Differential utilization of health care facilities by an elderly population as a function of internal versus external lo...


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Differential utilization of health care facilities by an elderly population as a function of internal versus external locus of control and subject sex
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vii, 72 leaves. : ; 28 cm.
Kirn, Steven Paul, 1947-
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Subjects / Keywords:
Older people -- Medical care   ( lcsh )
Physician and patient   ( lcsh )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )


Thesis--University of Florida.
Bibliography: leaves 60-64.
Statement of Responsibility:
by Steven P Kirn.
General Note:
General Note:

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Source Institution:
University of Florida
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All applicable rights reserved by the source institution and holding location.
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notis - ADB1063
oclc - 14162001
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Full Text







This study is dedicated to the time when all people will have

access to quality health care, without fear of financial catastrophe.


The author extends sincere thanks to Ms. Evelyn Bartylak of

Council H-ouse and to the many helpful employees in the Medical

Records section of the Labor Health Institute.

Thanks are also due to the members of the supervisory com-

mittee, particularly Dr. Louis Cohen, for their cooperation over the

long-distance lines.

And last, my deepest thanks to Katrine, who helped me through

even the darkest hours of calculators and computation, while working

as well on her own dissertation.



Acknowledgments ---------------------------------- 111

List of Tables ------------------------------------- v

Abstract ------------------------------------------ vi

I. Introduction and Review of the Literature ------------- 1

Introduction ----------------------------------- 1

Review of the Literature ------------------------ 3

Statement of the Problem ----------------------- 23

II. Method ------------------------------------------- 27

Subjects -------------------------------------- 27

Procedure ------------------------------------ 28

III. Results ----------------------------------------- 31

IV. Discussion ---------------------------------------- 49

Bibliography -------------------------------------- 60


A. Letter Accompanying Posted Announcements

of Data-Collection Meetings -------------------- 65

B. Research Questionnaire ------------------------ 66

C. Additional Instructions for Mail and Office

Pick-Up Questionnaire Administration ---------- 71

Biographical Sketch ------------------------------- 72


1. Least Squares Analysis:

2. Least Squares Analysis:

Visits ------------

3. Least Squares Analysis:

4. Least Squares Analysis:

Follow-Up Visits --

5. Least Squares Analysis:

Visits ------------

6. Least Squares Analysis:

Complaint Visits --

7. Least Squares Analysis:

Visits ------------

8. Least Squares Analysis:

Reported Sick Days --------

Total Non-Complaint


Preventive Visits ----------



Total Complaint


Minor and Major


Complaint Follow-Up

Total L-I Visits------------
Total LHI- Visits -----------










9. Group Means: Number of LHI Visits in Six-

Month Period---------------------------------

10. Summary of t-Tests: Outside Doctor Visits ---------

Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment
of the Requirements for the Degree of Doctor of Philosophy



Steven Paul Kirn

March, 1974

Chairman: Louis D. Cohen, Ph. D.
Major Department: Psychology

Locus of Control, a personality variable describing individuals'

expectations regarding the degree to which they control their rein-

forcements, has been shown in recent research to be an effective

predictor of illness behavior in inpatient medical settings. In the

present study, it was proposed that Internal/External Locus of Con-

trol and subject sex would have a significant effect on elderly subjects'

utilization of outpatient physician services.

It was predicted on the basis of experimental studies associating

subject sex and Locus of Control orientation and risk-taking,

information- and help-seeking, and reaction to anxiety, that Internals

and Externals would differ in both type and quantity of utilization of

physician services. Significant differences were shown between the

sex and Locus of Control groups on Total doctor visits and on Follow-

Up visits, the latter category comprised of those visits which were

scheduled as continuing care after an initial patient-initiated contact.

No significant difference was demonstrated on the measures of

strictly patient-initiated physician visits.

Consistently, Externals and Males were the highest users of

physician services in the Total visit and Follow-Up categories, al-

though overall usage rates by the males in this sample showed some

discrepancy with those typically reported in the literature of health

care utilization. The major contribution of this study is the indication

of the Locus of Control variable as an important factor in continuing

medical care, and its apparent significance in the crucial doctor/

patient interaction.




The medical model of physical health and illness has contributed

to major developments in improving the status of the human organism.

However, as Suchman (1970) points out, there is a strong emerging

trend towards an ecological theory of disease which views it as "... a

maladjustment of the human organism to his physical and social en-

vironment (p. 105). This viewpoint stresses the importance of the

interrelationship of attitudes and behavior to health. Suchman (1970)

continues to say that psychosocial factors are the important ones in

predicting how individuals and groups define and react to illness, thus

suggesting an approach to disease which emphasizes health attitudes

and behavior as major preventive forces. Included in these psycho-

social factors are the influences of culture or society as a whole --

the basic customs and values which are usually the study concern of

anthropology; specific group membership (family, church, socio-

economic grouping) leading to the adoption of typical norms and roles--

falling in the province of sociology; and finally, the individual dif-

ferences, personality variables and attitudes which are the topics of

interest to psychology.

One such psychosocial variable is described in the concept of

Locus of Control (Rotter, 1966) which refers to the degree to which an

individual expects that he will be able to influence events and outcomes

in his environment by his own behavior. Those persons w;,ho score

high on Internal Control believe that their outcomes are highly contin-

gent upon their own attributes or behavior, while External scorers

see themselves as under the control of fate, chance or powerful others.

As shown in several review articles (Hotter, 1966; Lefcourt, 1966;

Joe, 1971), Locus of Control has been demonstrated to be a good pre-

dictor of a number of different types of behavior. Of particular

importance to this study is the research relating Locus of Control to

subjects' behavior in medical situations. Although research to this

point has mainly focused on Locus of Control as a variable in patient

rehabilitation and on patients already in the medical treatment situation,

there is reason to believe that the Control variable is active also in the

context of deciding whether or not to seek professional medical help in

the first place. This study will focus on one area of that decision-

making process. Specifically, it will examine the relationship among

subjects' Locus of Control, sex, and the type and quantity of medical

care sought within the context of a completely prepaid comprehensive

medical practice.

Review of the Literature

Several major topics will be addressed in the following review

of research pertinent to the present study. First is a brief considera-

tion of some of the wealth of findings which exists in the sociological

literature, and an indication of how important these variables are to

any study of health care-seeking. Following that are two sections

which deal with the concept of Locus of Control; the first is a general

treatment of the Control variable and its development, while in the

latter section Locus of Control is examined as it applies specifically

to health-related behavior.

The health status and behavior of the elderly are considered in the

next section. This is a particularly important topic in light of the

unique health characteristics of this age group, which is the one studied

in the present research. Finally, because of its clear significance to

health care decisions and particular relevance to the Locus of Control

variable a brief section is devoted to the important differences in

patterns of health care-seeking between males and females.

Sociological and Related Research

The systematic study of "illness behavior" (Parsons, 1951) has,

for the most part, been performed by sociologists. In his general

text of medical sociology, mechanic (1963) summarizes a number of

the variables which may affect the type and quantity of help-seeking

behavior in response to illness. These include ". .the visibility,

recognizability, or perceptual salience of deviant signs and symptoms,

how often they appear and/or disrupt the person's functioning, cultural

and informational background of the perceiver, tolerance thresholds

and "... availability of treatment resources, physical proximity, and

psychological and monetary costs of taking action" (pp. 130-131).

In addition, Mechanic (1968) and Scheff (1966) have shown social

background and demographic factors, including socioeconomic status,

to be important factors in help-seeking. Mechanic (1968) concludes:

It seems fair to conclude that cultural and
social conditioning plays an important though
not an exclusive role in patterns of illness
behavior, and that ethnic membership, family
composition, peer pressures and age-sex
role learning to some extent influence attitudes
toward risks and the significance of common
threats, and also the receptivity to medical
services. (p. 125)

As a further variable of importance, Bloom (1963) and Mechanic

(1968) have both cited the significance of the doctor/patient interaction

in the determination of help-seeking and in the efficacy of the medical

intervention. Bloom (1963) discusses some facets of the sick role

as 1) exemption from the performance of normal social obligations,

2) exemption of responsibility for his (the sick person's) own state,

and 3) social pressure to be motivated to behave in such a way as to

get well quickly. It is likely, as Mechanic (1968) suggests, that there

may develop a clash between doctor and patient in terms of the

definition or social norms of illness, in the process of their inter-

action. The mutual expectations of behavior of a 'good" doctor or

patient and of one's own expected behavior may conflict. If they do,

one might expect reactions of hostility, frustration, or perhaps guilt

on the part of either or both parties, particularly when such emotions

are inconsistent with the operative social or professional roles. The

point here is that degree of mutual satisfaction and congruence of

perception of the medical situation will probably affect the patient's

likelihood of returning for further care, following the physician's

prescription, and so forth.

