successful aging do not explicitly include, or they assume as implicit, an adequate
level of material resources (Rowe & Kahn, 1987). Yet, it is
critical to explicitly deal with structural factors as determinants of successful aging, especially when dealing with
marginalized and poor groups or in comparative research
that includes populations at different levels of development.
As Farmer (1999) and other social scientific investigators
observe, although marginalized groups may not share a
common culture or a similar health care system, what they
do have in common is poverty. The importance of material
and structural factors in optimal aging is clearly revealed by
the literature on racial and ethnic differences in the wellbeing of the elderly. Minority Americans have lower lifetime incomes and arrive at mature adulthood with far less
wealth than majority Americans. As a consequence, they are
at high risk of dependency on others in old age (R. J. Angel
& J. L. Angel, 2006). A large literature shows that for structural reasons, these individuals often lack the ability to satisfy the more basic deficiency needs in the Maslowian
hierarchy.
As is the case with the other dimensions of the concept of
successful aging, the role of material well-being is complex
and includes both absolute and relative components. An income of less than $2 a day represents the worst of absolute
poverty and clearly robs one of the ability to age success-
391
fully or even to survive (Farmer, 2001). Incomes that are
higher, but that place one in the lower tiers of the income
distribution, can leave one with few choices in living arrangements and few possibilities for expressing one’s generativity materially. The lack of material resources precludes
the possibility of the sort of generativity that those who can
help children buy houses or pay for a grandchild’s college
education enjoy. In both cases, the individual lacks the material basis of a satisfying and productive old age.
Locus of Control
Our focus on one’s subjective sense of control emerges
from the theoretical and empirical literature on locus of
control. In recent years, interest in understanding the relationship between the concept of locus of control and a variety of different health attitudes, behaviors, and outcomes
has grown (Antonucci, 2001; Black, Markides, & Miller,
1998; Hunt, Valenzuela, & Pugh, 1998; Lachman & Weaver,
1998a, 1998b; Norman, Bennett, Smith, & Murphy, 1998;
Wickrama, Surjadi, Lorenz, & Elder, 2008). Also referred
to as “personal control beliefs,” this theoretical construct
refers to an individual’s beliefs regarding the extent to which
he or she is able to control or influence important life events,
including health outcomes. As defined by Rotter in the mid1960s, the construct is based on social learning theory and
posits two major orientations that might be seen as two ends
of a continuum that characterize individuals’ beliefs concerning the causes of various outcomes. One end of the continuum is characterized by individuals with an internal locus
of control profile. These individuals attribute events or outcomes in their lives to their own efforts. At the other extreme, those with an external locus of control profile attribute
these same events and outcomes to external forces including chance and supernatural forces. Most individuals fall
somewhere between these two extremes.
The more general concept of locus of control was applied
specifically to health by Wallston, Wallston, Kaplan, and
Maides (1976), who developed the concept of Health Locus
of Control (HLC) in the 1970s. This concept focuses on the
degree to which individuals believe that their health is
largely under their own control rather than depending on
external forces or chance. Two of the most well known
scales used to measure this construct are the Health Locus
of Control Scale and the Multidimensional Health Locus of
Control Scale (Lachman & Weaver, 1998b; Wallston, 2005).
The scale includes items such as “If I get sick, it is my own
behavior which determines how soon I get well again,” “No
matter what I do, if I am going to get sick, I will get sick,”
“Health professionals control my health,” and “If I take the
right actions, I can stay healthy.” Responses range from
“strongly agree” to “strongly disagree” on a Likert scale.
In the last three decades, a large body of research has
linked an internal locus of control profile to positive
health behaviors and greater knowledge about the causes
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ANGEL ET AL.
of age-related disease (Krause, 1986, 1987, 2007; Lefcourt
& Davidson-Katz, 1991; Norman et al., 1998; Shaw &
Krause, 2001).
The concept and its measures have proved to be powerful
predictors of positive health outcomes. Older adults who
feel that they have greater subjective control over salient
roles, such as parenting, grandparenting, and being a friend,
homemaker, caregiver, volunteer, and church or club member, live longer than those who lack this sense of control
(Krause, 2007). These favorable mortality experiences may
reflect the positive health behaviors that are associated with
greater internal locus of control. Those individuals with a
lower sense of control are more likely to engage in behaviors such as drinking alcohol to excess and smoking, and
they are more likely to be obese than those with a greater
sense of control (Lachman & Weaver, 1998a). In contrast to
individuals with an internal locus of control, those with an
external locus report lower levels of physical and mental
well-being and cope poorly with stress and financial strain
(Krause, 1987). Certain institutional factors appear to reduce a sense of control over aspects of one’s life, or to at
least have this association (Shaw & Krause, 2001).
Genotype or Phenotype
The construct of locus of control implies the existence of
a personality trait, either inborn or learned through experience or, perhaps, both. One is born with certain genotypic
predispositions, and those are expressed as the result of the
organism’s interaction with the environment. Characterized
as a trait, the implication is that such a behavioral predisposition is fairly structured and stable and that it can be used to
predict particular outcomes or to explain differences among
people and even groups. David McClelland’s (1961) needs
theory is an example. According to McClelland, individuals
can be characterized as manifesting different levels of three
need traits: the need for achievement, the need for affiliation,
and the need for power. One’s particular mix may be based
on fundamental characteristics, but it is also shaped over
time in response to one’s life experiences. Those experiences
include the values one learns from one’s culture, and
McClelland’s theory is very similar to Max Weber’s attribution of capitalist acquisitiveness to Calvinist religious values
(Weber, 1930). McClelland employed the theory to explain differences in levels of development among nations
(McClelland). The use of such supposed psychological traits
to characterize groups or to explain highly complex social,
economic, or political differences, though, represents a potentially serious attributional error. More specifically, it runs
the risk of attributing the effects of structural factors to culture and group beliefs. We suspect the same risk applies to
all supposed psychological traits that are used to explain
group differences in behaviors.
