The belief about who, or what, controls life’s outcomes is deeply personal. It does not take form in isolation, but it is shaped, moulded and reinforced by the cultural and social environment in which a person is raised. Understanding cross-cultural differences in locus of control is essential, particularly in today’s increasingly globalised and diverse societies where healthcare providers regularly encounter patients from a variety of cultural backgrounds.

Whether a person believes that they alone shape their future or that their path is governed by external forces, such as fate, family, God or government, is profoundly influenced by cultural norms, values and worldviews. These beliefs influence how individuals make decisions about their health, as well as how they interpret illness, healing and their role within the healthcare system.

Cultural Orientation and Locus of Control

One of the most commonly observed patterns in psychology and cross-cultural studies is the difference between individualistic and collectivist cultures and how these orientations shape perceptions of control.

·       Western, Individualistic Cultures: Internal Locus of Control

In Western societies, notably the USA, Canada, Germany, Australia and the United Kingdom, cultural values emphasise individual autonomy, self-determination and personal responsibility. Here, the internal locus of control is culturally valued.

People raised in individualistic cultures are often encouraged from a young age to “take control of their own lives”, “make their own decisions”, “be the master of their fate”. Success is seen as a product of hard work and initiative, while failure is attributed to personal shortcomings.

In healthcare, this can translate into a strong preference for shared decision-making, self-management and active patient engagement. Patients may expect to be presented with options and to have their autonomy respected and may even resist paternalistic medical advice that seems to override their sense of control.

·       Eastern Collectivist Cultures: External or Socially Mediated Locus of Control

Collectivist cultures, commonly found in East Asia, the Middle East, Africa, Latin America and Indigenous communities worldwide, place greater value on group harmony, social obligation and interdependence. Here, control is often understood in a more relational or socially embedded way.

Rather than being seen as a weakness, external or socially mediated locus of control can be viewed as culturally appropriate. People may defer to elders, religious leaders or family members in making decisions. Illness may be interpreted not just as a biological event, but as a spiritual imbalance, family or social disruption.

In these settings, it is not uncommon for patients to say:

·       “My family will decide what’s best”.

·       “It’s in God’s hands”.

·       “Whatever the doctor decides”.

These are not necessarily signalling passivity or disengagement. They may reflect deeply held cultural values around humility, respect for authority and the importance of aligning decisions with the needs of the family of the community.

Implications for Healthcare Delivery

These divergent beliefs about control can create friction in clinical settings, especially when healthcare professionals and patients come from different cultural backgrounds. What one person sees as “empowerment”, another might view as “disrespect”. What seems like “compliance” to what the doctor advised or prescribed may, to the patient, be an act of cultural devotion.

Amongst the key challenges include:

Miscommunication and Misinterpretation

A Western-trained doctor may misinterpret a patient’s deference as disengagement or a lack of understanding. Alternatively, a patient from a collectivist background may perceive the doctor’s insistence on individual choice as cold or overwhelming. So, shared decision-making can fall apart. If a doctor asks a patient, “What would you like to do about your treatment?” may be confusing or inappropriate to someone who expects guidance from authority figures or collaborative decision-making with family.

Misaligned Expectations

In multicultural settings, mismatched expectations around who makes decisions and how they make them can lead to dissatisfaction, non-compliance and even mistrust. A patient expecting to be “told what to do” may feel abandoned if asked to choose a treatment plan independently. Meanwhile, a provider might feel frustrated if their efforts to empower a patient seem to fall flat.

Cultural Blind Spots in Health Promotion

Public health campaigns that rely on internal control messaging, such as “Take charge of your health!” may be less effective in communities where external or collective values dominate. Tailoring these messages to align with cultural frameworks is critical for reaching diverse populations.

The Role of Religion and Tradition

Religion plays a particularly influential role in shaping control beliefs. In many traditions, life and health are seen as subject to divine will or cosmic forces, and illness may be understood as a test of faith, karmic consequence or spiritual imbalance. For example:

·       In Islamic cultures, the phrase ‘Inshallah’ (God willing) reflects a belief in divine orchestration.

·       In Christianity, many believers find comfort in the idea that illness is part of God’s plan.

·       In Hindu and Buddhist contexts, health may be seen as influenced by karma or spiritual imbalance, rather than personal choices alone.

·       In Indigenous traditions, wellness is often seen as interconnected with nature, ancestry and community, not just individual behaviour.

These frameworks can support resilience and provide emotional comfort, but they can also affect whether and how people engage with medical instructions or treatment interventions from a doctor.

We could compare two worldviews from two fictional patients diagnosed with Type 2 diabetes at the same time, one is Maria, a female, born and raised in the US, while the other, Wei, is a Chinese immigrant, settling in the USA in her early 30s.

Maria:

·       Diagnosis was a wake-up call.

·       Researches condition, creates a meal plan

·       Asks doctor about treatment alternatives

·       Sets fitness goals.

·       Her internal locus of control and her cultural norms of self-determination fuel her motivation.

Wei:

·       Sees diagnosis and condition through the lens of family and tradition.

·       Consults parents, visits a traditional healer.

·       Takes care not to make health decisions that might contradict her family’s wishes.

·       Takes a traditional Chinese medicine alongside pharma treatment but does not disclose this to her doctor.

·       Follows doctor’s recommendations but does not ask many questions.

·       Her deference to authority and communal decision-making reflect a culturally external orientation and, therefore, an external locus of control.

Both of these patients are engaged, but in different ways and each way has cultural meaning. Recognising this difference and these cultural meanings are essential to providing care that respects and supports each person’s values.

Healthcare professionals should:

·       Ask open-ended questions abouts beliefs, values and decision-making preferences.

·       Include family and community members in discussions when appropriate.

·       Respect spiritual or traditional healing practice and, when possible, integrate them with biomedical care.

·       Tailor health messages to reflect both individual and communal motivations.

Control is Culturally Constructed

The concept of control is culturally constructed. This means that it is not the same everywhere. An internal locus of control may empower in one context, but alienate in another. An external locus of control may seem passive from the outside but could be a deep source of strength and meaning within its own cultural context.

Healthcare systems need to be attuned to and understand these differences. By achieving this, healthcare professionals can help every patient find agency: in their own way and on their own terms.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025.