More immediately, it may be that these are important factors

in determining the symptoms reported, in the doctor's perception of

the patient's illness, the diagnostic cues to which he attends, or to his

perception of the patient's ability (or propensity) to carry out treat-

ment plans. Tagliacozzo and Ima (1970) confirmed these predictions

in their study of patients' knowledge of illness, showing that physicians

were inclined to consider knowledge of illness an important factor in

compliance, and that the physicians' assessment of patient knowledge

and understanding influenced their responses to the patients. Knowl-

edge of illness was also shown to be a factor in the propensity to

continue care after the initial medical contact, predicting through

the fourth scheduled visit after the diagnosis. (This finding is par-

ticularly interesting in light of several experimental studies of

information utilization and Locus of Control, to be discussed later).

In a recent article, Johnson (1972) summarizes a number of the

relevatit variables in health care-seeking, concluding that "The major

intervening variables in the decision to visit the physician are socio-

economic status, sex, ethnic origin, cultural background and per-

sonality type, plus the extent to which becoming ill will cause suffering

or hardship for others. (p. 526)

It is clear from even this brief review that a wide array of socio-

logical variables may contribute to patients' decision to seek medical

care. An adequate psychological analysis of care-seeking decisions

must be conducted in such a manner as to control for the influence of

as many of these variables as possible.

Locus of Control

In this section are reviewed a number of studies which focus on

the general definition and development of the concept of Locus of Con-

trol. Also considered are some subsequent research findings which,

while not specifically addressing the health care-seeking process,

point to the possible utility of the Locus of Control variable as a sig-

nificant contributing factor in medical decisions.

The Locus of Control variable has been one of increasing interest

in the years since Rotter's (1966) monograph describing his research

on the topic. In general, the research has been supportive of the

validity of the Locus of Control construct and suggests its applicability

to prediction of behavior in a number of situations (Joe, 1971).

In essence, the concept of Locus of Control describes individuals'

expectation of the degree to which reinforcements will be contingent

upon their own behavior. PerOso1ns nimay score anywhere alongL a corn-

tinuum of Internal External Locus of Control, with orientation

measured by means of a 23-item forced-chuice questionnaire. Internal

scorers believe that what happens to them is a result of their own

activity, abilities or behavior, while those who are more External ex-

pect (as a result of their past history of reinforcement contingencies)

that their outcomes will depend on the activity of luck, fate, powerful

others and so forth. Scores are arrived at by simply counting the num-

ber of "External" items endorsed on Rotter's (1966) questionnaire

(Appendix B); thus, the higher the score, the more External the expecta-

tion of control of the individual. The concept ot Locus ol Control was de-

veloped from social learning theory, in that the generalized expectancies

for either the Internal or External control orientation develop on the basis

of a person's total history ot reinforcement experiences. The premise

is that these experiences generate a basically consistent attitude toward

either an Internal or External locus as the source of reinforcement.

Joe (1971) and Rotter (1966) report consistency in reliability meas-

ures of the Locus of Control scale, with test-retest reliability coef-

ficients ranging from 49 to .83. Internal consistency estimates of

reliability, as reported by Rotter (1966) range from 65 to 79.

Rotter (1966), IIersch and Scheibe (1967) and Minton (1967) found

good discriminate validity for the Locus of Control scale, reporting

nonsignificant correlations with political affiliation, social desirability,

intelligence and attitudes on international relations. However, some


other findings are reported by Joe (1971) which are contradictory re-

garding possible contamination of the Locus of Control scale items

by a social desirability factor. Strickland (1965), Tolor (1967) and

Tolor and Jalowiec (1968) found no contamination of the scale items by

social desirability, though Feather (1967) and Altrocchi et al. (1968)

did find a significant relationship between the Locus of Control scale

and social desirability, as measured by the Marlowe-Crowne scale. It

is possible that the Locus of Control scale is not free of the social

desirability factor, but further study is needed.

Other studies have suggested the possibility of examining the Locus

of Control variable multi-dimensionally, for example, the factor

analytic research of Mirels (1970) and Abramowitz (1973), both of

whom indicate the need for consideration of a "personal control" and

a "political/social control" component. Nevertheless, as will be

shown later, the Locus of Control scale as it was revised by Rotter

(1966) has been shown to be related to a number of health-related

attitudes and behavior (e. g., MacDonald, 1970, and MacDonald and

Hall, 1971).

These criticisms noted, Joe (1971) ultimately agrees in sub-

stance with the conclusions of Rotter (1966) and Lefcourt (1966), con-

cluding that ". .. data tend to support Rotter's contention that the

internal-external control concept is a generalized expectancy operating

across many situations" with "the most significant evidence for the

construct validity of the internal-external control concept lying in the

area of personality functioning" (p. 634).


In the course of its popularity as a research variable, Locus of

Control has been shown to be a pertinent factor in a number of variables

relevant to the present study. Butterfield (1964) found that an External

control orientation was positively related to debilitating anxiety, as

measured by the Albert-Haber Facilitating-Debilitating Test Anxiety

Questionnaire. Similar findings were reported by Tolor and Resnikoff

(1967) in relation to death anxiety, and by Watson (1967) on the Manifest

Anxiety Scale. It would be interesting to have information regarding

the differential responses of individuals to such anxiety, as in

response to threat, but the research evidence has been "inconclusive"

(Joe, 1971). What studies there are suggest that Internals are more

denying of threat stimuli than Externals (Efran, 1964; Lipp et al.

1968). Consistent findings are supplied by Farley and Mealiea (1972)

who showed that Externals demonstrated a greater generalized fear of

potentially threatening objects, persons and events than did Internals.

Whether this is because Internals are more denying of threat, or less

likely to report fear is not discussed. MacDonald and Hall (1969)

found that Internals perceive emotional disorders as more threatening

than do Externals, suggesting some further differential responses to

threat. However, it is clear that further study, perhaps using dif-

ferent measures of reaction to threat, is called for.

Related to this research are the studies of Liverant and Scodel

(1960) and Julian et al. (1968) who found in laboratory experimental

studies of risk-taking that Internals as opposed to Externals: 1) made

significantly fewer low-probability bets, 2) wagered more money on

safe bets than on risky bets, and 3) generally made choices with higher

probabilities of success. Thus, Internals are seen as more cautious

and conservative in their attempts to effect outcomes. Baron (1968)

found further evidence for these results, finding that Externals were

more willing to take risks on choice-dilemma problems. It may be

that, translated into medical care-seeking terms, Internals are more

likely to make relatively "safe, conservative decisions (such as

regular physical check-ups, immediate attention to minor symptoms)

than are Externals, who would make more risky choices (e. g., ignoring

physical symptoms, neglect to make appointments for check-ups).

In general, Internals appear to adopt high personal control be-

havior patterns across situations. As MacDonald (1972) points out,

when told that they have personality deficiencies, Internals are more

open to remedial programs (Phares et al. 1968). In reformatories,

Internal inmates were found to learn parole-related information better

than Externals (Seeman, 1963). Internals acquire more knowledge

about their problems (Seeman and Evans, 1962) and are more ef-

fective at seeking information pertinent to tasks before them (Davis

and Phares, 1967). All of these findings point to a significant Locus

of Control effect in the medical care-seeking decision process.

Since follow-up visits constitute a significant portion of all phy-

sician contacts, it is important to note here several findings which

may bear on the Locus of Control variable once the person is in the

doctor/patient context. Tolor and Reznikoff (1967) and Altrocchi

et al. (1968) found that Internal scores were significantly related to

"repression" and External scores to "sensitization. These results

are particularly interesting in light of the Schwartz et al. (1971)

findings that repressors receive more organic medical diagnoses

than do sensitizers, who were more likely to receive diagnoses with

psychological components. It is interesting to speculate as to the

number of follow-up visits which would be required to deal with a

more explicit medical problem as opposed to psychosomatic and

related disorders, not to mention the different prescription and treat-

ment plans which would be required. For example, would vague,

psychosomatic complaints require increased follow-up attention for

accurate diagnosis?

Also of interest are the results reported by Borden and Hendrick

(1973), pointing out the importance of Locus of Control in interpersonal

attribution. Specifically, it appears that Internals, who expect their

wishes and intentions to have an effect on the environment, assume

this to be true of others as well; the same is true of Externals and

their expectations. Given the Tagliacozzo and Ima (1970) results

regarding physicians' perceptions of patient's level of knowledge, it

1 The Repression-Sensitization scale referred to here is one
designed to measure a continuum of psychological defenses ranging
from anxiety-avoidance behavior at one end (repression) to anxiety-
approach behavior, including obsessive thinking and worry, at the
other (sensitization).

may be that the compatiii o iitibility or incompatibility of doctor/patient con-

trol orientations will affect the efficacy of or satisfaction with the

medical intervention.