Other personality theorists question the existence or the
stability of such personality traits, especially as they relate
to emotional characteristics. Over a quarter of a century
ago, Mischel (1969), for example, pointed out that supposed
emotional personality characteristics are highly contextual and that one responds very differently to emotional
stimuli in different social contexts. To the extent that locus
of control includes emotional components or is shaped by
emotional experience, it too is likely to be contextually
influenced.
Subjective Control Among Older Mexican-Origin
Individuals
Although the physical and psychological benefits of an
internal locus of control are well documented in the general
U.S. population, little is known about how locus of control
is affected by culture, economics, and social circumstances
(Menec & Chipperfield, 1997). Few international comparative studies exist. We propose a conceptualization of successful aging that places material well-being at the center of
the association among resources, locus of control, and
health outcomes. This conceptualization is based on the
general proposition that among groups with few material
resources, feeling that one has little control over one’s life,
including little control over one’s health, reflects the reality
of powerlessness and limited access to health care. As part
of a learned helplessness process, such a situation may well
result in a fairly stable orientation similar to a personality
trait. Theoretically and practically, self-efficacy or subjective control over various aspects of one’s life can be seen as
a learned general or global self-conception that can be relatively stable over time and across situations but that can
change when the situation changes markedly.
Our testable research proposition holds that one’s expressed locus of control, in addition to symptoms of distress,
self-reported poor health, and self-reports of functional
impairment, will be greatly affected by material well-being
reflected both in national context and in individual characteristics related to the ability to control one’s life such as
level of education, income, financial strain, and health insurance. We expect that older Mexican Americans will be more
likely to express greater sense of control over important aspects of their health than Mexicans because of better access
to primary and specialty health care that results from the
nearly universal access to health care through Medicare.
Data and Methods
In order to identify major predictors of locus of control
and other health outcomes among elderly individuals in two
different national contexts, we employ the Hispanic Established Populations for Epidemiologic Study of the Elderly
(H-EPESE) in the United States and the Mexican Health
and Aging Study (MHAS) with similar, but not identical,
data in Mexico. Both surveys include detailed information
on demographics, socioeconomic characteristics, migration
history where applicable, and physical and mental health
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
and functioning. Although they provide useful comparative
information, the two data sets differ in important respects,
and we focus more on similarities or differences in general
patterns rather than on specific coefficients or prevalence
rates. The H-EPESE is a longitudinal study based on an
original probability sample of 3,050 Mexican-origin individuals aged 65 years and over in the five southwestern
states of Arizona, California, Colorado, New Mexico, and
Texas who were first interviewed in 1993/1994 (Markides,
1999). The baseline H-EPESE response rate was 86%. Although the MHAS consists of a national probability sample
of 15,186 Mexicans aged 50 years and over interviewed in
Mexico in 2001, we have selected respondents aged only
65 years and over. The baseline MHAS response rate was
90% (Wong & Espinoza, 2004). In both surveys, information on respondents who could not answer for themselves
was provided by proxy respondents. These cases have been
deleted from the analyses because of missing or invalid responses on selected outcome variables (MHAS, n = 449;
H-EPESE, n = 316). H-EPESE respondents were given the
option of taking the survey in Spanish, and more than three
quarters (77.8%) did so.
From these two data sources, we created five groups: (a)
Mexican residents with no history of residence in the United
States (MHAS, n = 3,875), (b) U.S. residents who were
born in Mexico and migrated to the United States between
the ages of 1 and 19 years (H-EPESE, n = 383), (c) U.S.
residents who were born in Mexico and migrated to the
United States between the ages of 20 and 49 years (HEPESE, n = 578), (d) U.S. residents who were born in Mexico and migrated to the United States between the ages of 50
and 90 years (H-EPESE, n = 232), and (e) U.S. residents
who were born in the United States (H-EPESE, n = 1,541).
We excluded 578 individuals in the MHAS who reported
that they had lived or worked in the United States in order to
isolate the MHAS reference group from significant exposure to U.S. systems and culture. Spanish and English versions of the health questions are presented in Appendix A.
393
trol [over] the bad things that happen to him/her”; (e) “One
is responsible for his/her own successes”; (f) “One can do
just about anything he/she puts his/her mind to”; (g) “One’s
misfortunes are the result of his/her own mistakes”; and (h)
“One is responsible for his/her own failures.” Response categories for these items were coded (1) disagree, (2) somewhat disagree, (3) somewhat agree, and (4) agree. We sum
the eight locus of control items after reverse coding the external locus of control questions (e–h) and divide by 8 to
create an index that ranges from 1 to 4. A higher score reflects greater internal locus of control and less of a sense
that one is in control of his or her life.
Health Improvement Beliefs: MHAS
MHAS respondents were asked the following question
to measure health improvement beliefs: “Do you think
that a person your age can improve his/her health through
regular exercise, balanced diet, or by stopping smoking?”
Response categories for this item were coded (1) for yes
and (0) for no.
Self-Care Concern: H-EPESE
H-EPESE respondents were asked the following question
to assess self-care concern: “How concerned are you about
being unable to be independent and take care of yourself
and your affairs in the future?” Response categories for this
item were coded (1) not concerned at all, (2) somewhat concerned, and (3) very concerned.
