COVID-19-related Behaviors Scale (CB-19)

1. Abstract

The COVID-19-related Behaviors Scale (CB-19) is a psychometric self-report instrument engineered to measure behavioral compliance and psychological reactivity associated with the coronavirus pandemic. Originally conceptualized during the initial outbreak phases of SARS-CoV-2 in 2020, the instrument was systematically formulated to capture both protective health practices and affective-cognitive manifestations of distress within community populations. From an initial pool of 25 candidate items evaluated by behavioral science experts for content validity, clarity, and contextual relevance, the scale was iteratively refined to 17 items, and subsequently established as a 14-item multidimensional measure through rigorous exploratory and structural modeling among a cohort of residents in Mashhad, Iran (mean age = 26.51 years). Psychometric validation confirmed a robust two-factor latent structure comprising Health Behaviors (7 items) and Psychological Behaviors (7 items). The scale employs an ordinal response format that assesses the frequency and intensity of engagement in targeted behaviors.

Empirical evaluation of the instrument demonstrated solid structural validity and acceptable internal consistency. Exploratory factor analysis supported the hypothesized two-dimensional architecture, yielding excellent goodness-of-fit indices (Root Mean Square Error of Approximation [RMSEA] = .06, Comparative Fit Index [CFI] = .95, and Goodness-of-Fit Index [GFI] = .95). Reliability assessments revealed a Cronbach’s alpha coefficient of .68 for the total 14-item scale, with factor-specific internal consistency estimates of .56 for the Health Behavior subscale and .70 for the Psychological Behavior subscale. By simultaneously mapping institutional adherence behaviors (such as sanitization, mask wearing, and physical distancing) alongside hypervigilant, threat-monitoring psychological responses (such as compulsive information seeking, somatic scanning, and threat-related sleep disturbances), the CB-19 serves as an essential empirical apparatus for behavioral medicine researchers, epidemiologists, and clinical psychologists monitoring public health compliance and mental health trajectories during viral epidemics.

2. Keywords

COVID-19-related Behaviors Scale, CB-19, Health Behavior, Psychological Behavior, Health Psychology, Psychometrics, Structural Validity, Pandemic Coping, Threat Monitoring, Behavioral Adherence, Infectious Disease Psychology, Health Belief Model

3. Authors

The COVID-19-related Behaviors Scale (CB-19) was developed and validated by a multidisciplinary team of behavioral scientists and psychological researchers specializing in cognitive processes, clinical assessment, and health psychology:

• Seyed-Mohammad-Mahdi Moshirian-Farahi — Affiliated with the Department of Psychology at Carleton University (Ottawa, Canada) and Imam Reza International University (Mashhad, Iran). Primary investigator focused on cognitive control, attentional allocation, and psychological distress during public health crises.
• Seyedeh-Maryam Moshirian-Farahi — Department of Psychology, Imam Reza International University, Mashhad, Iran. Corresponding author (Email: [email protected]).
• Maryam Ghazaei — Department of Humanities, Sadjad University, Mashhad, Iran. Research expertise encompassing social psychology, individual behavioral variance, and psychometric evaluation methodologies.

Correspondence regarding the instrument, its validation parameters, or prospective academic cross-cultural adaptations should be addressed to the Department of Psychology, Imam Reza International University, Mashhad, Islamic Republic of Iran.

4. Purpose

The emergence of the novel coronavirus disease 2019 (COVID-19) posed unparalleled global challenges that extended far beyond biological morbidity and mortality, disrupting societal infrastructure and precipitating widespread psychological turmoil. In early epidemiological phases, in the absence of pharmaceutical interventions or widespread vaccination, mitigation of viral transmission relied almost entirely on non-pharmaceutical interventions (NPIs) requiring immediate, sustained, and pervasive modification of individual and collective behavior. Concurrently, the proliferation of pandemic-related threat cues induced severe psychological distress, marked by health anxiety, acute stress, depressive states, and catastrophic rumination. Within this complex milieu, researchers required a psychometrically sound, parsimonious instrument capable of capturing the dual reality of pandemic adaptation: tangible compliance with preventative health directives and the emergent psychological, cognitive, and affective behavioral manifestations of pandemic-induced stress.

The fundamental purpose of the COVID-19-related Behaviors Scale (CB-19) was to systematically quantify and distinguish these behavioral dimensions within an Iranian community sample during the nascent surge of the pandemic in Mashhad. While numerous clinical inventories existed to gauge generalized psychiatric morbidity—such as the Depression, Anxiety and Stress Scale (DASS-21) or the Generalized Anxiety Disorder 7 (GAD-7)—these legacy instruments inherently lacked sensitivity to the unique, pathogen-specific behavioral manifestations prompted by an active epidemic. Conversely, standard behavioral adherence checklists frequently neglected the disruptive cognitive-behavioral correlates of health-focused hypervigilance, such as compulsive symptom checking, safety reassurance-seeking, and relentless media consumption.

