Chinese Compensatory Health Beliefs Scale

Abstract

The Chinese Compensatory Health Beliefs Scale (CHBs-C) is a psychometrically validated, culturally adapted self-report instrument designed to quantify the cognitive rationalizations individuals employ to justify unhealthy lifestyle choices through the anticipation of future health-promoting behaviors. Grounded in cognitive dissonance theory and the Compensatory Health Beliefs Model developed by Knäuper and colleagues, the scale addresses the distinct cultural, dietary, and behavioral nuances of mainland Chinese populations. While Western conceptualizations typically isolate dietary practices, physical activity, substance use, and sleep into distinct or differing dimensions, the CHBs-C captures a culturally grounded tripartite latent structure consisting of 14 items distributed across three correlated factors: (1) Exercising/Eating/Sleeping Habits, reflecting an interconnected, holistic view of daily restorative and metabolic practices; (2) Drinking/Smoking, indexing rationalizations surrounding high-risk substance consumption; and (3) Stress, measuring the justification of immediate hedonic indulgences as necessary psychological coping mechanisms for tension reduction.

Developed and evaluated by Hua Yu Shi and Ya Ru Zhang (2024), the psychometric architecture of the CHBs-C was established using three independent non-clinical adult samples ($N_1 = 476$, $N_2 = 308$, and $N_3 = 274$) recruited via the Credamo platform. Structural integrity was determined through sequential exploratory factor analysis (Principal Axis Factoring) and confirmatory factor analysis utilizing the Diagonally Weighted Least Squares (DWLS) estimation method, which is specifically suited for ordinal, non-normally distributed psychological data. The instrument demonstrated acceptable structural fit, robust discriminant validity supported by the Fornell-Larcker criterion, and high two-week test-retest temporal stability via Spearman rank correlation ($r_s$). Internal consistency was confirmed via McDonald’s omega ($\omega$). The CHBs-C provides researchers, epidemiologists, and behavioral medicine clinicians with an empirical framework to investigate modern behavioral paradoxes, including the socio-cultural phenomenon known as “punk health maintenance” (pengke yangsheng), and to design targeted public health interventions that neutralize maladaptive compensatory mechanisms.

Keywords

Compensatory Health Beliefs, CHBs-C, Psychometrics, Cross-Cultural Adaptation, Cognitive Dissonance, Health Psychology, Health Behavior, Scale Validation, Confirmatory Factor Analysis, Diagonally Weighted Least Squares, Punk Health Maintenance, Behavioral Medicine

Authors

The Chinese Compensatory Health Beliefs Scale was adapted, psychometrically evaluated, and published by researchers affiliated with the School of Economics and Management at Shanghai Institute of Technology in Shanghai, China:

• 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.

Purpose

The overarching objective of the Chinese Compensatory Health Beliefs Scale (CHBs-C) is to provide an empirically robust, culturally calibrated diagnostic instrument capable of assessing how individuals within Chinese society cognitively reconcile the discrepancy between short-term hedonic desires and long-term somatic health goals. In contemporary health psychology, individuals frequently confront self-regulatory failures wherein immediate temptations—such as consuming energy-dense foods, remaining sedentary, smoking, binge drinking, or sacrificing sleep for occupational or leisure pursuits—undermine personal health maintenance objectives. To resolve the resulting psychological discomfort, people often generate compensatory health beliefs (CHBs), positing that the prospective execution of a healthy behavior will counterbalance, neutralize, or “compensate for” the physiological harm induced by an immediate unhealthy choice.

Although the original Compensatory Health Beliefs Scale created by Knäuper et al. (2004) represented a major advance in self-regulation theory, its operationalization reflected Western cultural patterns, social interactions, and dietary environments. Standard Western inventories frequently operationalize compensatory scenarios that lack ecological validity in mainland China, such as omitting breakfast to manage caloric intake or consuming large quantities of coffee to remediate daytime fatigue caused by sleep deprivation. In Chinese culinary and lifestyle traditions, skipping staple meals or relying heavily on coffee does not function as a standard behavioral compensatory archetype. Furthermore, traditional Chinese perspectives often treat somatic and psychological well-being through an integrated lens, viewing dietary patterns, sleep timing, and physical movement not as isolated behavioral silos, but as co-dependent regulators of bodily equilibrium.

