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Int J Body Mind Culture, Vol. 1, No. 1, 2014 65
http://ijbmc.org
The Role of Locus of Control and Attributional Style in
Coping Strategies and Quality of Life among
Iranian Breast Cancer and Colorectal
Cancer Patients: A Pilot Study
Farzad Goli
1
, Carl Eduard Scheidt
2
, Ali Gholamrezaei
3
, Mahboubeh Farzanegan
4
1
Head of Danesh-e Tandorosti Institute, Isfahan, Iran AND Faculty Member, Energy Medicine University, California, USA
2
Department of Psychosomatic and Psychotherapeutic Medicine, University Hospital of Freiburg, Freiburg, Germany
3
Poursina Hakim Research Institution, Isfahan AND Reza Radiation and Oncology Center, Mashhad, Iran
4
Danesh-e Tandorosti Institute, Isfahan, Iran AND Energy Medicine University, California, USA
Abstract
Background: The influence of various psychological factors and coping mechanisms on quality of life (QOL) in
cancer patients has been well established. We evaluated locus of control and attributional styles, and their
association with coping styles and quality of life (QOL) among Iranian cancer patients.
Methods: This cross-sectional study was conducted on patients with breast cancer and patients with colorectal
cancer in stage I to III. Patients were assessed for demographic and disease characteristics, cancer-related symptoms,
locus of control, attributional styles, coping styles, and QOL.
Results: From 140 invited patients, 100 patients participated in the study. Data of 55 patients with breast cancer and
22 patients with colorectal cancer were appropriate and included for analysis (mean age of 47.5 ± 7.9 years, 89.6%
female). Factors positively associated with QOL included educational level, internal locus of control, overall
hopefulness, and confrontive, optimistic, and self-reliant coping styles (r = 0.228 to 0.426). Factors negatively
associated with QOL included age, symptoms severity, overall hopelessness, and fatalistic and emotive coping styles
(r = -0.221 to -0.674). Internal locus of control and hopefulness were associated with confrontive/adaptive coping
styles (r = 0.226 to 0.381), while external locus of control and hopelessness were associated with
evasive/maladaptive coping styles (r = 0.208 to 0.381).
Conclusion: These results indicate that internal locus of control, hopefulness, and positive attributional styles are
associated with more adaptive/confrontive coping strategies and better QOL in Iranian cancer patients. Further
studies with more comprehensive psychosocial evaluation in a larger sample of cancer patients are warranted.
Keywords: Cancer, Quality of life, Psychosocial, Coping, Health locus of control
Citation: Goli F, Scheidt CE, Gholamrezaei A, Farzanegan M. The Role of Locus
of Control and Attributional Style in Coping Strategies and Quality of Life
among Iranian Breast Cancer and Colorectal Cancer Patients: A Pilot
Study. Int J Body Mind Culture 2014; 1(1): 65-72.
1
Corresponding Author:
Farzad Goli
Email: dr.fgoli@yahoo.com
Quantitative Study
Received:
22
Sep
2013
Accepted: 2 Dec 2013
Locus of control in cancer patients Goli et al.
66 Int J Body Mind Culture, Vol. 1, No. 1, 2014
http://ijbmc.org
Introduction
During recent decades, survival rates for almost
all types of cancer have increased as a result of
earlier detection and better therapies. With
increasing survival, the chronicity of the
disease accompanied with the invasiveness of
the treatments significantly affect different
aspects of psychosocial health and quality of
life (QOL) of cancer patients (Naaman,
Radwan, Fergusson, & Johnson, 2009).
Evidences also confirmed that psychosocial
factors have a great impact on cancer patients’
QOL (Shapiro et al. 2001). Therefore, cancer has
received much attention regarding
psychological needs of the patients.
Different psychological interventions have
been adopted for patients with cancer and
resulted in improvement of psychological
status and QOL (Naaman et al., 2009). A major
pre-requisite of psychological interventions for
cancer patients is, however, knowledge about
the beliefs and attitudes of the patient in regard
to health and disease. The term health locus of
control (HLC) is attributed to the degree to
which individuals believe that their health is
controlled by internal or external factors.
Studies have shown that HLC has effects on
psychological status and QOL of patients with
different health conditions including cancer
(Cousson-Gelie, Irachabal, Bruchon-Schweitzer,
Dilhuydy, & Lakdja, 2005; De & Vinck, 1996;
Nau, Price, & Peter, 2005; Weis, Fitzpatrick, &
Bushfield, 2008). While locus of control is
linked to expectancies about the future events,
“attributional style” is linked to past events,
which in patients with cancer, may also have
effects on coping mechanisms, health seeking
behaviors, and adherence to treatments.