One may conclude from the Locus of Control literature above that

the variable does have some promise as a predictor of health-related

behavior. Internal control orientations have been shown to be related

to facilitating amniety, to more safe-bet behavior in risk situations,

and to more effective information-seeking behavior in problem-solving.

Further, Internals appear to be more prone to undertake remedial

programs when they perceive themselves as personally deficient, and

some indirect evidence suggests that even types of medical deficiency

may be related to the person's control orientation.

The decision of whether or not to seek physician services is one

which inherently raises questions of personal control. Surrendering

one's physical care to another may be seen in one sense as an act

indicating an admission that one's own efforts may not be adequate to

achieve the desired physical state -- an admission of insufficient

personal efficacy usually identified with an External Locus of Control

orientation. On the other hand, deciding to visit a doctor might be

described as reflective of a very Internal control orientation, with the

physician being seen as an expert consultant to be utilized in the pro-

cess of taking care of one's health problems. Tie physician visit then

becomes not so much a "giving up" of personal control to a sort of

higher power, but rather part of a process of taking and keeping

control of one's health status insofar as is hJumLanly possible.

It is proposed that the health and personal context within which

this decision to visit the physician is made will prove critical in the

outcome. Specifically, Internals should be more likely to visit the

physician \when there is no clear and present danger to personal health,

for example, for regular physical check-ups. It is somewhat less

certain what will be the case in visits in which there is some presenting

complaint, or when the decision becomes more of a collaborative one

involving doctor and patient as in the case of a follow-up visit. Never-

theless, it seems clear that an overall outlook on life as regards

Internal or External expectations of control will profoundly alter the

perception or the decision to consult a physician.

In the following section will be described the relatively few studies

which have specifically explored the relationship between Locus of

Control and illness behavior.

Locus of Control and Health Care

There have been several research studies published which suggest

that Locus of Control may serve as a differentiating attribute when

predicting patients' responses in medical treatment. In an early study

examining this relationship, Seeman and Evans (1962) suggested that

patients who are Internal scorers will try to control the environment

in the hospital setting. It was found that Internal patients were better

informed about their illness, and asked more questions of nurses and

physicians than did a group of Externals matched with them on hospital

experience and socioeconomic status. In a related study, Johnson,

Leventhal, and Dabbs (1971) also found that Locus of Control was

associated with surgical patients' ability to influence care; Internals

obtained more needed analgesics than did Externals.

Straits and Sechrest (1963) examined the relationship between

Locus of Control and cigarette smoking, finding first that smokers are

more External than non-smokers. Of more interest, however, are the

results of a study by James, Woodruff, and Werner (1965) which was

undertaken after the Surgeon General's report on the health hazards

of smoking. It was found that subjects who subsequently stopped

smoking were more Internal than those who did not stop smoking.

Although not specifically related to health problems, a study by Phares,

Ritchie and Davis (1968) supported these findings, concluding that

Internals were more willing to undertake remedial programs for "per-

sonality problems" than were Externals. In his review article, Joe

(1971) states "...... it appears safe to conclude that Internals, in con-

trast to Externals, would show a greater tendency to seek information

and adopt behavior patterns which facilitate personal control over their

environments. (p. 627).

In several articles dealing v.,ith Locus of Control as a variable in

patient rehabilitation, MacDonald has found further indications that

patients' Locus of Control will significantly affect their reaction to

various types of disability. MlacDonald (196)) concluded from research

literature that External scorers are more threatened by physical

disabilities, while Internals, relative to E:-:ternals, view emotional

disorders as m-ore debilitating than pIhys ical disabilities. These find-

ings were supported in another study (lacDol)nd ad n Hall, 1971).

MacDonald (1972) expanded on the earlier research, suggesting the

practical importance of Locus of Control orientation in efforts at


"Internals seem to acquire more knowledge about
their problems or the task before them. Consequently,
they are in a better position to cope with the problems
they have. (p. 45)

MacDonald (1972) further describes the importance of the negative

expectancy for success which is characteristic of Externals, pointing

out that even high levels of motivation will not effect appropriate

problem-solving strategies in the absence of reasonable success


There are some studies which indicate that Locus of Control may

serve to differentiate health-related behavior outside the sickness

context. Gochman (1971) predicted that Internal control (as measured

by the Bialer, 1961, scale) would be inversely related to health prob-

lem expectancies and directly to probabilism within expectancies.

Probabilism here refers to the greater differentiation of health problem

expectancies, the tendency to be less categorical in responses. This

is presumably a more reality-based, sophisticated way of predicting

health problems, and was found to be significantly related to Internal

Locus of Control. Overall expectancy (or perceived vulnerability) was

not shown to be associated with perceived Internal control.

Baunan and IUtdry (1972) found that among a sample of urban

Negro males, "powerlessness" or a sense of being unable to

influence one's outcomes, was a strong predictor of regularity of

contraceptive practice, even when eight other related variables were

controlled; powerlessness was associated with irregularity of practice.

These findings are consistent with other research on Locus of Control

and birth control practice by MacDonald (1970) and Keller (1970).

Dabbs and Kirscht (1971) examined Internal control and the taking

of influenza shots in a college student population. Using a modification

of the Rotter (1966) Locus of Control scale which they divided into

items measuring "expectancy of control" and "motivation to exert

control", it was found that high motivation to exert control was

associated with taking shots while high expectancy of control was asso-

ciated with not taking shots. While these findings seem inconsistent

with the birth control studies, in which Internals were more apt to

take preventive measures, it should be noted that influenza shots may

represent a unique case in "preventive health care". The shots often

innoculate against only one strain of flu and regularly produce side

effects which resemble the influenza itself. It may be that, consistent

with Gochman's (1971) findings, the "high expectancy for control"

group was deciding, on a probabilistic basis, the risk of contracting

influenza and weighing this against the possible aversive consequences

of taking the shots, then deciding against them. Dabbs and lKirscht

(1971) do report a correlation of 40 (p 01) between motivation and

expectancy, even though those scores were related to iinnoculation in

opposite directions. As Dabbs and Kirscht point out, "Very little is

known about the conditions under which expectancy of control becomes

linked to action or inaction. (p. 962).

Some possible elaboration on their question may come from

Millner (1969) who examined utilization of a prepaid health care fa-
cility. It was found that those who scored high on "treatment knowl-

edge" (a measure of sophistication and information about illness

symptomatology and treatment) were more likely to seek preventive

care than were those who had low treatment knowledge (p< 01).

Millner (1969) further found that there was no relation between type of

care sought (preventive, treatment of minor symptoms, traumatic

care) and age, sex, race, marital status, family size, income, white

collar/blue collar classification, or education, within this prepaid

context. It was also found that those families who sought medical

care outside the prepaid group context (from private physicians) scored

higher on the treatment knowledge index, a score which is likely

associated with an Internal Locus of Control (Joe, 1971).

The literature seems to suggest a likely relationship between sub-

jects' Locus of Control and types of medical care sought. Experimental

studies of infourmation-seeking and utilization \ would probably be

1 Millner's study examined utilization of the Labor Health Institute
in St. Louis, Alissouri. This is the same setting in which data were
gathered in the present study, and it is described in more detail in the
"Method" section of this paper.

associated with the treatment knowledge results reported in Millner

(1969). While the Dabbs and IKirscht (1971) data may appear some-

what inconsistent with behavior expected from Internal scorers on

Locus of Control, a more general study of preventive care-seeking

might clarify the findings. The Mac Donald (1970) and other findings

on birth control practice certainly suggest that Locus of Control can

be an important variable in predicting choices and patterns in health

care behavior. The early studies of Seeman and Evans (1962) plus the

more recent work of Johnson ct al. (1971) have shown Locus of

Control to be important in in-patient settings. The present study will

examine health care-seeking outside the hospital context, and it seems

reasonable to assume that the more adaptive responses shown related

to Internal control will again be demonstrated.

The Elderly and Health Care-Seeking

Since the present study examines some help-seeking behaviors of

an elderly population, it is important to review briefly some of the

general health and health care-seeking attributes of this age group.

This section reviews some such studies.

Chinn and Robins (1970) have reviewed the general health aspects

of aging and conclude that popular stereotypes of aged Americans are

inaccurate. Among other points, the data show that "The vast majority

of the elderly are not in poor health; they are not significantly dependent;

they are not institutionalized. (p. 209) Approximately 96(', of persons

over 65 live in the community, and of that group, 82% carry on the

activities of daily living. Although there may indeed be health prob-

lems of one sort or the other, most elderly people do function, and

this is an important facet in the concept of wellness. Thus, as Chinn

and Robins (1970) point out, the great challenge is not only to care

for the sick-aged, but to maintain the health status of the well-aged..."