In addition to bridging this theoretical and cultural divide, the CHBs-C serves as a timely response to contemporary behavioral trends documented among younger and working-class populations in urban China. A salient manifestation is the sociological phenomenon known as “punk health maintenance” (pengke yangsheng, “punk health preservation”). Within this subculture, individuals intentionally engage in high-risk health behaviors while simultaneously attempting to neutralize them with immediate, often superficial, health investments—such as staying up all night working or gaming while consuming goji berries, or drinking alcohol followed immediately by hepatoprotective teas and dietary supplements. The CHBs-C equips behavioral epidemiologists, health communication strategists, and clinical psychologists with a psychometrically sound scale to systematically quantify these rationalizations. By identifying specific cognitive trade-offs, health practitioners can design targeted interventions that address maladaptive compensatory expectations rather than relying solely on generic health literacy directives.

Psychological Construct

The psychological construct assessed by the CHBs-C is operationalized as an individual’s dynamic cognitive network of automatic or deliberate rationalizations which state that the negative physiological, biological, or psychological consequences of an unhealthy behavior can be offset, eliminated, or mitigated by engaging in a healthy behavior at a subsequent time point. Rooted in self-regulation and goal conflict theories, compensatory health beliefs function primarily as cognitive self-defense mechanisms. When individuals experience an acute conflict between a primary goal (such as maintaining somatic longevity, cardiovascular fitness, or metabolic health) and an immediate desire (such as indulging in palatable foods, tobacco, or sedentary rest), self-regulatory failure generates negative affect. By adopting or retrieving a compensatory health belief, the individual alleviates this discomfort without modifying the unhealthful behavior, effectively granting themselves permission to indulge.

Through systematic cross-cultural adaptation, translation, and psychometric reduction, the construct of compensatory health beliefs within the Chinese cultural paradigm was organized into three distinct, correlated latent dimensions:

1. Exercising/Eating/Sleeping Habits

This subscale assesses cognitive trade-offs that link daily metabolic and restorative behaviors. In contrast to Western models that statistically isolate diet, exercise, and sleep, Chinese participants demonstrated a conceptual merging of these three operational areas. Items in this factor measure beliefs such as the conviction that consuming an excessively oily, salty, or caloric dinner can be entirely “burned off” or corrected by an intense bout of physical exercise the following day, or that significant chronic sleep deprivation can be compensated for by consuming high-potency nutritional supplements, fruits, or engaging in weekend oversleeping. This dimension captures an underlying holistic health paradigm wherein bodily energy and balance are perceived as a fungible currency that can be redistributed across diet, sleep, and physical activity.

2. Drinking/Smoking

This dimension focuses explicitly on the physiological rationalizations associated with major substance use risks, specifically tobacco smoking and alcohol consumption. In China, smoking and communal drinking often play a prominent role in social cohesion, professional networking (guanxi), and traditional hospitality rituals. Consequently, individuals operating within these social environments frequently experience acute tension between normative health warnings and social drinking or smoking demands. This factor captures cognitive beliefs that the deleterious vascular and pulmonary consequences of smoking can be mitigated by high daily intake of green tea, antioxidant-rich foods, or regular aerobic activity, as well as the belief that heavy alcohol intake can be neutralized by drinking milk beforehand or taking liver-protection remedies the following morning.