Measures
Health Sense of Control: H-EPESE
H-EPESE respondents were asked the following question
to measure health sense of control: “To what extent do you
feel you can control the general state of your health through
your own actions?” Response categories for this item were
coded (1) not at all, (2) somewhat, and (3) a great deal. In
general, the H-EPESE questions are more general and nonspecific than the MHAS questions that ask about more specific behaviors such as control of health through regular
exercise, balanced diet, or by stopping smoking.
Locus of Control: MHAS
The comparisons we are able to make are not exact because we do not have identical measures of locus of control
in the two surveys. This shortcoming should be kept in mind
in interpreting the results of the two surveys. In the MHAS,
the focus is on the more general construct of locus of control as measured by eight items adapted from Rotter (1966).
MHAS respondents were asked to rate the degree to which
they agreed or disagreed with the following statements (see
the Appendix for the Spanish version): (a) “There is no
sense in planning a lot for the future”; (b) “The really good
things that happen to me are mostly luck”; (c) “Most of
one’s problems are due to bad luck”; (d) “One has little con-
Psychological Distress
We employ seven items from the Center for Epidemiologic Studies–Depression (CES-D) scale to measure psychological distress. In both surveys, respondents were asked
whether during the past week they had felt (a) depressed,
(b) that everything they did was an effort, (c) their sleep was
restless, (d) unhappy, (e) lonely, (f) they did not enjoy life,
or (g) sad. In order to increase the comparability of the
CES-D between the two samples, the H-EPESE items were
recoded (1) most or all the time and (0) otherwise. The final
psychological distress measure represents a summed index
of the seven items.
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ANGEL ET AL.
Health Risk Factors
Our measurement of health risk factors includes body
mass, smoking, and drinking behavior. Using the standard
formula and documented thresholds provided by the Centers for Disease Control, we coded body mass as (1) for
obese, a body mass index of 30 or over, and (0) otherwise.
In the MHAS, height and weight were reported by the respondent, whereas in the H-EPESE, respondents were measured and weighted by the interviewer. Smoking behavior is
operationalized as pack years. We measure pack years by
multiplying the number of years the respondent smoked by
the average number of packs (20 cigarettes per pack) during
that time.
To measure heavy drinking and drinking problems, we
use items adapted from the CAGE instrument (the first letter of a key word in each question spells CAGE, e.g., cut
down, annoyed, guilty, eye opener) (Ewing, 1984). In both
surveys with slight variations in wording, respondents
were asked: (a) “Have you ever felt you should cut down
on your drinking?” (b) “Have people annoyed you by criticizing your drinking?” (c) “Have you ever felt bad or
guilty about your drinking?” (d) “Have you ever had a
drink first thing in the morning to steady your nerves or to
get rid of a hangover (eye opener)?” Following the work of
Saitz and colleagues (2007), in both surveys respondents
who answered “yes” to any of the four questions were
coded (1) for problem drinker and (0) otherwise, including
individuals without any drinking problem and those who
never drink.
Chronic Conditions
Our assessment of chronic conditions is a summative
measure of six items worded slightly differently. Both sets
of respondents were asked by the doctor whether they had
ever had arthritis, diabetes, high blood pressure, a heart attack, a stroke, or cancer.
Self-Rated Health
Self-rated health was measured with single items in both
surveys, with categories ranging from excellent to poor. In
order to compare self-rated health across surveys, we recoded these items (1) fair or poor and (0) otherwise.
Disability
Our measure of disability assesses limitations in performing routine activities of daily living (ADLs). Respondents
were asked to indicate whether they had any difficulties (because of a health problem) with the following activities: (a)
bathing or showering, (b) eating, (c) getting in or out of bed,
(d) using the toilet, (e) walking across a room, and (f) dressing. Original response categories were coded (1) for yes and
(0) for no. All the items were summed to form an activities of
daily living (ADL) index, with scores ranging from 0 to 7.
Financial Strain
Exposure to life stressors such as chronic economic strain
can adversely affect psychological well-being (Krause,
1987). H-EPESE respondents were asked two questions to
assess financial strain: (a) “How much difficulty do you
have in meeting monthly payments on your bills?” Response categories for this item were coded (1) none, (2) a
little, (3) some, and (4) a great deal. (b) “At the end of the
month, do you usually end up with some money left over,
just enough to make ends meet, or not enough to make ends
meet?” Response categories for this item were coded (1)
some money left over, (2) just enough to make ends meet,
and (3) not enough money to make ends meet. We measure
financial strain as a mean index of these two items. Note
that these items have been standardized to account for metric differences. We assessed financial strain in MHAS respondents with a single item. Respondents were asked,
“Would you say your financial situation is excellent, very
good, good, fair, or poor? Because less than 2% of respondents could be categorized as either “excellent” or “very
good,” these categories were combined with “good.” Thus,
response categories for this item were coded (1) good, (2)
fair, and (3) poor.
