HEALTH EDUCATION RESEARCH
Theory & Practice
Vol.13 no.l 1998
Pages 25-32
Beliefs about alcohol, health locus of control, value for
health and reported consumption in a representative
population sample
Paul Bennett, Paul Norman1, Simon Murphy2, Laurence Moore and
Christopher Tudor-Smith3
Abstract
The 1990 Health in Wales Survey measured
beliefs about alcohol, health locus of control,
value for health and weekly alcohol consumption in over 11 000 individuals. Only 4% of
women and 14% of men drinking at 'dangerous'
levels considered their consumption likely to be
harmful to their health. In addition, 19% of
men and 27% of women who considered their
level of consumption to be harmful to their
health had increased their consumption within
the previous year. Health locus of control
explained only between 0.5 and 1% of the
variance in consumption in women and men,
respectively. The implications of these findings
for health promotion initiatives are discussed.
Introduction
Promoting appropriate levels of alcohol consumption remains a high priority for both international
(e.g. WHO, 1988) and national (e.g. Alcohol
Concern, 1987) health authorities. The WHO
(1988) have advocated a healthy public policy
approach, focusing on three broad approaches:
demand reduction, supply reduction and 'other'.
Demand reduction may be achieved, for example,
through taxation, increasing the risk of detection
University of Bristol, 5 Priory Road, Bristol BS8 1TN,
'Department of Psychology, University of Sheffield,
Sheffield S10 2UR, 2Department of Psychology,
University of the West of England, Bristol BS16 2JP,
3
Healtb Promotion Wales, Ffyn-On-Las, Ilex Close,
Ty Glas Avenue, Cardiff CF4 5DZ, UK
© Oxford University Press
for alcohol-related offences and tighter controls
over advertising, particularly that targeted at young
people. Supply reduction may be achieved through
restricting availability and manipulating the age of
legal drinking. The final policy approach includes a
variety of methods, mostly focused on encouraging
appropriate consumption through health promotion
initiatives targeted at the individual (see Bennett
etal., 1992)
A majority of health promotion initiatives have
adopted an educational approach, in particular
providing information on the levels of consumption
considered 'safe', 'risky' or 'dangerous'. However,
a number of authors have questioned whether such
knowledge will necessarily lead to behavioural
change (Goodstadt, 1978; Schaps etal., 1980).
What also remains unclear is how such messages
are received and interpreted by the public. Anecdotal evidence, at least, suggests that the lower
limit of 21 units per week for men and 14 units
for women is viewed with some disbelief by
many drinkers.
A second approach is to address higher level
beliefs such as self-efficacy or individuals' beliefs
in their ability to control their health (Allison,
1991). Such an approach may encourage individuals to become more actively involved in their
own health and be more likely to act upon their
knowledge about the negative effects of high
alcohol consumption levels. This approach may be
supplemented by initiatives that attempt to provide
the skills through which appropriate levels of
consumption may be achieved, e.g. by modelling
appropriate behaviour such as skills of resistance
to group pressure (Botvin etal., 1984; Kivlahan
etal., 1990; Froome etal., 1994).
25
P. Bennett et al.
The present study addresses issues pertinent to
both these approaches, reporting data from a large
representative sample which formed the 1990
Health in Wales Survey. It, firstly, examined individuals' beliefs concerning the harmful effects of
various levels of alcohol consumption. It, then,
examined the relationship between health locus of
control, value for health (VH) and consumption.
Health locus of control is considered to involve
three statistically independent dimensions of perceived control in relation to health: Internal, Chance
and Powerful Others (Wallston et al., 1978). Individuals who score highly on the Internal dimension
regard their health as largely within their own
control and are likely to engage in health maintaining behaviours. Conversely, those who score
highly on the Chance dimension view their health
as relatively independent of their behaviour and,
accordingly, are more likely to engage in healthdamaging behaviours than those with lower scores.