The CB-19 was engineered to bridge this diagnostic and psychometric divide. In clinical settings, the scale facilitates the rapid identification of maladaptive behavioral patterns, clarifying whether a patient’s behavioral profile reflects adaptive, hygiene-oriented preventative precautions or dysfunctional, threat-driven safety maneuvers that exacerbate panic, insomnia, and functional impairment. In research and epidemiological contexts, the CB-19 serves as an empirical tool to investigate how cognitive control, executive functioning, socioeconomic parameters, and risk communication channels shape protective health compliance versus psychological distress. Ultimately, the instrument provides public health agencies and behavioral medicine practitioners with actionable metric data to evaluate the behavioral efficacy of health directives and design targeted psychological interventions that encourage hygienic compliance without amplifying debilitating health anxiety.

5. Psychological Construct

The conceptual framework operationalized by the CB-19 is predicated on the theoretical bifurcation of behavioral adaptations during an infectious disease outbreak into two interrelated yet distinct domains: Health Behaviors (Factor 1) and Psychological Behaviors (Factor 2). Rather than conceptualizing behavioral responses to a pandemic as a unidimensional continuum of non-compliance to compliance, the construct models response patterns as an interaction between deliberate physical risk-reduction actions and automatic or distress-driven cognitive-behavioral reactions.

Factor 1: Health Behaviors (Preventative Adherence)

The Health Behaviors dimension encapsulates overt, volitional, non-pharmaceutical preventative measures directly designed to interrupt viral transmission pathways, consistent with empirical directives issued by the World Health Organization (WHO) and national centers for disease control. This factor operationalizes individual adherence to sanitation, barrier protocols, and spatial modification standards. Specifically, it assesses actions including frequent hand hygiene utilizing soap or alcohol-based sanitizer, deliberate avoidance of mucosal contact (touching eyes, nose, and mouth with unwashed hands), consistent utilization of protective facial coverings in public settings, strict maintenance of interpersonal physical distance (at least 1.5 to 2 meters), systematic avoidance of crowded gatherings, rigorous decontamination of ambient surfaces and purchased goods, and strict adherence to stay-at-home mandates except for essential needs.

From a behavioral medicine perspective, these actions represent instrumental problem-focused coping mechanisms. When executed appropriately, they diminish empirical pathogen exposure risk and foster an adaptive sense of perceived behavioral control over biological vulnerability. However, because health behaviors require sustained cognitive effort, lifestyle alteration, and personal discipline, capturing their precise frequency provides critical insight into societal compliance trajectories and public health guideline internalization.

Factor 2: Psychological Behaviors (Threat Reactivity and Hypervigilance)

The Psychological Behaviors dimension captures the covert and overt behavioral manifestations of affective distress, cognitive preoccupation, and threat-monitoring routines triggered by the pandemic environment. Rather than reflecting purely preventative physical barriers, these behaviors represent cognitive-behavioral correlates of anxiety, perceived vulnerability to disease, and compensatory safety strategies. Items within this subscale assess relentless tracking and consumption of COVID-19 news bulletins, visceral feelings of apprehension and distress upon encountering pandemic-related updates, repetitive somatic checking behaviors (such as hyper-focused monitoring of respiration, throat sensation, or body temperature), and persistent cognitive rumination concerning potential infection of oneself or family members.

Additionally, this dimension operationalizes interpersonal and social behaviors driven by pandemic stress, including intense social anxiety triggered by the mere presence of other individuals, perseverative discussions regarding the contagion with friends and family, and downstream neurovegetative disruptions such as sleep disturbances, insomnia, or profound alterations in daily operational routines directly tied to intrusive coronavirus ideation. In psychopathological models, while these behaviors frequently emerge as attempts to downregulate distress or verify safety, they frequently operate as maladaptive avoidance or reassurance-seeking rituals that perpetuate catastrophic threat appraisals, maintain cognitive bias toward somatic stimuli, and amplify chronic psychological distress.

6. Theoretical Framework

The construction and operationalization of the CB-19 intersect several foundational models within health psychology, cognitive-behavioral theory, and cognitive neuroscience, notably the Health Belief Model (HBM), Protection Motivation Theory (PMT), and the cognitive-behavioral model of health anxiety.

Health Belief Model and Protection Motivation Theory

The behavioral adherence measured in Factor 1 (Health Behaviors) maps directly onto the core tenets of the Health Belief Model developed by Rosenstock and colleagues, as well as Rogers’ Protection Motivation Theory. These frameworks posit that an individual’s decision to enact protective health behaviors is governed by two parallel appraisal processes: threat appraisal (composed of perceived susceptibility to an illness and perceived severity of its consequences) and coping appraisal (comprising perceived response efficacy of the preventative measure and perceived self-efficacy to execute the behavior, weighed against potential perceived barriers). In the context of COVID-19, when individuals perceive the viral agent as highly contagious and medically debilitating, they become motivated to implement recommended non-pharmaceutical interventions—such as mask-wearing, hand hygiene, and physical distancing—provided they view these actions as efficacious mechanisms for reducing infection probability.