(p. 209). As Suchman (1970) has observed, health attitudes and be-

havior are crucial to this endeavor.

Other data support these conclusions. Butler (1967) reports the

results of a longitudinal study of men over 65, finding that non-

survivors in the group were (among other things) heavy smokers,

were more dissatisfied with their current living situation, and had

more limited goals. Survival was thus seen as related to the indi-

vidual's self-view and his sense of continued usefulness. These data

suggest the efficacy of looking for further health-related personality

variables and attitudes. Palmore and Luikart (1972) found that a sense

of "Internal control" was second in importance only to self-rated

health as a constituent of overall life satisfaction. This Internal con-

trol orientation was significantly related to sex (males were more

Internal) and to a general "active-mastery" approach to life, which

the authors also describe as partially sex-related.

Johnson (1972) observes that the current widespread interest in

the health of old people has, for the most part, not been reflected in

the amount of research being conducted regarding their illness be-

havior. "What most studies do tell us is how old people rate their own


health status. (p. 526) For example, Rosencranz and Pihlbad (1970)

developed a scale for measuring the health of elderly people based on

their self-reports. The main factors in predicting clinically evaluated

health status were found to be mobility and self-perception of health.

Johnson (1972) got somewhat different findings regarding self-rated

health; the vast majority of elderly people reported their health as

"good" regardless of extensive illness or capacity, but he concurred

in the conclusion that when older people did rate health as "poor, it was

almost always due to impaired activity.

Desroches et al. (1968) studied the influence of age, physical

health and psychological state on the reporting of symptoms on

Cornell Medical Index (CMI). They found: 1) no general relationship

of age and reporting of symptoms in an elderly (domiciliary) popu-

lation; 2) CMI estimates of physical symptoms (a subjective measure)

were not related to health status based on a physician's examination;

3) subjective estimates of overall current health were not related to

admission of symptoms.

It is interesting to note that self-report of "good" health may be

unrelated to propensity to admit to symptoms on a checklist, and that

this admission of symptoms may not be associated with objective

(this is, physician-rated) health. Further study seems required to

get at people's expectations of health in old age, and also the under-

lying factors relating to sensitivity to and reporting of physical

symptoms. The Butler (1967) and Palmore and Luikart (1972) findings

suggest the importance of psychological factors to this health-related


These and other studies suggest that a strong case may be made

for examining the illness behavior of older Americans. Busse (1967)

cites United States Public Health Service figures which show that 2:',

of all private patients seen by physicians were 65 years or older.

National Health Survey data (1972) indicate that for an age/income

group comparable to the one in this study (income less than $4000 and

age over 65) average annual doctor visits are 6 per person. From a

fiscal standpoint alone, it can be seen that the elderly constitute a

major portion of all doctor visits, out of proportion to their numbers

in the population. From a practical standpoint, these rather high

levels of physician visits are useful in that the behavior of interest in

the present research occurs at a sufficiently high rate to permit study

without a very extended time of observation. It is important to find

out what types of health care services are used, under what circum-

stances, and by what types of people.

This section has shown several major points:

1. The elderly as a group do not fit the popular stereotypes of

institutionalization, extremely poor health and general depression over

their physical status.

2. Nevertheless, they are a very high-utilization group among

medical patients.

3. They report physical symptoms in a manner comparable to


younger groups, though mobility emerges as the most important factor

to self-rated health.

4. A number of psychological variables, particularly a sense

of personal efficacy, seem related not only to perception of health but

to survival.

Sex and Health Care-Seeking

Since it will be examined as an important variable in this study,

some brief mention must be made of the different levels of usage of

health services by males and females. As among other age groups,

utilization studies indicate that elderly females are proportionally

higher users of medical facilities than are elderly males (Mechanic, 1968;

Somers, 1968; National Health Survey, 1972). In particular, Somers

(1968) indicates that "The average American woman has considerably

more days of disability and uses more physician services per year

than the average man. (p. 15) National Health Survey data confirm

the latter findings within the elderly population, indicating an average

6. 5 doctor visits per year for women and 5. 5 for men.

Some research suggests that the higher usage levels by women

represent to some degree the over-utilization by some chronic com-

plainers. Busse (1967) described the modal "hypochondriac" in the

elderly group as a "female, of low socioeconomic status, with little

change in her work role. (p. 1231) However, other studies indicate

that the difference is a more general one. Plutchik et al. (1971)

studied sex and body image, finding that males tended to score lower

than females in terms of relative discomfort of a number of parts of

the body. In addition, females generally reported nI'ore b)ody worries

and discomfort than men. Clark and Mlehi (1971) looked at different

sex responses to pain, finding that older men endure a greater degree

of pain before reporting it as such; older women reported pain earlier

in the experimentally induced pain experiment. These findings were

elaborated in that they found that sensitivity was apparently not as

important as the decision criterion for reporting painful sensations

(from heat), i. e., men waited longer, to be "sure" that the sensation

was pain. While these findings may be related to stereotyped percep-

tions of women as hypochondriacs, it should also be noted that in the

study population (and the population in general) women do live longer.

Perhaps there is a pay-off for early pain reporting and relatively higher

physician usage.

Statement of the Problem

The purpose of the present study is to examine the effect of sub-

ject Locus of Control on the utilization of physician services. Also

studied are the effects of subject sex on the same dependent variable.

It is likely, based on the preceding review of research, that In-

ternals will benave in a manner consistent with a high personal control

orientation, particularly in the category of preventive health care-

seeking. While the evidence is somewhat less clear, it is also probable

that Internal subjects will make more doctor visits at which there is

a presenting complaint.

However, it is critical that a number of other factors be taken into

account, ones which have been shown in earlier research to be im-

portant in the decision to seek physician services. These include

financial and general socioeconomic status, ethnic and cultural back-

ground, physical access to facilities and others. One means by which

to accomplish this end is to gather data from a large sample population

in which many levels of these variables are represented, and then to

statistically control for their effects. Desirable as this technique may

be from the standpoint of reduction of sampling error, greater re-

liability and generalizability, it is also quite expensive, and was simply

not feasible in the present case.

An alternative solution is to select a smaller sample which, by its

composition, controls for the relevant variables; this was the tactic

adopted in the present research. A sample population was searched

out in which income level, physical access to services, residence, age,

social group and general physical health were roughly equalized.

The Labor Health Institute (LHI) of St. Louis, Missouri, and the

adjoining Council House residence for the elderly represent a unique

combination. The residents of Council House may join the LHI for

less than $55. 00 per year, and are thus guaranteed comprehensive,

pre-paid health care services within approximately 100 yards of their

residence. In addition, the Council House population is in itself

controlled on the variables of age(, income, cuI'irret social group and,

except for a few. non-white residents, race. Council House residents

also may be expected to be of rouLghly equal health status, since a

requirement for residence there is generally good physical health,

and participation in an extensive work/activity program.

Although some questions may be raised regarding generalizability

of results, it is felt that the population in this study represents an

ideal group for exploratory research on the effects of Locus of Con-

trol in health care-seeking.

The sex variable could have been dealt with by selecting subjects

of only one sex, but that decision hardly seems justified in light of

past indications of male-female differences in health care-seeking,

possible relationship to Locus of Control orientation, generalizability

considerations, and simple meaningfulness of results. Therefore,

subject sex and Locus of Control were examined jointly in their re-

lationship to health care-seeking.

The specific hypotheses tested were as follows:

1. Internals and Extcrnals will report no significant difference

in days of disability.

2. Females will report more days of disability than Males.

3. Internals will make more physician visits which are not

precipitated by a complaint of the patient than will Externals.

4. There will be no difference between Males and Females in

physician visits not precipitated by a complaint of the patient.

5. Internals will make ilmore physician visits at which the
patient reports some complaint or syniptom than will Externals.

6. Females will make more physician visits at which the

patient reports some complaint or symptom than will Males.

7. Internals will make more total physician visits than will


8. Females will make more total physician visits than will


1. There is actually conflicting evidence regarding this hypothesis.
The Efran (1964) and Lipp et al. (1968) studies and others indicating
internals' propensity to deny potential threat stimuli could reverse
the prediction. In contrast, Liverant and Scodel (1960) and Julian et al.
(1968) report less risk-taking, more "safe-bet" behavior for Internals,
which could be taken to indicate that Internals would be likely to report
suspicious symptoms more often and more quickly. This is further
confounded by the potential effect of the predicted increased preventive
care, which presumably should reduce the need for later "complaint"
visits. This hypothesis must be considered tentative.