3. Stress

The third dimension evaluates the cognitive rationalization that engaging in unhealthful behaviors is an acceptable, justified, and biologically adaptive mechanism for managing severe psychological distress, workplace tension, and emotional exhaustion. Modern socio-economic pressures in urban China—exemplified by intense corporate work cultures (such as the “996” schedule)—often deplete self-regulatory resources. This subscale measures the belief that indulging in high-sugar confectionery, late-night snacking, or tobacco use is necessary to restore psychological equilibrium and alleviate mental strain, framing health-compromising practices not as failures of discipline, but as necessary therapeutic interventions for emotional regulation.

Theoretical Framework

The Chinese Compensatory Health Beliefs Scale is theoretically anchored in Leon Festinger’s (1957) Cognitive Dissonance Theory, integrated with contemporary dual-system self-regulation models and the specific Compensatory Health Beliefs (CHB) Model formulated by Rabiau, Knäuper, and Miquelon (2006).

According to the CHB Model, the etiology of compensatory rationalizations occurs sequentially through four cognitive-affective phases:

1. Temptation and Goal Conflict: An individual encounters an environmental or internal cue prompting a behavior that provides immediate hedonic gratification (e.g., eating fried street food) but contradicts an internalized, long-term health objective (e.g., weight management or cardiovascular disease prevention).
2. Cognitive Dissonance Arousal: Awareness of this discrepancy triggers an aversive psychological state marked by guilt, tension, or perceived vulnerability. Festinger posited that humans are intrinsically driven to eliminate or reduce cognitive dissonance.
3. Activation of Compensatory Beliefs: To alleviate this tension without relinquishing the immediate reward, the executive system accesses a compensatory belief (e.g., “I can eat this high-fat meal now because I will walk an extra 5,000 steps tonight”). This belief alters the cognitive appraisal of the situation, shifting the perceived net health risk toward neutral.
4. Intention Formation and Temporal Discounting: The activation of the CHB generates an explicit or implicit behavioral intention to execute the compensatory action in the future. However, because future costs are discounted relative to present rewards (temporal discounting), the individual frequently fails to complete the compensatory behavior once the immediate indulgence has occurred, creating a continuous cycle of unfulfilled healthy intentions and accumulated behavioral risk.

At an epistemological and cultural level, the CHBs-C adapts these principles through the lens of cross-cultural health psychology. While Western cognitive appraisals often follow a compartmentalized, linear cause-and-effect structure, traditional and contemporary Chinese health concepts (influenced partly by Traditional Chinese Medicine and dialectical thinking) view physiological equilibrium as a continuous, fluctuating balance. In this cultural context, compensatory mechanisms may not be experienced merely as defensive cognitive rationalizations, but as common-sense restorative measures. Consequently, understanding these culturally specific cognitive models is essential for evaluating self-efficacy, behavioral maintenance, and relapse prevention within non-Western populations.

Validity

The construct, factorial, convergent, discriminant, and predictive validity of the CHBs-C were evaluated by Shi and Zhang (2024) across three independent sample cohorts. The validation protocol followed standard cross-cultural translation guidelines, incorporating initial forward translation, expert consensus panels, back-translation, and cognitive debriefing to verify linguistic equivalence, semantic clarity, and cultural relevance.

Construct and Factorial Validity

Following an initial Exploratory Factor Analysis (EFA) on Sample 1 ($N = 476$), the scale was refined from the original extended item pool down to 14 core items mapping onto three distinct dimensions. To establish construct validity, Confirmatory Factor Analysis (CFA) was conducted on Sample 2 ($N = 308$) using the Diagonally Weighted Least Squares (DWLS) estimator. The hypothesized three-factor model demonstrated an acceptable structural fit to the observed data:

• Chi-Square to Degrees of Freedom Ratio ($\chi^2/df$) was within the recommended parameter range (≤ 3.0).
• Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) both exceeded the 0.90 threshold, indicating adequate comparative fit.
• Root Mean Square Error of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR) met standard cutoffs (≤ 0.08), supporting the structural validity of the 14-item, three-factor configuration.