Although studies are available on HLC among
cancer patients, there is a lack of data regarding
attributional style among cancer patients,
especially in Iranian patients, and its effects on
psychosocial health and QOL are not clear.
Cancer in Iran is the third cause of death,
with breast cancer as the first cause of cancer
death in women and colorectal cancer (CRC) as
the third cause (Pourhoseingholi, Faghihzadeh,
Hajizadeh, Abadi, & Zali, 2009). Considering the
lack of knowledge about the meaning of
experienced personal control and its relationship
to QOL in cancer patients, especially in Iran, we
evaluated locus of control and attributional
styles, and their correlates with coping
mechanisms and QOL among a sample of
Iranian patients with breast cancer and CRC. We
hypothesized that the patients’ QOL and their
coping styles are closely linked to their theory of
illness, in particular the locus of control and the
attributional styles.
Methods
Participants and Settings
The present study is a cross-sectional
observational investigation conducted in Oct
2011 on a sample of patients with breast cancer
and CRC who had been registered in Mashhad
Cancer Registry (Reza Radiation and Oncology
Center, Mashhad, Iran). The study was
performed in cooperation with the Department
of Psychosomatic Medicine and Psychotherapy
of Freiburg University Medical Center (Freiburg,
Germany). It was approved by the local ethics
committee of Reza Radiation and Oncology
Center in Mashhad (Iran) and performed in
accordance with the Declaration of Helsinki. At
the time of the study, there were 543 breast
cancer and 1063 CRC patients registered at the
center. Adult patients, living in the city, having
pathologically proven breast cancer/CRC in
stage I to III, and with cancer duration of one to
three years were invited to participate in a
meeting. An informed consent was obtained
from all patients for using their medical
documents for gathering more information
about their disease.
Assessments
Socio-demographic and medical data. A
demographic survey obtained basic information
regarding participant’s age, marital status, and
education level. Medical and treatment
information were gathered from patients
Locus of control in cancer patients Goli et al.
Int J Body Mind Culture, Vol. 1, No. 1, 2014 67
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documents. These information included stage
and duration of the disease and the type of
medical treatments. Other evaluations are
described as follows.
Locus of control. Based on Levenson’s
multidimensional view of locus of control, we
used the Levenson Multidimensional Locus of
Control Scales (IPC). The IPC contains three
8-item sub-scales measuring perceptions of the
level of control concerning events and
circumstances in life. Participants scored items
on a 6-point scale, ranging from +3 (“strongly
agree”) to –3 (“strongly disagree”). Sub-scales
are internality (I), externality-chance (C), and
externality-powerful-others (P) (Farahani,
Cooper, & Jin, 1996; Levenson, 1973).
Attributional style. The Seligman Attributional
Style Questionnaire (SASQ, also known as the
ASQ) evaluates attributions for six negative and
six positive hypothetical events, and measures
the degree to which the cause is internal to the
self (versus external), stable across time (versus
unstable), and global in effects (versus specific).
The questionnaire contains 36 items; 6 good
events and 6 bad evens, each in 3 causal
dimensions. Scales constructed from the 6
negative situations presented are Internal
Negative, Stable Negative, Global Negative,
Hopelessness (the average of Global Negative
and Stable Negative), and Composite Negative
(the sum of the first three scales). Scales
constructed from the 6 positive situations
presented are Internal Positive, Stable Positive,
Global Positive, Hopefulness (the average of
Global Positive and Stable Positive), and
Composite Positive (the sum of the first three
scales) (Peterson et al., 1982).
Coping styles. As a widely used instrument for
measuring coping styles, we used the Jalowiec
Coping Scale (JCS). The JCS contains 60 items
(scoring from 1 to 3) in 8 dimensions including
confrontive (facing up to the problem), evasive
(avoiding the problem), optimistic (positive
thinking), fatalistic (pessimistic thinking),
emotive (releasing emotion), palliative (making
oneself feel better), supportive (using support
system), and self-reliant (depending on oneself)
(Jalowiec, 2003).
Quality of life. Quality of life was measured
using the Short Form Health Survey (SF-36).
With 36 items, this instrument yields an 8-scale
profile of functional health and well-being
resulting in two sum scores for physical and
mental health. It is a generic measure and has
proven useful in surveys of general and specific
populations. Dimensions include physical
functioning, role-physical, bodily pain, general
health, vitality, social functioning, role-
emotional, and mental health. All scores are
converted to a range of 0 to 100 in which higher
scores indicate better status (Montazeri,
Goshtasebi, Vahdaninia, & Gandek, 2005).