Subj e cts

Subjects for this study were 74 residents of Council House

apartment in St. Louis, Missouri; 50 subjects were Female and 24

were Male, reflecting a 2 to 1 Female to Male ratio in the Council

House population. Council House consists of two high-rise apartment

buildings with approximately 600 elderly residents, on the premises

of an office, health center, and housing complex (Council Plaza) which

is operated by Teamsters Local 688. The Labor Health Institute

(LHI) is a comprehensive health center with over 30, 000 members.

Council House residents may join the LHI for $4. 50 per person per

month, a real advantage since the LHI facility is within 100 yards of

the farther Council House tower. All subjects had been LHI members

for at least 6 months at the time of the study. Because of Council House

regulations, all subjects were age 62 or older and had annual incomes

of $4500 or less ($5500 per couple). All subjects were white.

Subjects were recruited by several methods. First, there was

a meeting announced on bulletin boards, explaining the purpose as a

study of health care practice and attitudes. This method was repeated

for another meeting, obtaining a total of 40 subjects. Next, subjects

were able to pick up questionnaires at the apartment office, providing

10 more completed questionnaires. Finally, a mailing was done to

50 residents whose names were selected at random from housing

lists. The final mailing resulted in 24 subjects, roughly a 50?3 return

rate. As may be seen from the recruitment methods, all subjects

were volunteers.


At the meetings a questionnaire (Appendix B) was distributed. The

questionnaire consisted of a cover sheet with a space for subjects to

print their names and sex, the Locus of Control scale (Rotter, 1966),

and a final page requesting the number of times each subject had

visited a private (non-LHI) physician during the preceding year, and

the number of daysf das debilitating illness during the preceding year.

For the mailing and office pick-up distributions, an additional sheet

of instructions was added (Appendix C).

The medical record of each subject was utilized as the source for

information on subjects' LHI doctor visits, for the 6-month period.

These records are contained in charts maintained in the central medi-

cal records unit of the LIII, with entries made directly by the LHI

physician who sees the patient. These charts represent the only

comprehensive listing of patient visits, beyond a computer print-out of

visits by particular service utilized, and are used by physicians at the

I.[[I as the source for information on previous patient treatment.

Although there was naturally some variation between physicians in

terms of length of chart notes, the charts did contain adequate infor-

mation for tlhe purposes of classification listed below.

The proccduce was to confi rm dates of patient entry into the ]. [I

program, and then to copy on a separate sheet the date and content of

each chart note entered during the experimental period. The visits

were then categorized into 5 groups.

1. Preventive. Included here were all visits not precipitated

by a physical symptom, nor resulting as a follow-up to some other

visit. Thus included were physical exams, gynecological exams, eye

exams, and so forth.

2. Minor Symptom. This group included all symptoms

defined as minor by the subject, e.g., mild pain, "I just didn't feel

right", etc.

3. Major Symptoms. These were symptoms defined as quite

serious by the subject, presumably so traumatic as to result in the

seeking of medical attention by the vast majority of all persons. Those

encountered in this study were fairly serious accidental injury and a

heart attack.

4. Non-Complaint Follow-Up. This group included all visits

of the nature of a follow-up check on another complaint or treatment,

but not associated with a continuation of the original presenting symptom

or a new one. In other words, the patient returns to check with the

doctor on the efficacy of some treatment, but does not initiate the

contact due to some personal concern or discomfort.

5. Complaint I'(flow-U p. This category is comparable to

category 4, except that a) the original condition which led to a visit

persists or b) a new condition has arisen and the fullow-up nature of

the visit was simply a convenient time to present the new symptom.

Subjects were divided into Internal and External groups by dividing

all obtained Locus of Control scores on the median. Since the median

score (8) was obtained by a number of subjects, this median-scoring

group was randomly assigned to the Internal and External groups.

Thus, Internal scores ranged from 1 through 8 and External scores

from 8 through 17, out of a possible 23 total. Since the largest pos-

sible cell size was desired, no subjects were discarded.



Although few of the original hypotheses were supported as

proposed, results of this study do indicate the importance of the Locus

of Control variable, particularly in combination with subject sex, in

prediction of health care utilization.

Since there was conflicting evidence from past research regarding

the relationship of sex and Locus of Control, a t-test was performed

on the present data. The results were quite clear: Male subjects

(mean = 6. 25) scored significantly more Internally than did Female

subjects (mean = 9. 02; t = 2. 98, df = 72, p< .001). The finding is

particularly interesting in light of some results to be reported later,

indicating especially high physician utilization among External Males,

while lowest frequency of visits was observed among Internal Females.

Nevertheless, this particular sample population tended to score rather

towards the Internal end of the Locus of Control scale, and this was

particularly so among the Males.

Hypothesis 1. Internals and Externals will report no significant

difference in the number of days of debilitating illness.

This hypothesis was confirmed. The literature review and theo-

retical formulations had not suggested that Internals and Externals

would differ in terms of actual physical status. However, the differ-

ence: was important to check, in that a difference in actual sick days

would have redefined the health context within which decisions to visit

the physician were made. It will be remembered that report of im-

paired activity because of illness is perhaps one of the best self-report

measures of health status, when compared with physician ratings

(Johnson, 1972), so it may be assumed that the Internal and External

groups possess roughly equal levels of objective physical health.

The results of the least squares analysis of Locus of Control and

sick days are summarized in Table 1. (This particular method of

analysis, especially appropriate when population characteristics cause

unequal numbers of subjects to occur in each of the cells, is discussed

in WViner, 1962, pp. 224-227 and pp. 291-297.)

Hypothesis 2. Females will report more days of debilitating

illness than Males.

This hypothesis was not confirmed by the data, a rather interesting

result in light of other research upon which the hypothesis was based.

However, in this population sample, there is no significant difference

between Males and Females in days of sickness so severe as to impair

daily activity. Results of the least squares analysis are also contained

in Table 1. Again, it may be assumed that differences in physician

visits between Male and Fenmale subjects are not the result of more

"actual" physical causes (i. e. if they had been independently examined

by a physician).





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THypothesis 3:. Inter'nals will make more physician visits which

are not precipitated by a complaint than will Externals.

This category of visits may be broadly considered "preventive

care-seelking", although it also includes follow-up visits at which

there was no presenting complaint. Contrary to expectations, this

hypothesis was not supported by the data; no significant difference was

observed between the Internal and External groups (see Table 2).

Though it did not reach statistical significance, there is even some

indication that the Locus of Control effect may be operating in the

opposite direction of that predicted, with Externals making more Total

Non-Complaint visits than Internals. This becomes somewhat more

clear as the data are analyzed in their original separate categories of

Preventive (purely patient-initiated, no presenting complaint) and

Non-Complaint Follow-Up (joint decision of doctor and patient, no

continuing or new presenting complaint). Table 3 indicates that there

is no statistically significant Locus of Control effect in the Preventive

category, nor even an indication of a trend in either direction.

However, the least squares analysis summarized in Table 4 does

indicate that External subjects (mean = 1. 45) may be making more

Non-Complaint Follow-Up visits than Internals (mean = 1. 11), al-

though the probability of the difference found occurring by chance is

just shy of the standard 5'i, level. The difference is reported here

because of its consistency with other results to be reported later.

Hypothesis 4. There will be no difference between Males and


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'Females in the number of physician visits which are not precipitated

by a complaint.

This hypothesis of no difference was not confirmed. Rather, Miale

subjects (mean = 3.33) made significantly more visits not associated

with a presenting complaint than did Female subjects (mean = 2.30,

< 025). Again, an analysis was done on the two visit categories

which comprise this total Non-Complaint visit classification: Pre-

ventive and Non-Complaint Follow-Up. As may be seen in Table 3,

no significant sex effect was observed on the Preventive visits variable

such as in the case of the same analysis of the Locus of Control groups.

However, it may be seen in Table 4 that Male subjects (mean = 2. 21)

are returning for significantly more Non-Complaint Follow-Up visits

than are Female subjects (mean = 0. 4; p 001). It appears that

for both of the experimental variables, the difference in physician

utilization occurs not so much in the independent decision to undertake

preventive treatment from a physician, but rather in the number of

Follow-Up visits at which there is no complaint. Males regardless of

Locus of Control orientation and maybe Externals of both sexes are

more likely to make Non-Complaint Follow-Up visits and this category

appears to largely account for the differences observed in overall

Non-Complaint physician visits.

Hypothesis 5. Internals will make more physician visits at which

there is a presenting symptom (Total Complaint visits) than will


As is summa riz(ed in Table 5, this hypothesis w.as not supported

by the data. In a fashion similar to some previous analyses, there is

even some indication that the reverse is true. External subjects

(mean 3. 26) demonstrated at least some tendency to make more

Total Complaint visits than did Internal subjects (mean = 2. 47), al-

though the difference was not quite large enough to reach statistical

significance. The trend seems to be emerging that Externals are

higher utilizers of physician services.

