Chinese Compensatory Health Beliefs Scale

1. Abstract

The Chinese Compensatory Health Beliefs Scale (CHBs-C) is an adapted psychometric instrument designed to evaluate cognitive rationalizations wherein individuals justify engaging in unhealthy behaviors by intending or expecting to perform subsequent healthy actions. Compensatory health beliefs (CHBs) represent cognitive strategies aimed at reducing cognitive dissonance arising from conflicts between immediate hedonistic desires and long-term health objectives. While the original compensatory health belief framework was developed and validated in Western contexts, lifestyle practices, dietary patterns, and cultural perspectives on health balance differ substantially in Eastern cultures. Developed by Hua Yu Shi and Ya Ru Zhang (2024), the CHBs-C contains 14 self-report items structured across three culturally grounded dimensions: Exercising/Eating/Sleeping Habits, Drinking/Smoking (substance regulation), and Stress mitigation. Items are rated along an ordinal response format assessing endorsement of specific cognitive trade-offs. Cross-cultural adaptation involved forward- and back-translation, expert panel reviews, and iterative contextual modifications—such as eliminating Western-centric references to coffee and meal-skipping while integrating pervasive modern phenomena such as sedentary screen time, late-night routines, and restorative leisure practices. Psychometric evaluation across three distinct adult samples (total N = 1,058) recruited via online sampling demonstrated robust construct validity via exploratory factor analysis (principal axis factoring) and confirmatory factor analysis utilizing diagonally weighted least squares (DWLS) estimation. The instrument demonstrated acceptable internal consistency using McDonald’s omega coefficient and strong two-week test-retest reliability via Spearman correlation, establishing the scale’s stability as an assessment tool for public health researchers, health psychologists, and clinical practitioners investigating health behavior change in China.

2. Keywords

Compensatory Health Beliefs, Chinese Compensatory Health Beliefs Scale, Psychometrics, Cross-Cultural Adaptation, Cognitive Dissonance, Health Psychology, Health Behavior Rationalization, Diagonally Weighted Least Squares, Factor Analysis, Punk Health Maintenance

3. Authors

The Chinese Compensatory Health Beliefs Scale was adapted and psychometrically validated by:

• Hua Yu Shi — School of Economics and Management, Shanghai Institute of Technology, Shanghai, China (Corresponding author: [email protected]).
• Ya Ru Zhang — School of Economics and Management, Shanghai Institute of Technology, Shanghai, China.

4. Purpose

The primary purpose of the Chinese Compensatory Health Beliefs Scale (CHBs-C) is to provide an empirically sound and culturally attuned measurement tool capable of assessing the cognitive rationalization strategies utilized by Chinese adults to reconcile lifestyle-related health compromises. In health psychology, compensatory health beliefs (CHBs) denote automatic or deliberative cognitive mechanisms through which individuals convince themselves that the negative physical consequences of an unhealthy indulgence (e.g., consuming high-calorie foods, remaining sedentary, or staying up late) can be neutralized, balanced, or negated by a future or concurrent healthy behavior (such as exercising on weekends, taking dietary supplements, or drinking green tea).

In contemporary Chinese society, rapid urbanization, socio-economic modernization, and demanding work environments have catalyzed unique health-compromising behaviors. A prominent sociological and behavioral manifestation among Chinese young adults is punk health maintenance (also known as “punk health preservation” or dangkang), wherein individuals deliberately juxtapose harmful habits with superficial, immediate compensatory remedies—such as staying awake all night while steeping goji berries in an insulated flask, or binge drinking alcohol followed by consuming liver-protection herbal tonics. Traditional Western CHB scales, initiated by Knäuper et al. (2004), feature behavioral paradigms that do not directly translate into Chinese dietary or lifestyle traditions. For instance, Western items frequently operationalized compensatory mechanisms around skipping lunch to justify a rich dinner, or compensating for excessive coffee consumption by drinking water. In contrast, Chinese traditional dietary wisdom emphasizes balanced meal regularity, hot water intake, herbal broths, and holistic circadian equilibrium, making direct literal translations of Western instruments conceptually incongruent and prone to measurement error.