Medical symptoms. The severity of symptoms
and their impact on patient’s daily life were
measured using the M.D. Anderson Symptom
Inventory (MDASI) which is a multi-symptom
patient-reported outcome measure for clinical
and research use. Thirteen core items include
symptoms found to have the highest frequency
and/or severity in patients with various cancers
and treatment types, and six items are related to
symptom interference with daily life. The
MDASI uses a 0–10 numerical rating scale to
assess the severity of symptoms and interference
(Cleeland et al., 2000).
Statistical analyses
Data were entered into the SPSS for Windows
(version 16.0; SPSS Inc., Chicago, IL, USA) and
were analyzed using descriptive and analytic
analyses including frequencies, mean and
standard deviations, t-test, and chi-square test
for comparison of quantitative and qualitative
variables, respectively. Pearson and Spearman
correlation coefficients were used to detect
associations between variables. A P value of
< 0.05 was considered significant in all analyses.
Results
From 140 invited patients, 100 patients
participated in the meeting. Fifty five patients
with breast cancer and 22 patients with CRC
Locus of control in cancer patients
Goli et al.
68 Int J Body Mind Culture, Vol. 1, No. 1, 2014
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(89.6% female) completed the questionnaires
and then were included in the analysis.
Questionnaires of the other patients could not be
included in whole or in part by missing data
management. Mean age of the included patients
was 47.5 ± 7.9 years and cancer duration ranged
from one to three years (1.7 ± 0.7 years).
Variables Associated with Quality of Life
Age (r = -0.221) and educational level (r = 0.266)
were associated with QOL. Moreover, both
symptom severity (r = -0.592) and symptom
interference (r = -0.674) were strongly associated
with QOL (Table 1). With regards to the locus of
control, the internal locus of control was
associated with better QOL (r = 0.228) and IPC
chance score was associated with worse mental
health (r = -0.251). Regarding attributional
styles, internal (r = 0.426), stable (r = 0.342), and
global positive scores (r = 0.235) were associated
with better overall QOL and/or its dimensions.
In addition, hopefulness (r = 0.327) and
composite positive scale (r = 0.398) were
associated with better QOL. In contrast, stable
(r = -0.278) and global negative scores (r = -0.248)
were associated with worse QOL. Furthermore,
hopelessness (r = -0.327) and composite negative
score (r = -0.312) were associated with worse
QOL (Table 2).
Table 1. Associations of Demographic and Clinical Characteristics with Patients Quality of Life
Physical health Mental health Total SF-36 score
Age -0.199
*
-0.226
*
-0.221
*
Cancer duration 0.024 0.009 0.036
Education 0.250
*
0.305
*
0.266
*
Stage -0.024 -0.125 -0.013
Symptoms
Symptom severity -0.591
**
-0.527
**
-0.592
**
Symptom interference -0.640
**
-0.605
**
-0.674
**
Data are presented as correlation coefficient.
* p < 0.05, ** p < 0.001
Table 2. Associations of Locus of Control and Attributional Styles with Patients Quality of Life
Locus of control Physical health Mental health Total SF-36 score
Internality 0.214 0.188 0.228
*
Powerful others -0.087 -0.086 -0.076
Chance -0.155 -0.251
*
-0.185
Attributional style
Internal Positive 0.402
**
0.405
**
0.426
**
Stable Positive 0.312
*
0.404
**
0.342
**
Global Positive 0.161 0.235
*
0.208
Hopefulness 0.281
*
0.380
**
0.327
*
Composite Positive 0.355
*
0.430
**
0.398
**
Internal Negative -0.046 0.008 -0.032
Stable Negative -0.278
*
-0.272
*
-0.278
*
Global Negative -0.189
*
-0.310
*
-0.248
*
Hopelessness -0.285
*
-0.367
**
-0.327
*
Composite Negative -0.279
*
-0.330
*
-0.312
*
Data are presented as correlation coefficient.
* p < 0.05, ** p < 0.001
Locus of control in cancer patients Goli et al.
Int J Body Mind Culture, Vol. 1, No. 1, 2014 69
http://ijbmc.org
Concerning coping styles, confrontive
(r = 0.264) and optimistic (r = 0.333) coping
styles were associated with better QOL while
fatalistic (r = -0.224) and emotive (r = -0.258)
styles were associated with worse QOL
(Table 3).