This Total Complaint category is comprised of two types of visits:

purely patient-initiated contacts at which a Minor or Major Complaint

is presented, and Follow-Up visits at which a new Complaint is pre-

sented or an old one demands continued attention (Complaint Follow-

Up). These categories were analyzed separately as were the Non-

Complaint categories, since it seems appropriate to divide visits into

those which are patient-initiated and those which require the collabora-

tion of a physician.

Minor and Major Complaints were combined in this analysis since

only two subjects experienced what were clearly Major health problems.

In addition, this combination eliminates a possible source of experi-

menter bias in interpretation of Minor versus Major symptoms. There

was no significant difference demonstrated between Internal and Ex-

termal subjects in frequency of Minor/Major Complaint visits (see

Table 6).

However, subjects' Locus of Control orientation did indeed have

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an effect on frequency of Cornplaint FIollow-Up visits. Externals

(mean 1. 45) made significantly more such visits than did Internal

subjects (mean 0.72, p <.01), as shown in Table 7. This is con-

sistent with the tendency noted on Non-Complaint Follow-Up visits,

and suggests the importance of subject Locus of Control in the

decision of doctor and patient regarding the need for additional treat-

ment contacts in the process of dealing with health problems.

Hypothesis 6. Females will make more physician visits at which

there is a presenting symptom (Total Complaint visits) than will Males.

This hypothesis was not confirmed by the data, and there was

some indication that the amount of physician utilization for presenting

complaints by this population may even be in the opposite direction of

that usually reported. As may be seen in Table 5, it appears that

M'l.les (mean = 3. 46) may make more Total Complaint visits than

Females (mean = 2. 46; 05< p <. 10). Of course, this difference is not

statistically significant.

More information is gained, as before, from the breakdown

of the Total Complaint category into its components. No significant

difference was shown between the sexes in terms of frequency of Minor/

Major Complaint visits (see Table 6). However, some evidence

exists indicating that Males make more Complaint Follow-[Up visits

than do F'emales, although this difference did not quite meet the

criterion for statistical significance (s-ee Table 7).

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Hypothesis 7. Internals will make more total physician visits

than Externals.

This hypothesis, which of course hinged on confirmation of earlier

ones, was not confirmed. Instead, the opposite of the predicted effect

was demonstrated with Externals (mean = 6.21) making significantly

more total physician visits during the six-month period than Internal

subjects (mean = 4.81, p < .05). The results of this analysis are

contained in Table 8.

Hypothesis 8. Females will make more total physician visits

than Males.

As in the case of the preceding hypothesis, this prediction was

based on data contained in the more detailed hypotheses. Based firmly

though it was in previous data, this hypothesis was not confirmed, the

analysis indicating instead that Males in this sample (mean = 6. 79),

made more physician visits than Females (mean = 4.92, p 4 .025).

Results of the least squares analysis are summarized in Table 8.

It is interesting to note that the two extreme groups in the various

physician visit categories are practically always the same: External

Males are easily the highest utilizers of physician services, while

Internal Females have the lowest rate of the four groups. As may

be seen in Table 9, this difference appears very consistently across

visit categories, with the Internal Males and External Females falling

generally between the other two groups with almost equal numbers of

average visits. Although no statistical analysis was made of this




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pattern, tiLhe trend s2ceems quCite clear; it is rnot simply the effect oi sex

or of Locus of Control which permits distinction of different service

utilizers, but specific combinations of sex and 1.ocus of Control. (It

is perhaps notable that External MIales are tie lowest utilizers of Pre-

ventive physician visits, in contrast to their other high levels).

It was not possible to examine the relative frequency of outside

doctor visits as planned, since it was discovered that the majority of

subjects had been LIII members for less than one year. Since the

questionnaire had asked for the number of outside-LIII visits "during

the past year", it was not appropriate to combine the group (N = 23)

who had access to LIII services for the full year with those who had

been members for less than one year (N = 51). There was no method

by which to assign the outside doctor visits to the 6-month period ex-

amined in the data. However, a t-test was computed in order to

examine the frequency of outside doctor visits for the full-year mem-

bers versus the less than one year members. The test indicated a

significant difference (p <. 01) between the groups, with less than one

year members making more outside doctor visits (mean = 3. 16) than

full year members (mean 0. 83). Even though it would have been

inappropriate to include the results in the total analysis, t-tests were

computed in order to determine sex or Locus of Control differences on

outside doctor visits within the full-year and 6-month member groups.

None of the results were significant at tihe 05 level. The results of

these tests are contained in Table 10.






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The major findings of this study occurred in the category of

Follow-Up visits, rather than in the independent patient choice to make

use of physician services. These findings are interesting in particular

since Follow-Up treatment decisions actually involve the activity of

at least two people -- doctor and patient. The data analysis indicates

that, consistently, Males made more Follow-Up visits than Females,

and Externals made more such visits than Internals. However, these

are only subject variables and tell us little about the other member of

the decision-making dyad: the physician. The only bit of information

available is that all those involved were Male, a particularly pertinent

bit of information in view of the importance of the sex effect.

One of the major questions raised by this study has to do with the

possible differential perceptions of patients by doctors. Do Males

actually require larger numbers of Follow-Up care in order to deal

with illness, or is it possible that the effect is in fact in the other

direction, i. e., are Females, traditionally seen as hypochondriacal in

their symptoms and as overutilizers of medical services for other

than simple medical reasons, being followed up less by the male

medical staff at the LHI? There is no information in the data to


answer such questions.

However, it is important to note that Males and Females do not

report significantly different numbers of sick days, nor do they differ

in the number of LHI visits seeking treatment for specific symptoms.

It may be at least supposed from these data that illness is affecting the

two groups on a roughly equal level, but that somehow, in the doctor/

patient joint decision to make additional contact, the health situation of

the two sexes is being perceived differently.

There is virtually no possibility that either the sex differences or

the Locus of Control differences were due to differentially missed

appointments; only a few such instances were observed, and these were

far too few to examine statistically (a total of three subjects cancelled

as much as one appointment that was not rescheduled).

The one category of visits, other than total visits, in which a

significant Locus of Control effect was observed was that of Follow-Up

visits associated with a complaint. Here, Externals were significantly

more likely to make such visits than Internals. Included in this cate-

gory are visits in which the patient returned with the original complaint,

and those in which the Follow-Up visit was actually the means by which

the patient was able to present a new complaint. Since no differences

were observed between groups on totally self-initiated complaint

visits, it is possible that External subjects, who were predicted to

take a more passive role in the treatment-seeking situation, are using

the doctors' initiative in establishing a Follow-Up meeting as an

opportunity' for presenting furthii complaints, rather than initiating

a course of treatr mnt on their own. A stronger case might be mad:

for this point if larger differences had cbncc observed in subjects'

treatment-seeking for various Minor and Major complaints, but this

difference was not found. Oft course, there remains the possibility

that Internals simply respond more quickly and effectively to treat-

ment in the first place, thus reducing the need for Follow-Up visits

with continuing complaints.

MacDonald and Hall (1971) found that Externally controlled sub-

jects rated physical disabilities in general as moie debilitating than

did Internals, suggesting the possibility that Internals were perceived

as less "ill" in the initial contact with the doctor, and thus less in need

of additional Follow-Up treatment. A further alternate explanation

is that Internals, who are probably more likely to engage in self-

treatment in the first place, are much less likely to use the Follow-

Up visit interaction with the doctor as a chance to bring up new Minor

complaints for which they otherwise might not have sought treatment.

Further study would be required to adequately deal with this point,

perhaps having each patient rate the severity of each symptom brought

up in the Follow-Up visit, and whether or not it would have otherwise

precipitated a doctor visit.

MacDonald (1972) pointed out the negative expectancy for success

among Externals; those who do not see themselves as real controllers

of their own fate could hardly be expected to anticipate a high proba-

bility of effecting favorable outcomes. It is possible that this negative

success expectancy may be coinimunicat:d to the physician, somehow

impressing him with the' need for additional lollow-Up care to fully

treat the symptoms. It is especially interesting that the additional

Follow-Up visits were scheduled for External Males, and less so

among Females. The discrepancy between traditional male stereo-

types of Internal control and this group may make the External

orientation particularly noticeable.