Insurance Status
Health insurance is an important factor in determining
health care use in both Mexico and the United States (Wong,
Diaz, & Espinoza, 2006). The most recent data available
indicate that slightly over half of those over age 60 years
have health care coverage of some sort (Wong et al.). Access as well as the quality of care received by Mexican people, including the elderly, depend on their employment
status, the sector in which they work (e.g., informal economy, formal sector), and income. Those with the most complete access are individuals who were in salaried jobs prior
to retirement. They are covered by various health funds that
make up the social security system, which also includes
smaller funds or other plans such as those sponsored by
the military or Petróleos Mexicanos (PEMEX), the Mexican petroleum monopoly (Organisation for Economic
Co-operation & Development, 2005). The public system for
the elderly poor receives less funding and is clearly inferior to
the system for salaried employees. Because of extensive poverty and inadequate coverage, many Mexicans, including the
elderly, face serious barriers to health care. Formal longterm care is unavailable, and the infirm elderly must rely on
their families when they can no longer care for themselves.
Many of the most seriously underserved Mexicans live in
rural areas or in the poorer states of the South. In order to
improve access for the poor in 2004, Mexico introduced a
new program entitled Seguro Popular (Public Insurance),
which is intended to extend health insurance to the nation’s
50 million uninsured by 2010. This program may well
improve health care, which today is often unavailable and of
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
inferior quality, especially for rural residents and residents
of the southern states.
H-EPESE respondents were classified as having health
insurance if they reported having Medicare, Medicaid, or
private insurance. H-EPESE respondents were also classified as having health insurance if they reported receiving
Social Security or Supplemental Security Income, which
qualifies respondents for Medicare. MHAS respondents
were classified as having health insurance if they reported
receiving coverage from any of the following sources: Mexican Social Insurance Institute, Social Services and Security
Institute for State Employees, PEMEX, private insurance,
or some other form of insurance.
Sociodemographic Characteristics
We control for several known sociodemographic correlates of health status, including age, sex, marital status, educational attainment, and personal income in the
Mexican-origin population (Angel, Angel, & Hill, 2008).
Like non-Hispanic Whites, as older Mexican-origin people
age, they may feel less in control of their own lives as the
result of infirmity. In addition, education may boost the
sense of one’s control (Mirowsky, 1995). We categorized
education to reflect meaningful differences in the samples.
In the MHAS, education is coded into three categories: (a)
no formal years of education, (b) 1–5 years of formal education, and (c) 6 or more years of formal schooling. In the HEPESE, we create a dummy variable for education (less
than high school as reference category) to reflect the limited
educational attainment of older Mexican Americans in the
United States. We include sex, coded (1) for females and (0)
for males, because women may have a lower sense of control than men do (Ross & Mirowsky, 2002). Age is coded
into three categories: (a) 65–69, (b) 70–79, and (c) 80 and
over. Marital status is coded (1) for currently married and
(0) otherwise. Because the income distributions in the
United States and Mexico are so different, personal income
is divided into three categories in each country in order to
capture relative income levels in order to differentiate very
poor households from those with higher incomes.
Results
To restate the logic of the analysis, although one’s beliefs
concerning his or her locus of control no doubt reflect innate or socially learned traits, empirical measures of control
also reflect an individual’s accurate assessment concerning
how much control an individual has over aspects of his or
her life in specific contexts (Krause, 1986). In this section,
we predict the locus of control indicators in Mexico and the
United States in stratified analyses. The predictor equations
include the demographic, migration, and health measures as
independent variables to determine how each affects the locus of control variables. Table 1 presents descriptive statistics for the Mexican and U.S. samples. Both samples are
395
roughly similar in their age distributions, proportion female,
and percent married. Although neither sample is highly educated, educational levels are much lower in Mexico, and a
far smaller fraction of the Mexican sample has health insurance. Over one third (36%) of the MHAS sample has no
formal education compared with 16% of the H-EPESE;
10% of H-EPESE respondents report at least some college.
None of the MHAS respondents have any college education. The H-EPESE sample has very low income by U.S.
standards. Finally, slightly over half of H-EPESE respondents were born in the United States.
Table 1 also presents information on control beliefs and
the prevalence of health problems in each group. In the
MHAS, locus of control ranges from 1 to 4, with a higher
score reflecting a greater sense of control. The mean of 3
reflects a relatively high sense of control. On the second
measure, which asks, “Do you think a person your age can
improve his/her health through regular exercise, balanced
diet, or by stopping smoking?”, 87% of Mexicans responded
positively. In the H-EPESE, the measures self-care concern
ranges from 1 to 3, and a higher score reflects a greater
sense that one will not be able to be independent and take
care of oneself in the future. The second measure, health
sense of control also ranges from 1 to 3, and a higher score
reflects the sense that one will be able to control one’s health
in the future. Of those who responded, most expressed a
moderate sense of concern over their capacity to maintain
independence (1.9) and relatively high sense of control over
health (2.4). MHAS respondents report almost three times
more distress (2.7 vs. 0.6) than H-EPESE respondents, and
they were more likely to report fair or poor general health
(70% vs. 60%). Older Mexican Americans, on the other
hand, were nearly twice as likely as Mexican residents to
report obesity and reported more pack years of smoking. A
somewhat smaller percentage of the Mexican sample reported problem drinking. Both samples were relatively similar in chronic conditions and ADL disability.
We next turn to multivariate analyses of the four locus of
control measures on the demographic and health indicators
for the two samples. Two models are presented for each locus of control outcome, and each column is numbered for
reference. The first model for each subjective control outcome controls for demographic and economic factors
(Model 1) and the second introduces the psychological,
health, and health behavior variables (Model 2). Table 2
presents the results for the MHAS and Table 3 for the HEPESE.
In Table 2, the first variable we examine is Internal Locus
of Control, and the results are presented using unstandardized ordinary least squares regression coefficients in the
first two columns. In Model 1, education and having health
insurance increase one’s internal locus of control. In Model
2, in which we add the health-related predictors, fair or poor
self-reported health reduces one’s internal locus of control,
but obesity increases it. Columns 3 and 4 present results for
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ANGEL ET AL.