Variables Associated with Coping Styles
Factors associated with coping styles are
presented in table 4. Younger age was associated
with optimistic coping (r = -0.229), and higher
education was associated with confrontive
(r = 0.269) and less emotive coping styles
(r = -0.265). Symptom severity (r = 0.384) and
symptom interference (r = 0.298) were associated
with emotive style. Internal locus of control was
associated with confrontive, optimistic, and
self-reliant coping styles (r = 0.280 to 0.307), while
powerful others and chance were associated with
evasive, fatalistic, and emotive styles (r = 0.223 to
0.381). With regard to attributional style, positive
internality, stability, and globality and overall
hopefulness were associated with confrontive,
optimistic, and self-reliant coping styles (r = 0.226
to 0.381), while negative stability and globality
were associated with emotive and fatalistic
coping styles (r = 0.208 to 0.211).
Table 3. Associations of Coping Styles with Patients Quality of Life
Coping style Physical health Mental health Total SF-36 score
Confrontive 0.320
*
0.213
*
0.264
*
Evasive 0.047 -0.059 0.018
Optimistic 0.320
*
0.326
*
0.333
**
Fatalistic -0.192
*
-0.267
*
-0.224
*
Emotive -0.217
*
-0.338
**
-0.258
*
Palliative 0.043 -0.028 0.036
Supportive 0.108 0.039 0.079
Self-reliant 0.169 0.091 0.138
Data are presented as correlation coefficient.
* p < 0.05, ** p < 0.001
Table 4. Associations of Demographic Data, Locus of Control, and Attributional Style with Coping Mechanisms
Confrontive Evasive Optimistic Fatalistic Emotive Palliative Supportive Self-
reliant
Locus of control
Age -0.052 -0.088 -0.229
*
0.043 0.083 0.027 0.011 -0.035
Education 0.269
*
0.009 0.123 -0.161 -0.265
*
0.003 0.061 0.111
Internality 0.295
*
0.111 0.307
*
-0.042 0.056 0.150 0.120 0.280
*
Powerful others -0.095 0.223
*
0.014 0.300
*
0.128 0.136 0.011 0.073
Chance -0.245
*
0.275
*
-0.049 0.381
*
0.310
*
0.140 -0.058 0.022
Attributional styles
Internal Positive 0.264
*
0.058 0.162 0.048 -0.012 0.022 0.066 0.268
*
Stable Positive 0.362
**
0.015 0.323
*
-0.133 -0.209
*
0.085 0.127 0.313
*
Global Positive 0.270
*
0.172 0.226
*
-0.027 0.118 0.296
*
0.169 0.318
*
Hopefulness 0.379
**
0.109 0.328
*
-0.093 -0.044 0.237
*
0.180 0.381
**
Internal Negative -0.087 -0.142 -0.078 -0.115 -0.213
*
-0.274
*
-0.070 -0.139
Stable Negative -0.240
*
0.030 -0.265
*
0.208
*
0.032 -0.117 -0.028 -0.240
*
Global Negative 0.083 0.196 0.021 0.024 0.211
*
-0.045 0.077 0.194
Hopelessness -0.068 0.152 -0.124 0.126 0.163 -0.092 0.039 0.009
Data are presented as correlation coefficient.
* p < 0.05, ** p < 0.001
Locus of control in cancer patients Goli et al.
70 Int J Body Mind Culture, Vol. 1, No. 1, 2014
http://ijbmc.org
Discussion
Since cancer is often a chronic and life
threatening, but not necessarily life terminating,
disease, knowledge about aspects of coping with
the disease is of great clinical importance.
Regarding the influence of health/disease
control perception on health behaviors and well-
being, we therefore investigated the associations
of the illness theory of cancer patients’ in
particular the concepts of locus of control and
attributional style and their impact on coping
strategies and QOL.