Clinically and in public health research, the CHBs-C serves several critical functions. First, it enables health behavior researchers to quantify the prevalence and intensity of compensatory beliefs within community, occupational, and clinical populations. Second, because CHBs have been shown to undermine genuine behavioral intentions to adopt healthier lifestyles—acting as psychological self-licensing mechanisms—measuring these cognitions allows researchers to model the causal pathways that inhibit adherence to chronic disease prevention protocols (e.g., for type 2 diabetes, hypertension, and cardiovascular disorders). Finally, the tool equips intervention planners with granular diagnostic data, facilitating targeted cognitive-behavioral public health messaging that directly dismantles flawed compensatory assumptions rather than relying solely on generic prescriptive guidance.

5. Psychological Construct

Compensatory health beliefs represent a specialized domain within social cognition, operating predominantly as an intra-individual conflict-resolution mechanism. The construct is grounded in the reality that human daily living constantly involves tensions between short-term affective rewards (hedonistic pleasure, social affiliation, immediate convenience, stress relief) and long-term prudential goals (somatic health, functional longevity, disease prevention). When an individual succumbs to an immediate gratification behavior that directly violates an internalized health goal, the resulting psychological tension threatens the individual’s self-image as a rational, health-conscious agent. Compensatory health beliefs resolve this dissonance by establishing an internal subjective “bargain” or equilibrium equation: “Indulgence X is permissible because subsequent Action Y will neutralize its physiological harm.”

Within the Chinese Compensatory Health Beliefs Scale, this broad psychological construct is operationalized through three distinct, culturally verified dimensions:

1. Exercising, Eating, and Sleeping Habits

Unlike Western factor solutions that commonly separate dietary behavior, physical exercise, and sleep into independent orthogonal factors, the CHBs-C identifies an integrated factor uniting daily visceral habits: diet, physical activity, and sleep rhythms. This structure reflects a holistic Eastern concept of everyday living, wherein bodily recovery, nutrition, and metabolic expenditure are perceived as interconnected facets of yangsheng (nourishing life). Subscale items capture cognitive trade-offs such as:

• Compensating for greasy or calorie-dense banquets by fasting, consuming fresh fruit, or eating bland porridge in subsequent meals.
• Believing that sitting for prolonged working hours can be completely counteracted by a single session of vigorous evening exercise.
• Rationalizing chronic weekday sleep deprivation or staying up past midnight with the expectation that extended weekend sleep or daytime naps fully restore physiological homeostasis.

2. Drinking and Smoking (Substance Regulation)

The second dimension specifically addresses tobacco and alcohol consumption. In China, cigarette smoking and communal alcohol consumption (e.g., baijiu during commercial dinners and social celebrations) possess strong relational and cultural capital. Consequently, individuals regularly find themselves caught between institutionalized social etiquette and individual health awareness. This subscale measures cognitive rationalizations wherein individuals convince themselves that the toxicological and physiological burdens of occasional smoking or binge drinking can be mitigated through compensatory health maneuvers, such as adhering to a wholesome baseline diet, taking nutritional supplements, or staying well-hydrated.

3. Stress

The third dimension evaluates stress-justified compensatory rationalizations. Under intense academic, professional, and familial demands, individuals frequently operationalize unhealthy behaviors (such as consuming high-sugar bubble tea, eating fast food, or engaging in sedentary electronic indulgence) not merely as hedonistic choices, but as essential coping strategies to combat mental fatigue and emotional depletion. The stress dimension measures the conviction that engaging in acute health-risk behaviors is legitimate and functional because the immediate psychological benefit of stress alleviation outweighs or neutralizes potential physiological detriments.

6. Theoretical Framework

The theoretical architecture of the CHBs-C rests at the intersection of classical social-cognitive theory, the Cognitive Dissonance Theory of Leon Festinger (1957), and the formal Compensatory Health Beliefs Model formulated by Rabiau, Knäuper, and Miquelon (2006).

Festinger’s cognitive dissonance paradigm posits that holding two psychologically inconsistent cognitions—such as “I want to preserve my cardiovascular health” and “I am eating high-fat deep-fried food”—generates an aversive motivational state. To diminish this discomfort, an individual has three primary theoretical routes: (a) cease the unhealthy behavior immediately, (b) alter the overarching health goal, or (c) introduce new cognitive elements that reconcile the inconsistency. In health contexts, changing addictive or habitual behaviors in real time is effortful and biochemically taxing, while explicitly abandoning long-term health values produces guilt and anxiety. Thus, the introduction of compensatory health beliefs represents the path of least cognitive resistance: it allows the individual to maintain the long-term health goal while continuing the short-term unhealthy behavior without experiencing debilitating guilt.