It should also be noted in this context that it is fairly likely that

Follow-Up treatment visits may simply be occurring so frequently in

this particular population, that it is simple to just wait for one's next

regularly scheduled Follow-Up to mention any treatment needs. For

example, External Males are making Follow-Up visits to the LHI on

the average of once every four or five weeks, and visits of all types

on the average of once every three weeks! This is an extremely high

frequency, particularly when it is considered that one of the re-

quirements for residence in the Council House project is that the

individual be mobile, and in generally good health. An initial screen-

ing eliminates those potential residents who would have difficulty in

the high-rise complex and in participating in the numerous mandatory

and voluntary work and recreational activities.

Both sex and ,ocus of Control were shown to exert significant

effects on frequency of overall LHI doctor visits. tHowever, the sex

effect was in the opposite direction of that typically reported in the

health care literature. In this study, both Internal and External Males

made more LIII visits than did either group of Females. In contrast,

the United States National Center for HIealth statistics reports average

yearly visits for a nearly com)lparahbl e age group (age 65 and over as

opposed to age 62 and over in this study) as 6. 6 for ,women and 5. 5

for men, with data collected for the year 1969.

This reversal of typical male/female usage patterns is certainly

surprising, but there is little in the data to explain it. It seems im-

portant to attempt to replicate the findings, particularly within a

context comparable to the Council House/LHI setting. Perhaps the

increased Male visits are related to the ease of physical and financial

access of the facility, but only additional research can answer the

questions raised by this study; there is little more in the present ex-

ploratory data to support additional speculation.

In addition, the average yearly number of doctor visits for com-

parable income groups to those studied at the LII was 6. 0. These

figures are quite different from the number of average yearly visits

for this study group (arrived at by doubling the 6-month figures):

Female mean 9. 8, Male mean = 13. 6. It is likely that the proximity

and low cost of the LHI to the study group contributes to these in-

creased numbers of visits.

As is always the case with research of this design, there is the

possibility that the observed main effects are actually related to

some other variable which was not controlled for. In the case of

the sex variable, there is no way to avoid this situation; "sex" as a

psychological variablie is in reality a sort of summation of the effects

of differential socialization, perceptual e'xp(eriences and so forth. It

is impossible to say which of these sex-related differences or which

complex of differences might be active in the health care-seeking

situation. The Locus of Control variable is somewhat more open to

suspicion. Iowever, the homogeneous nature of this population on the

characteristics of age, income, access to services, race, and

(because of the Council House screening process, which limits residency

to those who are in generally good physical health) basic health and

mobility, controls for many of the factors shown to affect Locus of

Control (Joe, 1971). The sex variable, important since Females

appear in some studies to be more External (Feather, 1967 and 1968),

is controlled for by the experimental design of the study.

Even though statistical examination of the separate components

did not always confirm the effect, it is important to note the trend of

the results in the visit categories which did show some level of

statistical significance. With only one exception, 1Males made more

visits than Females, and Externals made more visits than Internals.

The order is essentially reversed on Preventive visits, suggesting

that preventive care may contribute to the need for fewer Follow-Up

treatment visits. Overall, the data seem to indicate again, that in

the doctor/patient joint decision to arrange for Follow -L'-p visits,

the two experimental variables exert : differential effect. Further

research should focus on tils interaction in the care-seeking


situation. It may be that Internals, shown in other studies (Tolor and

Reznikoff, 1967; Altrocchi et al. 1968) to score significantly more

as repressors than Externals (who tend to score as sensitizers), are

communicating to doctors fewer symptoms, and then only relatively

"major, harder-to-deny ones, than are Externals. Thus, the

doctor, assuming a wait-and-see approach for the vague symptoms

which are likely associated with the anxiety-approach behavior of the

External/sensitizers, might feel the need for requesting Follow-Up

appointments to check the development of any of these symptoms. The

significant Locus of Control effect on Follow-Up visits associated with

a complaint lends some credence to this possibility. Although their

focus was solely on the repression sensitization dimension, Schwartz,

Krupp, and Byrne (1971) found that repressors tended to receive

purely organic medical diagnoses, while sensitizers received diagnoses

involving psychological components. These data support further the

suggestion of differential reporting and diagnosis of the two Locus of

Control groups. Further research might examine the interaction of

doctor and patient Loci of Control; no research such as this exists.

A number of circumstances made it unfeasible to obtain informa-

tion about the LHI physicians at the time of data collection, except

that they were male. In hindsight, it can be seen that this was un-

fortunate, particularly in light of the importance of Follow-Up visits.

Clearly, future research must focus on the interaction of doctor and

patient characteristics in the determination of continuing medical care.


It is clear that although the Male/!Female and Internal/External

'groups are reporting roughly equal nurimbers of actual sick days, and

seeking initial treatment for symptoms at the same rate, the doctor/

patient interaction is somehcow leading to differential Follow-Up visit

rates. Whether this results from differences in the groups in re-

porting of symptoms, from doctor perceptions of the patient's problem

or from the interaction of the two is an important area for future study.

It would be helpful if these results were replicated in a non-prepaid

setting, in order to see if the requirement of financial outlay for

Follow-Up contacts would eliminate the differences between the groups.

There is also experimental evidence suggesting an interaction effect

of L.oci of Control in interpersonal perception. Borden and Hendrick

(1973) report data which indicate a tendency to perceive others as

having a Locus of Control consistent with one's own, suggesting dif-

ferential perception of others' attitudes and motives as a function of

the perceiver's control orientation. This is clearly important in the

doctor-patient interaction, but the literature does not presently indi-

cate what the specific effect may be. If the Locus of Control orientation

is further demonstrated to affect Follow-Up visit rate, it will be of

interest to anyone concerned with health service planning or evaluation;

at least within this context, the groups differ on a type of visit which in

the case of Male Externals account for more than half of their total

visits. ises a final oit to cosio ificnt a
This raises a final point to be considered. No significant sex and

;) I
Locus of Control interactions were observed, but it appeIars that this

may be due in part to a masking effect prod(uc(ed by almost identical

numbers of visits by Internal Males and IExtena! Females. In con-

trast, very large different( ces were noted betv, cen the two remaining

groups in the Followv-Up and total visit categories. Apart from the

separate effects of sex and Locus of Control in physician utilization,

what is it about the Male External and Female Internal groups which

places them at the high and low extremes of frequency of visits?

These groups may be seen as ones whose Locus of Control orientations

are in some ways inconsistent with the cultural roles prescribed for

the respective sexes; traditionally men are seen as persons expected to

behave in an independent, controlling manner, while women are bound

more by passive, submissive roles. Overall, men in this study did

demonstrate an Internal control orientation and women an External one.

The real differences between the two extreme groups occurred in

the Follow-Up visit categories, again raising the issue of different

physician perceptions of the patients. Are the External Males being

scheduled for additional appointments because they somehow communi-

cate to physicians the need for external intervention in order to deal

with their health problems? The communication might carry particular

impact occurring in the context of the cultural expectations described

above. This might also explain the fact that Internal Females have

the fewest visits, especially Follo\w-Vp visits, in that the Internal

control orientation is especially striking when it is found among Females.


Almost no difference was found in frequency of visits between Internal

Males and External Females, combinations which are consistent with

traditional cultural expectations.

This question really cannot be answered in a vacuum; information

is needed on the physician's Locus of Control (all were male) and on

ways in which the different Locus of Control groups behave. It is known

that Internals behave in a more active information-seeking manner in

inpatient settings, and know more about their illnesses. Perhaps

physicians are influenced differentially by such behavior (or lack of it)

depending on the sex of the patient in which it occurs. Further research

should focus on the Locus of Control and sex of patients and physicians,

and on precisely what transpires in the decision to schedule Follow-Up

care such that the large difference in External Male and Internal Female

frequency of visits occurs.

It is also clear that physician visits must be examined in some

detail; the lack of differences in Minor/Major Complaint and Preventive

categories, plus the significant effects observed in Follow-Up care

suggests that simple gross totals of visits may mask the importance of

the doctor/patient interaction in determining frequency of visits.

Some comments seem called for concerning the setting within

which this study was carried out. Within the limitations inherent in

the selection of a single sub-group of the population for research pur-

poses, the Council House population is nearly ideal. Residency

requirements control extremely well for age, income, and general


physical health. The location of the two Council House towers on the

same premises as the LHI provides a truly unique research setting

in terms of ease of physical access to medical treatment, and the

small $4. 50 per month membership fee allows for virtually free

financial access to physician services. In all, these conditions sug-

gested the Council House/LHI setting as an excellent one for health

care-seeking research.