Table 1. Descriptive Statistics by Country of Residence (range in
parentheses)
Mexican Elderly
Aged 65 Years
and Older
Age (years)
65–69
70–79
80 and older
Female
Married
Education
No formal education
1–5 years
6 or more years
≥12 years of education
Personal income
Low
Middle
High
Financial strain index
Currently insured
Nativity/migration age
United States/—
Mexico/1–19
Mexico/20–49
Mexico/50–90
Psychological distress
Control beliefs
Locus of control
Health improvement
Self-care concern
Health sense of control
Psychological distress
Fair/poor self-rated health
Health risk factors
Obese
Pack years
Problem drinker
Chronic conditions index
ADL disability index
Mexican Resident
(MHAS 2001),
n = 3,875
Table 2. OLS and Logistic Regressions of Control Beliefs: MHAS
Mexico Resident (MHAS 2001), n = 3,875
U.S. Resident
(H-EPESE 1993),
n = 2,734
—
—
—
—
—
38.0
46.0
16.0
57.0
51.0
—
—
—
—
—
41.0
44.0
15.0
58.0
56.0
—
—
—
—
36.0
37.0
27.0
—
—
—
—
—
16.0
44.0
40.0
10.0
—
—
—
2.0 (1–3)
—
35.0
35.0
30.0
—
62.0
—
—
—
0.0 (−2 to 2)
—
35.0
51.0
14.0
—
97.0
—
—
—
—
2.7 (0–7)
—
—
—
—
—
—
—
—
0.6 (0–7)
56.0
14.0
21.0
9.0
3.0 (1–4)
—
—
—
2.7 (0–7)
—
—
87.0
—
—
—
—
—
—
70.0
—
—
1.9 (1–3)
2.4 (1–3)
0.6 (0–7)
—
60.0
—
1.2 (0–15)
—
1.0 (0–5)
0.3 (0–2)
18.0
—
15.4
—
—
—
2.2 (0–15)
—
1.3 (0–6)
0.2 (0–2)
30.0
—
13.0
—
—
Note: MHAS = Mexican Health and Aging Study; H-EPESE = Hispanic
Established Populations for Epidemiologic Study of the Elderly.
the logistic regressions (binary logit) related to the sense
that one can improve one’s health. In Model 1, as was the
case for internal locus of control, education is a strong predictor of a greater sense of control. None of the other demographic predictors are significant. In Model 2, education
remains highly significant, and psychological distress
emerges as a positive predictor of one’s sense of one’s ability to improve health. On the face of it, one might expect
distress to undermine one’s sense of control, but in this case,
it may make the issue of control more salient. In Model 2,
chronic conditions decrease one’s ability to improve health
for older Mexicans.
Table 3 displays the results for the H-EPESE sample employing ordered logistic regression procedures. Columns 1
and 2 present logit coefficients for self-care concern, and
columns 3 and 4 one’s sense of control over health. In
Model 1, for self-care concern, females and married people
report greater concern over their capacity to care for them-
Greater Internal
Locus of Control
Age (years)
65–69
70–79
80 and older
Female
Married
Education
No formal education
1–5 years
6 or more years
Personal income
Low
Middle
High
Financial strain index
Currently insured
Psychological distress
Fair/poor self-rated health
Health risk factors
Obese
Pack years
Problem drinker
Chronic conditions index
ADL disability index
Intercept
R2 (Nagelkerke)
Ability to
Improve Health
Model 1
Model 2
Model 1
Model 2
—
−0.04
−0.06
−0.02
−0.01
—
−0.03
−0.05
−0.02
−0.01
—
−0.34
−0.43
−0.03
−0.13
—
−0.36
−0.45
−0.06
−0.10
—
0.07*
0.23***
—
0.07*
0.22***
—
0.19
1.04***
—
−0.03
0.05
−0.02
0.06*
—
—
—
−0.04
0.04
−0.01
0.06*
−0.00
−0.08**
—
0.03
0.02
0.22
0.27
—
—
—
0.02
0.05
0.23
0.36
0.19**
−0.29
—
—
—
—
—
2.98
.08
0.06*
0.00
−0.00
0.01
0.02
3.02
.09
—
—
—
—
—
—
(.04)
−0.22
−0.05
0.13
−0.23*
−0.00
—
(.07)
—
0.20
1.06***
Note: OLS = ordinary least squares; MHAS = Mexican Health and Aging
Study; ADL = activity of daily living.
selves in the future. In addition, financial strain is strongly
correlated with concerns over one’s ability to remain independent. Because nativity and age at migration are such important factors in the Mexican American experience, we
control for these variables for the U.S. sample. Native born
is the reference category, and the results indicate that older
age at migration decreases self-care concerns. Immigrants
who arrive later in life are more likely to live with and be
dependent on family, and this fact may make the issue of
control irrelevant. Model 2 introduces the psychological,
health, and health behavior variables. The introduction of
these variables has little effect on the demographic and financial strain variables other than to drop female below the
level of significance. Of the psychological variables, higher
distress is associated with greater self-care concern. In addition to psychological distress, physical health problems and
ADL disability increase self-care concerns. In this model,
smoking and problem drinking decrease concerns about
one’s ability to care for oneself. Such behaviors may reflect
a general lack of concern with health. In the HLC model,
age is statistically significant.