Rabiau et al. (2006) formalized this process into the Compensatory Health Beliefs Model, outlining the cognitive-affective sequence:

1. Temptation and Goal Conflict: An individual encounters a health-compromising stimulus or stressor, eliciting a motivational conflict between immediate gratification and distal self-regulation.
2. Dissonance and Negative Affect: Awareness of the violation generates cognitive dissonance, anticipated regret, or subjective discomfort.
3. Activation of CHBs: The individual retrieves or constructs a compensatory belief (e.g., “I will exercise extra hard tomorrow”), which functions as a subjective cognitive bridge, neutralizing the perceived risk.
4. Behavioral Enactment: With cognitive dissonance resolved, the individual engages in the unhealthy behavior without distress.
5. Compensatory Execution Failure: Crucially, empirical research across various countries demonstrates that the intended compensatory behavior is rarely executed in the future. As time elapses, the motivational urgency of the original guilt diminishes, leaving the unhealthy behavior uncompensated and contributing cumulatively to negative health outcomes.

Furthermore, within contemporary health psychology models such as Ralf Schwarzer’s Health Action Process Approach (HAPA), CHBs function as powerful modern impediments in the volitional phase. While high self-efficacy typically translates health intentions into concrete action plans, the presence of strong compensatory health beliefs permits individuals to delay, dilute, or substitute planned protective actions, serving as an underlying driver of behavioral relapse and chronic self-licensing.

7. Validity

The psychometric validation of the Chinese Compensatory Health Beliefs Scale was executed through a multi-stage empirical methodology across three independent participant samples (total N = 1,058), recruited via the Credamo empirical data platform.

Content and Cross-Cultural Validity

Initial content validity was established using the cross-cultural adaptation guidelines proposed by Beaton et al. (2000). The original pool of items was subjected to parallel forward translation, synthesis, blind back-translation by bilingual behavioral scientists, and review by an expert committee. Cultural decontextualization was systematically resolved: items involving Western meal patterns (e.g., skipping meals as an automatic trade-off) and high-volume coffee intake were eliminated due to their incongruence with normative Chinese health behaviors. Culturally salient items reflecting post-pandemic lifestyle realignments, modern Chinese dietary customs, and communal socialization practices were drafted and screened using Content Validity Index (CVI) standards, ensuring exceptional face and semantic validity.

Construct and Structural Validity

Construct validity was demonstrated sequentially across Samples 1 and 2. Exploratory factor analysis (EFA) on Sample 1 (n = 476) supported a clear, theoretically coherent three-factor structure explaining substantial variance across the 14 retained items. Confirmatory factor analysis (CFA) performed on Sample 2 (n = 308) verified the stability of this three-factor dimensional structure using diagonally weighted least squares (DWLS) estimation, which is specifically suited for categorical, ordinal survey metrics. The structural model yielded strong goodness-of-fit indices:

• Comparative Fit Index (CFI) > 0.95
• Tucker-Lewis Index (TLI) > 0.95
• Root Mean Square Error of Approximation (RMSEA) < 0.06
• Standardized Root Mean Square Residual (SRMR) < 0.08

Discriminant and Convergent Validity

Discriminant validity was established utilizing the Fornell-Larcker criterion. For each latent factor, the square root of the Average Variance Extracted (AVE) was higher than its bivariate correlation with any other latent factor in the model, demonstrating that Exercising/Eating/Sleeping Habits, Drinking/Smoking, and Stress measure statistically separable dimensions of health belief rationalizations.

Convergent validity presented typical characteristics observed in domain-specific health cognition measures. While Composite Reliability (CR) for the primary lifestyle factor and substance use factor exceeded the conventional threshold of 0.70, the stress factor exhibited a slightly lower CR. Average Variance Extracted (AVE) across the factors fell slightly below the conservative 0.50 benchmark, indicating that individual items contain moderate amounts of item-specific variance alongside the shared construct variance. However, such findings are recognized in psychometric literature (Hair et al., 2020) as common and acceptable when an instrument measures broad, multi-behavioral cognitive domains with high composite internal consistency.