The implications of a strong belief in Powerful
Others (typically doctors) influencing health are
more difficult to predict. High ratings may indicate
a receptivity to health messages endorsed by medical authorities. Conversely, they may suggest a
strong belief in the ability of the medical system
to cure any relevant illness. Each would result in
different patterns of health-related behaviours.
A number of studies have examined the relationship between health locus of control and engaging
in health-related behaviours. A majority have
reported a positive relationship between scores
on the Internal dimension and health promoting
behaviours (e.g. Weiss and Larsen, 1990) or a
negative relationship between scores on the Chance
dimension and positive health behaviours (e.g.
Steptoe etal., 1994). While the strength of the
relationship between health locus of control and
health-related behaviour reported is only modest
(Norman and Bennett, 1995), much research has
been compromised by a failure to address the
moderating effects of the value individuals place
on their health. Wallston (e.g. Wallston and Smith,
1994) suggests that only amongst people who place
a high value on their health will a strong and
consistent relationship be found between health
26
locus of control and behaviour. VH (Lau and Ware,
1981) should act as a moderator of the relationship
between health locus of control and health behaviour. Studies which have examined this interaction
have generally produced positive results (e.g. Weiss
and Larsen, 1990; Bennett etal., 1995).
This interaction has been largely ignored in the
alcohol-related research. In addition, much of the
research has focused on problem drinkers'
responses to treatment programmes (Dean and
Edwards, 1990; Johnson etal., 1991). Fewer studies have examined the relationship between locus
of control and drinking behaviour, and these have
frequently involved generalized expectancy beliefs
and adolescent populations. These have reported
mixed results, with some finding positive associations between consumption and externality (Cox
and Luhrs, 1978) and others reporting weak negative correlations with Powerful Others and Chance
scores (Calnan, 1989). Still others (Jones-Saumty
and Zeiner, 1985; Norman, 1990) have reported
no significant relationship between health locus of
control dimensions and consumption.
In the present study, it was hypothesized that
higher consumption of alcohol would be found
amongst individuals with low Internal scores and
high Chance scores. In line with Wallston's
reasoning, it was also predicted that these relationships would be strongest amongst participants who
placed a high value on their health. No predictions
were made concerning the direction of relationship
between scores on the Powerful Others dimension
and alcohol consumption. The study also examined
participants' perceptions of health-related harm as
a consequence of their differing levels of alcohol
consumption.
Method
Participants
Data were collected during the summer and autumn
of 1990, using a stratified multi-stage cluster
design. The strata were the nine District Health
Authorities of Wales. Electoral wards were ran-
Beliefs about alcohol
domly selected from each Health Authority
stratum. Within each ward, two polling districts
were randomly chosen. From these, 30 addresses
were randomly selected. If an address was found
to be unoccupied, an additional, randomly selected,
address was added to the sample. A total of 15
489 households were visited. At each household a
short interview was conducted in which demographic details were obtained. All household occupants aged 18-64 years (N = 21 403) were left a
self-completion questionnaire to be returned in a
stamped addressed envelope to the research team.
Two reminder letters (and further questionnaires)
were sent if necessary. Further details of the
methodology employed in the survey are detailed
elsewhere (Smith et al, 1992).
Measures
Participants were asked to complete questions
measuring:
• Multi-dimensional Health Locus of Control
(MHLCQ-S: Wallston, 1989; Bennett et al.,
1995). This short-form version of the MHLCQ
comprised three questions measuring strength of
belief for each of the three control dimensions:
Internal (Cronbach's a = 0.58), Chance (Cronbach's a = 0.69) and Powerful Others (Cronbach's a = 0.61). Each question comprised a
statement (e.g. 'The main thing which affects
my health is what I do myself') and a sixpoint Likert scale (strongly agree to strongly
disagree).
• Value for Health (VH: Lau and Ware, 1981)
This questionnaire comprised four statements
(e.g. 'If you don't have your health, you don't
have anything') assessed using the same Likert
scale (Cronbach's a = 0.65).