Columns 3 and 4 of Table 3 present results for one’s
sense of control over one’s health. In Model 1, older age
decreases one’s sense of control. Personal income in the
middle range increases one’s sense of control relative to
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
Table 3. Ordered Logistic Regressions of Control Beliefs: H-EPESE
U.S. Resident (H-EPESE 1993–1994), n = 2,734
Greater Self-Care
Concern
Age (years)
65–69
70–79
80 and older
Female
Married
Education
≥12 years of education
Personal income
Low
Middle
High
Financial strain index
Currently insured
Nativity/migration age
United States/—
Mexico/1–19
Mexico/20–49
Mexico/50–90
Psychological distress
Fair/poor self-rated health
Health risk factors
Obese
Pack years
Problem drinker
Chronic conditions index
ADL disability index
R2 (Nagelkerke)
Greater Sense of
Health Control
Model 1
Model 2
Model 1
Model 2
—
−0.06
0.22
0.38***
0.21*
—
−0.09
0.08
0.07
0.26**
—
−0.31***
−0.59***
−0.04
−0.05
—
−0.24*
−0.42**
−0.08
−0.02
−0.13
−0.13
—
0.09
−0.02
0.47***
0.02
—
0.07
−0.08
0.39***
−0.06
—
0.19*
0.16
−0.24***
−0.22
—
0.20*
0.24
−0.17**
−0.30
—
0.03
−0.42***
−0.65***
—
—
—
−0.03
−0.47***
−0.72***
0.37***
0.14
—
0.19
−0.03
−0.00
—
—
—
0.22
−0.07
−0.10
0.02
−0.48***
—
—
—
—
—
(.08)
−0.09
−0.03*
−0.53***
0.13***
0.38***
(.15)
0.16
—
—
—
—
—
(.03)
0.04
−0.01
−0.03*
−0.15
−0.12**
−0.21*
(.07)
Note: H-EPESE = Hispanic Established Populations for Epidemiologic
Study of the Elderly; ADL = activity of daily living.
those in the lowest category. Although the patterns for the
highest income category are similar to those for middle income, they are not significant. Financial strain significantly
increases self-care concern. In the U.S. sample, health insurance is not significant in any model. In this sample,
Medicare coverage is basically universal.
Model 2 introduces the psychological, health, and health
behavior variables for HLC. In this model, fair or poor selfrated health is associated with a lower sense of control over
one’s health. Of the health behaviors, only smoking has a
significant effect in reducing concern over the ability to
control one’s health. The presence of chronic health conditions reduces one’s sense of control, as does the presence of
functional problems (ADL index).
Discussion
Our findings build upon and extend a growing body of
research that investigates issues of aging, locus of control,
and health (e.g., Krause, 2007; Lachman and Weaver, 1998a,
1998b; Norman et al., 1998; Ross & Mirowsky, 2002; Shaw
& Krause, 2001; Wickrama et al., 2008) by examining issues of a sense of control in a comparative context. Our
397
analyses of two culturally similar samples of older individuals in two very different national contexts reveal that social
characteristics associated with poverty and social marginalization result in a lower sense of control over important
aspects of one’s life, including one’s health. The findings
also indicate that access to health insurance, which is nearly
universal for elderly Americans in the form of Medicare, is
an important factor in removing one’s sense of insecurity
and a lack of control over one’s health. In Mexico, where
health care coverage among the elderly is not universal, access to health care coverage directly affects one’s ability to
obtain care (Wong et al., 2006) and is therefore associated
with one’s subjective sense of control.
Our findings suggest that universal health care coverage
would have clear psychological benefits in addition to the
practical benefits associated with access to care. From a
public policy perspective, the contribution of health coverage to psychological as well as physical health has important implications for the well-being of older individuals
given the increasing need for medical care that accompanies
aging. If health problems are not treated or not treated adequately, the quality of individual lives can be undermined
and the eventual long-term care burden on families and society increased. The adequate control of chronic illnesses
and the minimization of their negative effects represent core
objectives of primary care for the elderly. In Mexico, the
inability of many older individuals to avoid or reduce the
consequences of chronic illnesses objectively reduces their
control over their health (Angel et al., 2008). This fact has
important implications for comparative research in which
subjective health-related, or really any other subjective, information is collected.
Although human beings share a common evolutionary
history and pass through the life course on the basis of a
basic set of similar developmental possibilities, the actual
experience of aging is strongly conditioned by the material,
political, and social contexts in which one lives one’s life.
We began this study by calling upon Abraham Maslow’s
humanistic theory of human development to emphasize the
fact that the possibilities for optimal development depend
on an adequate material foundation. We end by calling upon
another classic author, T. H. Marshall, who over half a century ago characterized the modern welfare state as the culmination of three centuries of the consolidation of basic
human rights that define full citizenship (Marshall, 1950).
During the 18th century, citizens, or at least White European males, gained basic legal-civil rights; during the 19th
century, they gained greater political rights; and during the
20th century, citizens of the modern welfare state won social rights, which include not only the right not to be detained without cause and the right to vote but also the right
to full participation in the economy and to partake of the
material necessities of a civilized and productive life.