Discriminant Validity

Discriminant validity across the three latent dimensions was tested using the Fornell-Larcker criterion. The square root of the Average Variance Extracted (AVE) for each of the three factors exceeded the inter-construct correlation coefficients between that factor and all other latent factors. This confirmed that although the dimensions of Exercising/Eating/Sleeping Habits, Drinking/Smoking, and Stress are moderately correlated, they represent conceptually distinct psychological domains rather than an undifferentiated general factor.

Convergent and Predictive Validity Nuances

Psychometric evaluation also revealed specific statistical constraints regarding convergent validity. The calculated Average Variance Extracted (AVE) for the individual latent factors fell below the conventional psychometric threshold of 0.50, and while Composite Reliability (CR) for the first two dimensions exceeded the recommended 0.70 benchmark, the CR for the Stress dimension fell slightly below 0.70. This pattern indicates that while items within each subscale share a common conceptual focus, they also retain item-specific variance. In predictive validity testing conducted on Sample 3 ($N = 274$), broad global CHB scores showed modest associations with generalized health outcomes, whereas targeted subscales demonstrated significant, domain-specific correlations with corresponding health-risk behaviors (e.g., the Drinking/Smoking subscale correlated significantly with frequency and quantity of alcohol and tobacco use). This indicates that the CHBs-C is best interpreted as a multidimensional diagnostic tool targeting specific compensatory behaviors rather than as a uniform global score.

Reliability

The reliability of the CHBs-C was evaluated across multiple testing waves, focusing on internal consistency and temporal stability (test-retest reliability).

Internal Consistency: McDonald’s Omega ($\omega$) and Composite Reliability

Given the ordinal nature of Likert response data and the restrictive assumptions of classical test theory (specifically essential tau-equivalence), the scale developers evaluated internal consistency using McDonald’s omega ($\omega$) alongside Composite Reliability (CR). The resulting omega coefficients confirmed that the items reliably measure their designated latent constructs at an acceptable psychometric level:

• Exercising/eating/sleeping habits: Demonstrated acceptable internal consistency, with Composite Reliability exceeding the 0.70 threshold.
• Drinking/smoking: Demonstrated acceptable internal consistency, with Composite Reliability exceeding the 0.70 threshold.
• Stress: Exhibited lower composite reliability (CR < 0.70), reflecting the fewer items in this subscale and the broader variety of stress-coping rationalizations reported by participants.

Temporal Stability: Test-Retest Reliability

To evaluate whether the CHBs-C measures stable cognitive dispositions or fluctuating situational states, Sample 2 ($N = 308$) completed the 14-item instrument across two measurement points separated by a two-week interval. Non-parametric temporal stability was evaluated using Spearman rank-order correlation analysis ($r_s$) across the test and retest sessions. The resulting coefficients demonstrated strong temporal stability across all subscales, confirming that compensatory health beliefs function as relatively stable cognitive schemas rather than transient affective responses. This stability supports the utility of the CHBs-C for longitudinal tracking and pre-post intervention studies.

Factor Analysis

The structural composition of the CHBs-C was determined through an empirical factor-analytic workflow conducted in two sequential stages across separate participant cohorts.

Exploratory Factor Analysis (EFA)

In the first phase, Sample 1 ($N = 476$; 44.1% female, predominantly aged 21–40 years) was administered the preliminary translated item pool. To examine the underlying latent structure without imposing restrictive a priori assumptions, the data were subjected to Exploratory Factor Analysis utilizing Principal Axis Factoring (PAF) with oblique rotation, allowing latent factors to correlate naturally. Items demonstrating poor factor loadings (< 0.40), significant cross-loadings across multiple factors, or poor semantic clarity were systematically eliminated. This process yielded a 14-item, three-factor solution that accounted for the majority of the common variance.

This empirical three-factor structure differed from the original four-factor model described by Knäuper et al. (2004), which separated eating and exercise into independent dimensions. In the Chinese sample, items reflecting dietary intake, physical exercise, and sleep patterns loaded cleanly onto a single unified dimension, leading researchers to label Factor 1 as Exercising/Eating/Sleeping Habits. Factors representing Drinking/Smoking (Factor 2) and Stress (Factor 3) emerged as distinct, independent constructs.