• Weekly consumption of alcohol. Participants
were provided with a card showing the unit
equivalent of various drinks and asked to record
the number of units they typically drank during
the week (Monday-Friday) and at weekends.
These were summed to provide a measure of
typical weekly consumption.
• Perceived harm to health of present consumption. Participants were asked whether they considered their present level of drinking to be
harmful to their health. Response categories
were 'yes', 'no' and 'not sure'.
• Changes in consumption. Participants were
asked how their consumption had changed in
comparison to one year ago. Response categories were 'more', 'about the same' and 'less'.
Analyses and results
The number of people to complete each of the
relevant questions varied between 11 198 and
11 336 (a full completion rate of between 52
and 53%). Where descriptive analyses were
conducted, consumption data from men and
women were collapsed to form groups according
to levels of consumption.1 For men, these
comprised: 'abstainer' (n = 563); 'sensible
drinking', 1-21 units of alcohol per week (n =
3404); 'at risk', 2 2 ^ 9 units per week (n =
1148); and 'harmful', >50 units per week
(n = 1107). For women, the corresponding
categories were abstainer (n = 1205), 1-14 units
(n = 3578), 15-34 units (n = 421) and >35
units (n = 1619). Where correlations or regression
analyses were conducted, weekly consumption
measured in units formed the dependent variable.
Separate analyses were conducted amongst men
and women.
Perceived harm
With some minor discrepancies, data from men
and women, reported in Tables I and II,
were remarkably similar. Perceived risk differed
significantly according to level of consumption
for both men fr2(6) = 120.12, P < 0.0001] and
women ft2(6) = 248.31, P < 0.0001]. Of
particular interest was the finding that about half
those drinking at 'at risk' levels considered their
consumption not to be harmful to their health
(see Table I). Moreover, the percentage of those
considering their consumption not to be harmful to
their health amongst those drinking at 'dangerous'
levels rose to 73% of men and 91% of women.
Only a quarter of those who considered their
27
P. Bennett et al.
Table I. Percentage of male and female participants who
considered their consumption to be harmful to their health
according to level of consumption
Perceived harm
Level of consumption
Safe
Yes
men
women
No
men
women
Not sure
men
women
At risk
Dangerous
4
4
22
25
14
4
86
86
55
50
73
91
10
10
23
26
13
4
Table II. Changes of consumption in alcohol over the
previous year as a function of the perceived harm to health
of reported consumption
Perceived harm
Level of consumption
More
Less
Same
19
27
23
23
58
50
5
5
28
29
66
66
10
16
25
25
65
58
Yes
men
women
No
men
women
Not sure
men
women
consumption to be harmful to their health had
reduced their consumption during the previous
year, while a fifth of respondents with this belief
had increased their consumption over this period
(see Table II).
Locus of control and VH
Correlational analyses
To test the theoretical model proposed by Wallston,
the samples were subjected to a median split on
the measure of VH, with separate correlation
analyses conducted on male and female participants
scoring in the high and low VH groups. Results
28
Table IIL Correlations between weekly consumption of units
of alcohol and health locus of control dimensions in high and
low VH participants
Women
high VH
low VH
Men
high VH
low VH
Internal
Chance
Powerful others
-0.040
0.026
-0.053"
0.007
-0.087"
-O.O85d
0.021
0.030
0.023
0.072c
-0.055 b
-O.O371
•P < 0.05; bP < 0.01; CP < 0.001; dP < 0.0001.
differed according to gender and VH (see
Table HI).
A belief in internal control was not associated
with consumption in either men or women. Chance
scores were negatively associated with consumption in high VH women, but no association was
found amongst low VH women. These correlations
differed significantly (z = 2.50, P < 0.05). In
men the opposite pattern of scores was found.
Consumption increased with Chance scores, with
the association between Chance scores and consumption highest in the low VH group (z =
2.0, P < 0.05). Scores on the Powerful Others
dimension were negatively correlated with consumption amongst both men and women, with no
differences according to VH.