Factors Affecting QOL
We found that younger age is associated with
better QOL which was similar to most of
previous studies (Moro-Valdezate et al., 2012; Lu
et al., 2009). The association of age with QOL is,
however, influenced by different factors
including educational level, patient reaction to
cancer diagnosis, physical and psychological
comorbidities, and treatment adherence. Some
studies reported controversial results in this
regard (Mehnert & Koch, 2008; Cimprich, Ronis,
& Martinez-Ramos, 2002). Therefore,
understanding the specific needs of cancer
survivors at each life stage is important in
developing tailored interventions. As expected,
the severity of cancer-related symptoms was
strongly associated with lower QOL which
highlights the importance of interventions
aiming to alleviate such symptoms. With regard
to the locus of control, we found that internal
source of control is associated with better QOL
and external source of control (chance) with
worse QOL. Moreover, we found that hopeful
attributions are associated with better QOL. In
contrast, hopeless attributions were associated
with worse QOL. These results are similar to
other studies on cancer survivors in different
populations which showed that internal health
locus of control is positively related to health
promoting behaviors and QOL (Allart,
Soubeyran, & Cousson-Gelie, 2013; Cai, Zhou,
Yu, & Wan, 2011; Chung, Chao, Chou, & Lee,
2009; Frank-Stromborg, Pender, Walker, &
Sechrist, 1990; Watson, Pruyn, Greer, & van den
Borne, 1990; Yi, & Kim, 2013)). With influence on
the patient’s beliefs regarding the personal
control over health/cancer, HLC can affect
coping mechanisms, health seeking behaviors,
and adherence to treatments which in turn may
change the disease course and QOL (Cousson-
Gelie et al., 2005). It must be noted however that
HLC is not a simple issue and that several
factors may modulate its effects on
health/disease and well-being. Studies showed
that physician-patient relationship, the severity
of the illness, subjective stress, family and social
supports, and sociocultural issues have effects
on HLC (Sørlie & Sexton, 2004; Wrightson &
Wardle, 1997). The cultural aspects of the
influence of HLC on cancer QOL and patients
coping mechanisms is the matter of our future
study in Iran and Germany.
Factors Affecting Coping Styles
Several factors could be associated with coping
strategies in cancer patients which should be
considered in developing educational
interventions. We found that younger age is
associated with optimistic coping. The association
of age with coping styles is influenced by
different factors including education level,
psychological comorbidities, fears of disease
progression, hope, and social support (Compas et
al., 1999; Reuter et al., 2006; Schnoll, Harlow,
Stolbach, & Brandt, 1998). In our study, younger
patients had higher education level which was
associated with confrontive and less emotive
coping styles, and older patients had higher
hopelessness scores. In addition, we found that
symptom severity is associated with emotive
coping style, though the direction of this
association is not clear from our study. It might
be a bi-directional relationship between physical
symptoms severity and coping styles which
needs declaration in longitudinal studies.
With regard to the influence of locus of control
and attributional styles on coping styles, we
found that internal locus of control and
hopefulness are associated with confrontive and
Locus of control in cancer patients Goli et al.
Int J Body Mind Culture, Vol. 1, No. 1, 2014 71
http://ijbmc.org
adaptive coping styles, the styles that were
associated with better QOL. While, external
source of control (powerful others and chance)
were associated with evasive and maladaptive
styles, the styles that were associated with lower
QOL. People reflecting an internal locus of
control believe that they can exert control over
their environment to bring about desirable
consequences. Conversely, people with an
external locus of control believe that larger social
forces, powerful persons or groups,
or chance will determine their fate (Ogden, 2007).
Hence, evaluation of locus of control
and attributional styles are important in
designing the psycheducational intervention for
cancer patients.
Study Limitations
There are limitations to this study which must be
considered. The sample size of our study was
small which does not permit for a precise analysis
of different factors associated with QOL and
coping styles, and comparison between breast
cancer and CRC patients. Moreover, we did not
evaluate psychological morbidity and
family/social support which can affect QOL and
coping mechanisms, and mediate the above
mentioned associations among cancer patients
(Allart et al., 2013; Al-Azri, Al-Awisi, &
Al-Moundhri, 2009; Yi & Kim, 2013). And finally,
our study was cross-sectional and does not allow
inferences on the direction of the observed
associations.
Conclusion
The results of this study showed that internal
locus of control, hopefulness, and positive
attributional styles are associated with more
adaptive/confrontive coping styles and better
QOL in Iranian cancer patients. Attributional
style, locus of control, and also coping strategies
can be modulated by psychoeducation and
psychotherapy. Therefore, we can change the
story of cancer and hopefully we can expect that
the psychological wellbeing and even the hard
reality of cancer will be changed. Further studies
with larger sample of patients and more
comprehensive psychosocial evaluation are
warranted.
Conflict of Interests
Authors have no conflict of interests.
Acknowledgments
The authors would like to thank all colleagues
and students who contributed to this study. We
are grateful to Dr. Abolfazl Aghvami and Mrs.
Maryam Rouzbeh for their very kind
organization and close and supportive relation
with the patients. We appreciate Reza Radiation
and Oncology Center's physicians and managers
for accepting this project, especially Dr. Fatima
Varshoei and Miss Akram Solaymani for their
collaboration during preliminary investigations,
organizing the patients, and helping us in data
gathering.
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