To summarize, it was predicted on the basis of experimental

studies associating subject sex and Locus of Control orientation with

risk-taking, information- and help-seeking, and reaction to anxiety,

that Internal and External subjects would differ in the type and quantity

of utilization of physician services. Significant differences were shown

between the sex and Locus of Control groups on total doctor visits and

in particular, on numbers of Follow-Up visits. No significant dif-

ference was demonstrated on the measures of strictly patient-initiated

physician visits. Consistently, however, Externals and Males were

the highest users of physician services in the Total visit and Follow-

Up categories, although overall usage rates by the Males in this

sample showed some discrepancy with those typically reported in the

literature of health care utilization. The major contribution of this

study is the indication of the Locus of Control variable as an important

factor in continuing medical care, and its apparent significance in the

crucial doctor/patient interaction.


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Feather, N. T., "Change in confidence following success or failure
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Gochman, D. S., "Some steps toward a psychological matrix of
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Johnson, J. E., H. Leventhal and J. M. Dabbs, "Contribution
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Dear Council House Resident:

I am a graduate student in psychology at the University of

Florida, doing a year's internship in St. Louis. As part of the

research for my doctoral degree, I would like to ask for your help.

I am interested in the ways people use doctors and health care

centers in dealing with illness. In order to study this problem, I

would like to ask those of you who are members of the Labor Health

Institute to complete a questionnaire which asks some questions

about your health and attitudes. The questionnaire is simple to fill

out, and your answers will be strictly confidential.

Your cooperation is, of course, completely voluntary, but it

would be of great help to me in my studies.

Thank you very much for your consideration. I hope that we

shall be able to work together.


Steven P. Kirn, M.A.



This questionnaire is designed to measure some of your

attitudes. It is part of a larger study about people's health care

practices, and hopefully will contribute to better planning of all

health facilities.

There are no "right" answers to any of the questions: we are

interested in YOUR opinions and YOUR experiences. All of your

responses will be kept strictly confidential.

If you have a question, please do not hesitate to ask, and we

shall attempt to help you with it.

NOTE: Your participation in this study is not associated in any

way with your eligibility for benefits at the Labor Health


(Please Print)


In the following set of items, pl as e choose, the on" statement from
pair which iimos.t closely reflects Xour own oimnpn. Indicate your
choice by circling either "a" or ''". 1 en tnberl there are no r' it
or wrong answers; we want your opinion.

1. a. Children get into trouble because their parents punish them
too much.
b. The trouble with most children nowadays is that their parents
are too easy with them.

2. a. Many of the unhappy things in people's lives are partly due
to bad luck.
b. People's misfortunes result from the mistakes they make.

3. a. One of the major reasons why we have wars is because
people don't take enough interest in politics.
b. There will always be wars no matter how hard people try
to prevent them.

4. a. In the long run people get the respect they deserve in this
b. Unfortunately, an individual's worth often passes un-
recognized no matter how hard he tries.

5. a. The idea that teachers are unfair to students is nonsense.
b. Most students don't realize the extent to which their grades
are influenced by accidental happenings.

6. a. Without the right breaks one cannot be an effective leader.
b. Capable people who fail to become leaders have not taken
advantage of their opportunities.

7. a. No matter how hard you try some people just don't like you.
b. People who can't get others to like them don't understand
how to get along with others.

8. a. Heredity plays a major role in determining one's person-
b. It is one's experiences in life which determine what they're

9. a. I have often found that what is going to happen will happen.
b. Trusting to fate has never turned out as well for me as
making a decision to take a definite course of action.

10. a. In the case of the well prepared student there is rarely if
ever such a thing as an unfair test.
b. MAlnya times exam questions tend to be so unrelated to
course work that studying is really useless.

11. a. Becoming a success is a matter of hard work, luck has
little or nothing to do with it.
b. Getting a good job depends mainly on being in the right
place at the, right time.

12. a. The average citizen can have an influence in government
deci sions.
b. This world is run by the few people in power, and there is
not much the little guy can do about it.

13. a. When I make plans, I am almost certain that I can make
them work.
b. It is not always wise to plan too far ahead because many
things turn out to be a matter of good or bad fortune anyhow.

14. a. There are certain people who are just no good.
b. There is some good in everybody.

15. a. In my case getting what I want has little or nothing to do
with luck.
b. Many times we might just as well decide what to do by
flipping a coin.

16. a. Who gets to be the boss often depends on who was lucky
enough to be in the right place first.
b. Getting people to do the right thing depends upon ability,
luck has little or nothing to do with it.

17. a. As far as world affairs are concerned, most of us are the
victims of forces we can neither understand nor control.
b. By taking an active part in political and social affairs the
people can control world events.

18. a. Most people don't realize the extent to which their lives
are controlled by accidental happenings.
b. There is really no such thing as "luck".

19. a. One should always be willing to admit mistakes.
b. It is usually best to cover up one's mistakes.

20. a. It is hard to know whether or not a person really likes
b. How mann friends you have depends on how nice a person
you a're.

21. a. In the long run the bad things that happen to us are
balanced by the good ones.
b. lMost misfortunes are the result of lack of ability,
ignorance, laziness, or all three.

22. a. With enough effort we can wipe out political corruption.
b. It i. difficult for people to have much control ovei the
things politicians do in office.

23. a. Sometimes I can't understand how teacher's arrive at the
grades they give.
b. There is a direct connection between ho)\ hard I study and
the grades I get.

24. a. A good leader expects people to decide for themselves what
they should do.
b. A good leader makes it clear to everybody what their
jobs are.

25. a. Many times I feel like I have little influence over the things
that happen to me.
b. It is impossible for me to believe that chance or luck plays
an important role in my life.

26. a. People are lonely because they don't try to be friendly.
b. There's not much use in trying too hard to please people;
if they like you, they like you.

27. a. There is too much emphasis on athletics in high school.
b. Team sports are an excellent way to build character.

28. a. What happens to me is my own doing.
b. Sometimes I feel that I don't have enough control over the
direction my life is taking.

29. a. Most of the time I can't understand \why politicians behave
the way they do.
b. In the long run the people are responsible for bad govern-
ment on a national as well as on a local level.

During the past year, liow\ many days were you so sick that you were

unable to go about your usual activities '

During the past year, how many times did you visit a private

physician (one not associated with the Labor Health Institute)?

We would like to thank you very much for your generous

cooperation in this study. If you have any question about the nature

of the research or would like other more specific information, please

do not hesitate to ask us. Or, you may phone us at 241-7600, ext. 218

from 9-5, Monday through Friday.

Steven P. Kirn, I. A.





Thank you very much for your cooperation in this project. Since

I am not there to give specific instructions, please read these ad-

ditional notes carefully before beginning.

1. This questionnaire is to be filled out by persons who are LHI

members only.

2. Please answer all items on the questionnaire; this is extremely

important. Do not skip any, even though some selections may

be more difficult than others.

3. On the last page of the questionnaire, the phrase "During the

past year. refers to the past twelve months, not the

calendar year 1972. Thus, if today's date is April 26, you

count the number of sick days from April 26, 1972, to April

26, 1973.

If you have any further questions, please feel free to call me

at the number listed on the last page of the questionnaire.

Steven P. Kirn, M.A.



Steven Paul Kirn was born May 10, 1947, in Louisville,

Kentucky. He graduated from St. Xavier High School in Louisville

in June, 1965. He received a Bachelor of Arts degree with a major

in psychology from Bellarmine College in 1969. While at Bellarmine,

he was president of the student government and received the Spirit

of Bellarmine Award as the outstanding senior in his year of gradua-

tion. He enrolled at the University of Florida with a United States

Public Health Service Fellowship in 1969, and was awarded the

Master of Arts degree in psychology in March, 1971. He later worked

as a psychology trainee at the Veterans' Administration Hospital

in Gainesville, Florida. In 1973, he completed a year's internship

in community and clinical psychology at the Malcolm Bliss Mental

Health Center in St. Louis, Missouri. He assumed the position of

staff psychologist at the Comprehensive Care Center in Elizabeth-

town, Kentucky, in September, 1973. He is married to Katrine

Geha Kirn, Ph. D.

I certify that I have read this study and tMht in my opinion it
conforms to acceptable standards of scholarly presentation and is
fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.

Louis D. Cohen, Chairman
Professor of Clinical Psychology

I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is
fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.

Hugh C. Davis
Professor of Clinical Psychology

I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is
fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.

Norman N. Market
Professor of Psychology

I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is
fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.

George J WV "heit
Assistant Professor of Sociology

I certify that I have read this study and that in my opinion it
conforms to acceptable standards of scholarly presentation and is
fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.

Robert C. Zil.er
Professor of Psychology

This dissertation was submitted to the Graduate Faculty of the
Department of Psychology in the College of Arts and Sciences and to
the Graduate Council, and was accepted as partial fulfillment of the
requirements for the degree of Doctor of Philosophy.

March, 1974

Dean, Graduate School

3 1262 08553 6968I I
3 1262 08553 6968