Multiple regression
Two hierarchical multiple regressions were conducted on both male and female samples to identify
both the contribution of individual health locus of
control dimensions and the significance of health
value as a moderator of dimension scores' impact
on behaviour. The variables of Chance, Powerful
Others and Internal were entered in the first block,
with their interaction terms with VH in the second
Weekly consumption measured in units formed the
dependent variable (see Tables IV and V). As locus
of control is associated with age and social class
(Bennett et al., 1995), a second series of regressions
controlled for these variables by forcing them
into the regression equation as a first step before
entering Chance, Powerful Others and Internal as
Beliefs about alcohol
Table IV. Hierarchical multiple regressions amongst men with and without demographic measures, locus of control and their
interaction terms with VH as independent variables, and consumption as the dependent variable
Sig»
SES
Age
Chance
Internal
Powerful others
CHXVH
INTXVH
POXVH
0.064
-0.125
R2 = 0.023
F (2,5101) =
P < 0.0001
0.063
-0.104
0.159
additional R2
F (5^098) =
P < 0.001
0.004
0.222
-0.251
additional R2
F (8,5095) =
P < 0.0001
4.53
-8.76
< 0.001
< 0.001
0.83
-2.45
2.02
NS
< 0.05
< 0.05
0.05
3.67
-2.66
NS
< 0.001
<0.01
Sigr
58.289
0.076
0.98
-0.097
-2.26
0.115
1.45
R2 = 0.008
F (3,5100) = 13.94
P < 0.001
-0.014
-0.16
0.222
3.62
-0.221
-2.31
additional R2 = 0.004
F (6,5097) = 10.897
P < 0.0001
= 0.007
30.655
= 0.003
22.104
NS
< 0.05
NS
NS
< 0.001
<0.05
Table V. Hierarchical multiple regressions amongst women with and without demographic measures, locus of control and their
interaction terms with VH as independent variables, and consumption as the dependent variable
Sig/
Sigt
SES
Age
Chance
Internal
Powerful others
CHXVH
INTXVH
POXVH
0.011
-0.150
R2 = 0.024
F (2,4844) =
P < 0.0001
0.020
-0.003
0.093
additional R2
F (5,4841) =
P < 0.001
0.04
0.022
-0.008
additional R2
F (8,4838) =
P < 0.0001
0.73
-10.27
NS
< 0.0001
0.23
-0.58
-1.04
NS
NS
NS
0.33
0.33
-0.08
NS
NS
NS
60.46
= 0.004
27.75
= 0.0003
17.696
the second block, and the interaction terms as the
third. This allowed the contribution of locus of
control independent of these demographic variables
to be assessed.
In the first analysis the only significant main
-0.008
0.09
0.098
-0.21
-0.131
-1.44
R2 = 0.006
F (3,4843) = 19.928
P < 0.001
-0.013
-0.13
-0.057
0.52
0.011
-0.52
additional R2 = 0.0004
F (6,4840) = 5.296
P < 0.0001
NS
NS
NS
NS
NS
NS
effect for men was for the internal scale, which
was negatively associated with consumption. The
interaction terms for both Internal and Powerful
Other scales were also significantly associated
with consumption. However, the total variance in
29
P. Bennett et al.
consumption of alcohol explained by the model
was 1.3%. For women, the results were more
disappointing with no variables achieving a significant association with consumption. When the
demographic variables were forced into the equation prior to die locus of control variables and VH,
there was little change in the variance explained by
the latter variables at each stage of the regression.
Discussion
The present survey provides large population data
on two types of variables relevant to alcohol
control. The first measured the relationship between
consumption and its perceived harm. The second
examined more distal variables considered to
influence health-related behaviour: health locus of
control and VH.