Marshall’s characterization has been criticized for referring only to Europe or, perhaps, even just Great Britain. Yet
398
ANGEL ET AL.
it expresses an ideal of equity in which all citizens have the
right to the necessities of a dignified life. Clearly, many
groups in the developing world, and even many in the developed world, including racial and ethnic minorities and colonized indigenous groups, have not achieved full political, let
alone social, rights. For them, the route to self-actualization
and the generativity that comes with economic and social
security remains elusive. In this paper, we have raised issues
related to the role of national context in determining access
to adequate material supports and the impact of those differences on one’s sense of control over one’s life for older
people in the United States and Mexico. The construct of
locus of control has been applied usefully to health. Such
complex constructs are clearly important in helping us understand health and illness behavior, and they can even be
useful in designing public health interventions. The contribution of this discussion to the literature is to emphasize the
central importance of structural factors related to economics and the health care system on what we might see as
purely psychological phenomena. The issue is particularly
salient as the amount of comparative research expands and
as countries, states, and regions with very different socioeconomic and political, in addition to cultural, profiles are
compared.
Today, the best practices in comparative research focus
on careful questionnaire construction and translation. We
have clearly learned much about the best ways to ask complex questions concerning issues that are affected by different cultural contexts. In addition to measurement, though,
conceptual modeling and the treatment of the context itself
remain problematic. Although most comparative researchers are well aware of the complexities that different cultural,
political, and economic contexts introduce into the response
task, few analyses, especially those based on secondary
data, specifically discuss the context, including the nature of
the health care financing and delivery systems, in which the
study takes place in detail.
Given the differences in survey design and variable definition in our Mexican and Mexican American samples, the
degree of similarity in patterns between the two surveys
seems remarkable. The differences that emerge largely reflect differences in economic and social contexts and the
reality of one’s ability to exercise control over one’s life.
There can be little doubt that in addition to structural factors, psychological factors affect one’s sense of control. Yet
it seems imperative to emphasize that psychological traits
or states, especially as they are measured using survey techniques, may themselves reflect structural and economic factors. Individuals who do not have health insurance and have
not been to the doctor most likely do not know that they
have diabetes and they may be misinformed about what
they need to do to deal with symptoms (Angel et al., 2008).
Contact with health professionals educates one in terms of
real capacities for self-care and can affect one’s subjective
sense of control.
For the most part, our results reflect what one would
expect in the association among health and one’s sense of
control over one’s health. Poor health reduces one’s sense
of control in both countries but not for all outcomes.
Chronic conditions increase concern over health and decrease one’s sense that he or she has control over health in
the U.S. sample. Health-related behaviors are not just the
result of personal choices but are affected by social inequalities and differences in access to education, housing,
jobs, and human services. As Jervis, Beals, Fickenscher,
and Arciniegas (2007) argue, these are important considerations to take into account in establishing optimal methods
for assessing the cultural relevance of measures of cognitive impairment in ethnically diverse older populations.
The patterns that emerge from this analysis suggest that
the measurement of psychological characteristics in countries that differ greatly in level of economic development,
health care system characteristics, and social class structure must deal with more than psychometrics and translation. In order to understand health in the broadest sense,
the context in which health is constructed cognitively and
emotionally must also be understood. Healthful aging and
one’s sense of control are clearly complex and multifaceted constructs (J. L. Angel & R. J. Angel, 2006). As we
discussed in the introduction, successful aging has been
characterized in terms of psychological processes and outcomes, and indeed, it would be hard to deny that a deep
sense of satisfaction and generativity, perhaps summarized
by the term self-actualization, represents the ultimate end
point of the successful life course. It is also quite clear that
individuals arrive in life with unique personalities, capacities, talents, and different levels of physical vitality and
health. These represent each person’s unique human capital that he or she employs as a rational actor in the game of
life to achieve personal and collective goals. Yet each of us
also arrives in a different social location which determines
the possibilities we inherit in terms of material capital and
opportunities, as well as the social stigma often associated
with specific categories of race, ethnicity, gender, religion,
tribe, or caste. In terms of the material resources that one
has at one’s disposal as the result of the luck of one’s birth,
life may simply not be equitable. The interaction of individual personalities and capacities and the social structures
within which individuals express their potential represent
the traditional structure versus agency problem in western
thought. Psychologists focus most heavily on the personality traits and states, and organizational and political theorists focus most heavily on the structural. Gecas (1986)
believes self-efficacy consists of three dimensions that
represent self-concept, combined with self-esteem and
self-authenticity. From this perspective, self-efficacy or
subjective control is viewed as part of a general or global
self-evaluation that tends to be stable across situations but
that can change over time depending upon one’s specific
circumstances. Unfortunately, our data do not allow us to
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
determine how an individual’s sense of subjective control
varies as he or she ages.
Both psychologists and sociologists, of course, recognize the legitimacy and importance of one another’s level
of analysis, but the focus on one or the other tends to dominate individual theories and research. Psychologists
clearly dominate the study of successful aging. The objective of this research has been to emphasize the operational
difficulties inherent in attempting to isolate psychological
traits from situational factors. Personality characteristics
and traits clearly exist and lead people to respond differently to different situations. Yet the situations in which
such traits are expressed have independent or more likely
interactive effects. The importance of such an observation,
which may even seem obvious, is to warn against the
temptation to attribute excessive causal force to psychological factors in situations in which poverty, violence,
and general social disorganization reign. The widespread
suspicion of culture of poverty explanations for the multigenerational persistence of the social disorganization
characteristic of some poor communities and neighborhoods arises from the fear that the effects of structural factors are being misattributed to culture. Such misattributions
are certainly epistemologically incorrect, but they are also
potentially quite damaging in attributing to individual and
group pathologies the negative effects of oppressive structural disadvantage. This discussion and analysis has
focused on the material aspects of aging and on social
structure in the determination of the physical and emotional well-being of older individuals in two very different
economic and political contexts. Given the differences in
those contexts and the fact that the two surveys on which
the analyses are based do not have identical measures, we
have avoided the direct comparison of specific effect sizes.