Predictive Validity

To evaluate predictive validity, Sample 3 (n = 274) was evaluated against empirical self-reported lifestyle practices and health behaviors. Subscale scores exhibited meaningful, statistically significant associations with corresponding targeted behaviors. Specifically, higher scores on the substance use subscale significantly correlated with self-reported alcohol and tobacco consumption patterns, while higher scores on the lifestyle habit subscale tracked with irregular circadian habits and episodic sedentary compensation, proving the instrument’s utility for behavioral prediction at the subscale level.

8. Reliability

The reliability of the Chinese Compensatory Health Beliefs Scale was comprehensively established through both internal consistency metrics and temporal test-retest stability assessments.

Internal Consistency

Recognizing the well-documented psychometric limitations of Cronbach’s alpha—particularly its unrealistic assumption of tau-equivalence (equal factor loadings across all items) and vulnerability to inflation—the authors evaluated internal consistency utilizing both McDonald’s omega (ω) and conventional Cronbach’s alpha (α). McDonald’s omega coefficients across the full scale and individual subscales demonstrated strong reliability:

• Full 14-Item Scale: McDonald’s ω > 0.80, demonstrating strong internal consistency across the total measure.
• Subscale 1 (Exercising/Eating/Sleeping): Exhibited high composite reliability (CR > 0.75) and satisfactory omega values.
• Subscale 2 (Drinking/Smoking): Demonstrated composite reliability exceeding 0.70.
• Subscale 3 (Stress): Displayed acceptable internal consistency given its focused item composition.

Test-Retest Stability

To ensure that the scale captures stable cognitive styles rather than transient affective fluctuations, a longitudinal test-retest protocol was administered to Sample 2 (n = 308) across a two-week temporal interval. Given the non-normal distribution of ordinal rating scores, stability was calculated using Spearman rank correlation coefficients (r_s).

The two-week test-retest correlations were positive, statistically significant, and high across all three subscales and the total composite score (r_s ranging from 0.65 to 0.78, p < 0.001). This demonstrates that compensatory health cognitions, as measured by the CHBs-C, operate as relatively enduring psychological heuristics, giving researchers confidence in the instrument’s utility for pre-test/post-test longitudinal interventions and multi-wave epidemiological cohort studies.

9. Factor Analysis

The underlying factor structure of the CHBs-C was identified and validated through a sequential psychometric workflow combining Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

In Sample 1 (n = 476), the initial item pool underwent exploratory factor extraction using principal axis factoring with oblique (Promax) rotation, acknowledging the expected theoretical correlations between distinct health belief domains. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s Test of Sphericity confirmed that the data matrix was well-suited for factor extraction. The analysis supported a parsimonious 14-item, three-factor latent model:

• Factor 1: Exercising, Eating, and Sleeping Habits: Captured integrated physical living routines, merging what Western scales traditionally separated into independent diet, exercise, and sleep components.
• Factor 2: Drinking and Smoking: Grouped items focused specifically on cognitive neutralization of tobacco and alcohol risks through diet or physical remedies.
• Factor 3: Stress: Clustered items framing unhealthy indulgences as functional cognitive remedies to mitigate emotional and occupational stress.

Confirmatory Factor Analysis (CFA)

To confirm this empirical structure in an independent cohort, CFA was conducted on Sample 2 (n = 308) using the lavaan package in R (Rosseel, 2012). Because self-report survey data on Likert-type scales violate multivariate normality assumptions and present ordered categorical properties, traditional Maximum Likelihood (ML) estimation can inflate chi-square statistics and distort standard errors. Consequently, researchers utilized the Diagonally Weighted Least Squares (DWLS) estimation method, widely recognized as superior for ordinal health survey data (Flora & Curran, 2004; Yang-Wallentin et al., 2010).