Confirmatory Factor Analysis (CFA)

To cross-validate this newly identified structure, Confirmatory Factor Analysis was performed on Sample 2 ($N = 308$; 57.8% female). Because self-report survey items generate ordered categorical (ordinal) distributions that typically violate assumptions of multivariate normality, parameter estimation was conducted using Diagonally Weighted Least Squares (DWLS) via the lavaan package in R. As established by methodological literature (Flora & Curran, 2004; Savalei, 2021; Shi et al., 2020), traditional Maximum Likelihood (ML) estimation can inflate chi-square statistics and distort standard errors when applied to ordinal data, whereas DWLS yields unbiased, robust parameter estimates and reliable model fit indices.

The CFA results confirmed that the 14-item, three-factor model provided a good fit to the observed data:

• $\chi^2/df le 3.0$
• Comparative Fit Index ($ ext{CFI}$) > 0.90
• Tucker-Lewis Index ($ ext{TLI}$) > 0.90
• Root Mean Square Error of Approximation ($ ext{RMSEA}$) ≤ 0.08
• Standardized Root Mean Square Residual ($ ext{SRMR}$) ≤ 0.08

All 14 standardized factor loadings were statistically significant ($p < 0.001$). These findings support the structural stability and construct validity of the three-factor model within the target population.

Instrument / Measurement Tool

• Test Type: Psychometric self-report questionnaire / Behavioral rating inventory
• Construct Assessed: Compensatory Health Beliefs (culturally adapted for Chinese populations)
• Primary Target Population: General Chinese adult population (community-dwelling, clinical, or workplace cohorts)
• Age Group: Adults aged 18 years and older
• Administration Mode: Self-administered; compatible with paper-and-pencil or online digital survey formats
• Language: Standard Simplified Chinese (Mandarin)
• Completion Time: Approximately 3 to 6 minutes
• Item Count: 14 items
• Latent Structural Dimensions:
  • Dimension 1: Exercising/Eating/Sleeping Habits (holistic lifestyle compensation)
  • Dimension 2: Drinking/Smoking (substance-use rationalizations)
  • Dimension 3: Stress (stress-reduction justifications for indulgence)
• Response Scale: Ordinal Likert-type scale ranging across graduated levels of agreement or endorsement
• Scoring Procedures:
  • Subscale scores are computed by summing or averaging the individual item ratings belonging to each latent factor.
  • Higher numerical scores reflect a greater endorsement of compensatory rationalizations, indicating higher cognitive susceptibility to self-regulatory failure.
  • Researchers are advised to analyze subscale scores independently rather than relying solely on a total global score, as predictive validity is highest when examining specific behavioral domains (e.g., substance use, stress-induced eating).

Permissions & Fee and Test Year

The Chinese Compensatory Health Beliefs Scale (CHBs-C) was developed and validated by Hua Yu Shi and Ya Ru Zhang and published in 2024. The corresponding validation study is published in Frontiers in Public Health under an open-access Creative Commons Attribution License (CC BY 4.0), permitting non-commercial and commercial distribution of the published research article with proper academic attribution.

However, the specific, finalized 14-item operational scale inventory was not fully reproduced in the open text of the original research article. Researchers, clinicians, and institutional investigators wishing to obtain the authoritative Chinese-language items, detailed scoring keys, or administrative guidelines must contact the lead author directly:

• Lead Author: Hua Yu Shi
• Affiliation: School of Economics and Management, Shanghai Institute of Technology, Shanghai, China
• Direct Inquiries: [email protected]

Academic use of the scale for non-commercial educational and research purposes is generally granted upon written request to the authors, provided that full bibliographic citation is given in resulting presentations, theses, and publications.

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Items of the Scale