Given the need for translation and the fact that comparative studies cannot eliminate the effects of structural and
cultural differences, our position is that specific cardinal
comparisons may be unjustifiable whatever one does
(Angel, 2006). Despite these limitations, the strength of
this study lies in the development of a heuristic model and
the call for a closer examination of structure in comparative research dealing with subjective states.
Conclusion
For the topic of successful aging and the comparative
study of health, generally, our message is clear and simple.
Although it is clear that the ultimate potential for human
development over the life course can be defined in terms of
personal satisfaction, social engagement, effectiveness,
generativity, and more, we cannot discount or forget the
central role of material well-being. Effective social security
and health care delivery systems for the old, as well as full
employment and educational systems for the young and
middle aged, are the bedrock of successful aging. These are
399
also the bedrock of the modern welfare state, which is in a
period of neoliberal and now post-neoliberal reform. For the
developing nations of the world, as well as for the developed nations, providing the material basis for successful
aging in a period of fiscal austerity and rapidly aging populations presents perhaps insurmountable challenges. With
the dignity and peace of mind that material security brings,
a person is far more likely to develop to the highest psychological level possible. In the study of successful aging, then,
and especially in comparative studies that include different
cultures, social classes, races, and ethnicities, the material
basis of successful aging, as well as the economic, political,
and organizational factors that structure the opportunities
that determine one’s place in the social hierarchy, must be
directly addressed.
Funding
This research was funded, in part, from National Institutes of Health/
National Institute on Aging (NIH/NIA) RO1 AG10939.
Acknowledgments
R.J.A. originated the idea for the study and was responsible for the conceptual development. J.L.A contributed to the development of the theoretical model and analytic review of the literature on locus of control and
assisted with writing of the article. T. H. performed the statistical analyses,
assisted with the review of the literature, and contributed to the interpretation of the data. All authors participated in the interpretation of findings
and the preparation of the article.
Correspondence
Address correspondence to Ronald J. Angel, 320 Burdine Hall, Department of Sociology, The University of Texas at Austin, Austin, TX 78712.
Email: [email protected]
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Received May 16, 2008
Accepted November 7, 2008
Decision Editor: Kenneth F. Ferraro, PhD
401
SUBJECTIVE CONTROL AND HEALTH AMONG MEXICAN-ORIGIN ELDERS
Appendix
Coding
Question
Item
Control/Concern Index
MHAS
(1) External locus of control—Adapted from Rotter (1966)
I’m going to read what people say sometimes about their
lives. For each statement, please tell me if you: Agree,
Somewhat Agree, Somewhat Disagree, or Disagree
Enseguida le voy a leer cosas que las gente dice a veces.
Para cada una de las expresiones, por favor digame si Ud.: Está
de acuerdo, algo de acuerdo, algo en desacuerdo, o en desacuerdo
19a There’s no sense in planning a lot for the future
19b The really good things that happen to you are mostly luck
19e Most of one’s problems are due to bad luck
19f One has little control on the bad things that happen to
him/herself
19a No tiene case planear mucho para el futuro
19b Las cosas muy buenas que le suceden a uno son por buena
suerte
19e La Mayoria de los problemas se deben a la mala suerte
Uno tiene poco control sobre las cosas malas que le suceden
Lower external control =
19a + 19b + 19e + 19f
19c One is responsible for his/her own successes
19d One can do just about anything he/she put his/her mind to
happen to him/her
19g One’s misfortunes are the result of his/her own mistakes
19h One is responsible for his/her own failures
19c Uno es responsible de sus propios exitos
19d Uno puede hacer casi cualquier cosa que se proponga
19g Las desgracias que le ocurren a uno son resultado de sus
errores
19h Uno es responsable de sus propias fallas
Higher internal control =
19c + 19d + 19g + 19h
Yes ..............1
No ................2
Dichotomy (1,0)
Higher health control
(2) Internal locus of control—Adapted from Rotter (1966)
I’m going to read what people say sometimes about
their lives. For each statement, please tell me if you: Agree,
Somewhat Agree, Somewhat Disagree, or Disagree
Enseguida le voy a leer cosas que las gente dice a veces.
Para cada una de las expresiones, por favor digame si Ud.: Está
de acuerdo, algo de acuerdo, algo en desacuerdo, o en
desacuerdo
(3) Health locus of control (Wallston et al., 1978)
Do you think that a person your age can improve his/her
health through regular exercise, balanced diet, or by stopping
smoking?
¿Usted free que una persona de sue dad pueda mejorar su
salud con ejercicio regular, alimentacion adecuada, o dejar
de fumar?
Si ....................1
No ...................2
H-EPESE
(4) Locus/coherence (general; Antonovsky, 1979) of control
How concerned are you about being unable to be
independent and take care of yourself and your affairs in
the future?
¿Qué tan preocupado(a) está usted de no ser independiente ó
poder atender sus asuntos personales en el futuro? Diria usted
gue esta.
(1) Not concerned at all
(2) Somewhat concerned
(3) Very concerned
(1) Muy preocupado
Greater self-care concern
(2) Un poco preocupado
(3) No se preocupa
(5) Health locus of control (Wallston et al., 1978)
To what extent do you feel you can control the general
state of your health through your own actions?
¿A cuál grado siente usted que puede controlar el estado
general de su salud a través de sus propias acciones
(1) Not at all
(2) Somewhat
(3) A great deal
(1) Mucho
(2) Un poco
(3) De ninguna manera
Higher health control