The DWLS confirmatory model exhibited good fit to the data, satisfying modern structural equation modeling criteria (Hu & Bentler, 1999):

• χ²/df: < 2.5 (indicating acceptable model parsimony)
• CFI (Comparative Fit Index): > 0.95
• TLI (Tucker-Lewis Index): > 0.95
• RMSEA: < 0.06 (with 90% confidence intervals within acceptable boundaries)
• SRMR: < 0.08

All standardized factor loadings of the 14 retained items loaded significantly (p < 0.001) on their assigned latent constructs, verifying the construct validity of the Chinese three-factor architecture.

10. Instrument / Measurement Tool

• Full Instrument Name: Chinese Compensatory Health Beliefs Scale (CHBs-C)
• Test Type: Self-report psychological questionnaire / Behavioral cognition inventory
• Target Population: General Chinese population, adults (aged 18 and older)
• Number of Items: 14 items
• Language: Chinese (validated translation)
• Response Scale: 14 items
• Subscales:
  • Exercising/Eating/Sleeping Habits: Measures rationalizations that poor diet, physical inactivity, or irregular sleep can be compensated by subsequent physical adjustments or corrective habits.
  • Drinking/Smoking: Measures rationalizations that the toxicological harms of alcohol or tobacco use are mitigated by healthy living practices.
  • Stress: Measures beliefs that indulging in unhealthy behaviors is justifiable when serving to alleviate acute psychological stress.
• Administration Mode: Self-administered online or via paper-and-pencil; completion time is approximately 3 to 5 minutes.
• Scoring Rules: Items are summed or averaged to create an overall compensatory health belief score or evaluated across subdimensions (e.g., diet/eating habits, physical exercise, sleep/rest, stress/substance regulation). Higher scores indicate higher levels of compensatory health beliefs.

11. Permissions & Fee and Test Year

• Year of Publication: 2024
• Original Authors: Hua Yu Shi and Ya Ru Zhang (School of Economics and Management, Shanghai Institute of Technology, Shanghai, China).
• Copyright & Licensing: Published in Frontiers in Public Health under the terms of the Creative Commons Attribution License (CC BY 4.0). This open-access licensing permits unrestricted non-commercial and commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
• Access and Fee: The scale is completely free of charge for academic, research, and non-profit educational purposes. Researchers wishing to utilize the instrument in its native Chinese characters or conduct collaborative research are encouraged to cite the original validation paper or reach out directly to the corresponding author (Hua Yu Shi, email: [email protected]).

12. References

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• Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press.
• Flora, D. B., & Curran, P. J. (2004). An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychological Methods, 9(4), 466–491. https://doi.org/10.1037/1082-989X.9.4.466
• Hair, J. F., Howard, M. C., & Nitzl, C. (2020). Assessing measurement model quality in PLS-SEM using confirmatory composite analysis. Journal of Business Research, 109, 101–110. https://doi.org/10.1016/j.jbusres.2019.11.069
• Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
• Knäuper, B., Rabiau, M., Cohen, O., & Patriciu, N. (2004). Compensatory health beliefs: Scale development and psychometric properties. Psychology & Health, 19(5), 607–624. https://doi.org/10.1080/0887044042000196737
• Rabiau, M., Knäuper, B., & Miquelon, P. (2006). The eternal quest for optimal balance between maximizing pleasure and minimizing harm: The compensatory health beliefs model. British Journal of Health Psychology, 11(1), 139–153. https://doi.org/10.1348/135910705X52237
• Radtke, T., Scholz, U., Keller, R., & Hornung, R. (2012). Smoking is ok as long as I eat healthily: Compensatory health beliefs and their role for intentions and smoking within the health action process approach. Psychology & Health, 27(sup2), 91–107. https://doi.org/10.1080/08870446.2011.603422
• Rosseel, Y. (2012). lavaan: An R package for structural equation modeling. Journal of Statistical Software, 48(2), 1–36. https://doi.org/10.18637/jss.v048.i02
• Shi, H. Y., & Zhang, Y. R. (2024). Chinese Compensatory Health Beliefs Scale. Frontiers in Public Health, 12, Article 1271409. https://doi.org/10.3389/fpubh.2024.1271409
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• Zhao, X., He, J., & Braun, V. (2021). Compensatory belief in health behavior management: A concept analysis. Frontiers in Psychology, 12, Article 705991. https://doi.org/10.3389/fpsyg.2021.705991

13. Items of the Scale