From a health promotion perspective, data concerning peoples' beliefs about the health consequences of their drinking was disquieting. Only
4% of women and 14% of men drinking at 'dangerous' levels considered their consumption likely to
be harmful to their health, whilst 91 and 73%,
respectively, considered such consumption was not
harmful to their health. Of interest is that these
figures are greater than those in the 'at risk'
category, where slightly more than half the sample
considered their level of consumption to be potentially harmful.
Of perhaps even greater concern was the finding
that 19% of men and 27% of women who considered their level of consumption to be harmful to
their health had increased their consumption within
the previous year, while over half consumed the
same amount. Why this pattern of findings should
be so unclear is not known and can only be
speculated upon. Some may not have considered
their consumption 1 year previously to have been
potentially harmful. Others may have engaged in
a process of cognitive dissonance and disregarded
the health messages promoted by the various health
education bodies. Whatever the explanation, the
finding that a significant number of individuals
who acknowledged the potential health risks of
their present consumption and continued to drink
30
at that level suggests that such knowledge alone
is insufficient in itself to strongly influence consumption.
On the basis of the present results, health locus
of control provides little further explanatory power.
Inconsistent and differing patterns of relationships
between alcohol consumption and locus of control
dimensions were found for both men and women,
and amongst high and low VH groups. Where
correlations between measures achieved statistical
significance, the association between the variables
was very low and significance only achieved due
to the large sample size. At its best the model
explained only 1% of the variance in consumption.
A possible explanation for the low percentage of
variance explained by the model may be that many
participants did not view alcohol as affecting their
health, rendering the influence of health control
beliefs irrelevant. Accordingly, each analysis was
conducted again using only data from participants
who viewed their present level of drinking as
adversely affecting their health. No improvement
in the predictive power of the regressions was
found.2 However, this weak association may reflect
other methodological shortcomings and a failure
to address wider contextual factors.
A stronger, and more consistent, relationship
may have been found using a behaviour-specific
measure of locus of control (e.g. Georgiou and
Bradley, 1992). In addition, Marshall (1991) has
suggested that there may be different kinds of
internal health locus of control beliefs, referring
to self-mastery, illness prevention, illness management and self-blame. All, or some, of these measures may have a stronger relationship with alcohol
consumption than those found in the present study.
Nevertheless, the relationship is likely to remain
only modest
Contextual factors such as exposure to drinking
situations and size of drinking group may have a
greater influence on consumption than not only
locus of control beliefs, but also perceived norms
and self-efficacy beliefs (Dorn, 1983; Knibbe et al.,
1991). However, such cognitions may interact in
a relatively subtle manner to influence consumption
or otiier drinking behaviours. Breckenridge and
Beliefs about alcohol
Dodd (1991), for example, found that subjects who
scored high on measures of externality reported
higher levels of intoxication than internals at the
same level of alcohol consumption and that high
externals' performance of motor skills was more
affected than that of internals (Breckenridge and
Berger, 1990). Similarly, higher internal scores
may be associated with the ability to refuse alcohol
(Shopee/a/., 1993).
In conclusion, the present findings reinforce the
need to understand how the general population
receive and interpret health messages concerning
alcohol-related health damage. It may be more
appropriate for such messages to focus on shortterm negative consequences of excess consumption
(Leathar, 1981), rather than long-term probabalistic
health outcomes. That this may impact significantly
on drinking behaviour is reflected in the significant
changes in young persons' drink-driving behaviour
following successive campaigns (Federal Office of
Road Safety, 1993). Further, understanding how
situational variables interact with health-related
cognitions may be important not only for theory
development, but also in the design of future health
promotion initiatives (Yates and Hebblethwaite,
1983; Yates, 1988).
Acknowledgements
This research was funded by Health Promotion
Wales.
Notes
1. At the time of preparing this report, the UK Government
was in the process of revising these limits. However, as the
data concerns individuals beliefs based on the guidelines
available in 1990, they have not been altered.
2. For reasons of brevity, these analyses are not reported in this
article. However, they are available from the corresponding
author.
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Received July 18, 1996; accepted February 2, 1997