Cognitive-Behavioral Models of Health Anxiety and Safety-Seeking

Conversely, Factor 2 (Psychological Behaviors) is strongly informed by cognitive-behavioral formulations of health anxiety, originally articulated by Salkovskis, Warwick, and Clark. According to these paradigms, individuals who misinterpret ambiguous physiological sensations or external threat cues as definitive indicators of catastrophic danger enter a cycle of hypervigilance. During a global pandemic, this cognitive bias manifests in overt safety behaviors and cognitive rituals: compulsive media monitoring (infodemic consumption), continuous somatic scanning for atypical bodily sensations (cough, throat irritation, dyspnea), and perseverative reassurance seeking via constant verbal communication about the pathogen.

Crucially, cognitive-behavioral theory asserts that while safety-seeking behaviors (e.g., repeated symptom checking or constant news consumption) are executed to neutralize acute anxiety and restore perceived equilibrium, they paradoxically reinforce fear conditioning. They prevent cognitive reappraisal, perpetuate attention toward threat-related stimuli, and disrupt biological rhythms, leading to the insomnia and behavioral interference captured by the CB-19. In their primary empirical validation, Moshirian-Farahi and colleagues integrated these perspectives with attentional control theory, demonstrating that an individual’s neurocognitive capacity to shift and focus attention acts as a fundamental moderator: deficits in attentional control diminish the capacity to inhibit threat-related rumination, directly amplifying the pathological expression of these psychological behaviors.

7. Validity

The psychometric integrity of the CB-19 was established through rigorous methodological procedures assessing content, face, and structural construct validity during its initial scale development and empirical deployment.

Content and Face Validity

The scale development began with an expansive pool of 25 preliminary items generated from a comprehensive review of emerging epidemiological guidelines and clinical literature on pandemic stress responses. To establish robust content validity, this item pool was submitted to a panel of expert judges specializing in clinical psychology, psychometrics, and behavioral medicine. These experts systematically evaluated each candidate item for linguistic clarity, conceptual distinctiveness, face validity, and empirical relevance to the lived reality of the COVID-19 outbreak. Items exhibiting semantic ambiguity, redundant operational scope, or poor alignment with the underlying constructs were modified or excised, condensing the pool from 25 to 17 items prior to quantitative field testing.

Structural and Construct Validity

Structural construct validity was quantitatively evaluated using empirical data collected from community residents in Mashhad, Iran. The structural dimensionality was explored and tested using exploratory factor analysis (EFA). The resulting structural architecture demonstrated that 14 items retained optimal psychometric properties, cleanly loading onto two distinct, theoretically coherent latent dimensions: Health Behaviors (7 items) and Psychological Behaviors (7 items), with items failing to meet psychometric retention thresholds eliminated.

Goodness-of-fit indices demonstrated an exceptional fit between the empirical covariance matrix and the hypothesized two-factor measurement model. The structural validity was underscored by the following definitive fit parameters:

• Root Mean Square Error of Approximation (RMSEA): .06. In structural equation modeling and factor analysis, an RMSEA value of ≤ .06 indicates a close approximate fit of the model in the population, confirming minimal residual error.
• Comparative Fit Index (CFI): .95. A CFI value of ≥ .95 reflects excellent model fit relative to the null independence model, confirming that the hypothesized two-factor structure accounts for 95% of the covariation in the observed data.
• Goodness-of-Fit Index (GFI): .95. A GFI coefficient of .95 indicates that the proportion of variance and covariance collectively explained by the two latent factors meets the highest psychometric criteria for empirical adequacy.

In addition to structural parameters, the construct validity of the CB-19 was evidenced by its theoretical convergence with validated measures of affective psychopathology. Moshirian-Farahi et al. (2023) demonstrated significant associations between the CB-19 subscales and indices of psychological distress (depression, anxiety, and stress as measured by the DASS-21) and attentional control capacities, substantiating the scale’s construct and criterion-related validity within community health assessment.

8. Reliability

The internal consistency of the COVID-19-related Behaviors Scale (CB-19) was rigorously examined through the computation of Cronbach’s alpha coefficients across the multidimensional components and the overarching composite scale.

Internal Consistency Metrics

For the overall 14-item composite measure, the internal consistency reliability was documented at:

• Total Scale Cronbach’s α: .68

When evaluated across its discrete structural subscales, the instrument yielded distinct internal consistency estimates reflecting the inherent nature of the operationalized dimensions:

• Factor 1: Health Behavior (7 items): Cronbach’s α = .56
• Factor 2: Psychological Behavior (7 items): Cronbach’s α = .70

Psychometric Interpretation of Reliability Coefficients

The observed Cronbach’s alpha of .70 for Factor 2 (Psychological Behaviors) meets the conventional threshold of psychometric acceptability for novel behavioral assessment scales in exploratory research, indicating that the seven items tapping threat reactivity, reassurance seeking, and pandemic-induced distress demonstrate coherent inter-item correlations. Conversely, the alpha coefficient of .56 observed for Factor 1 (Health Behaviors), while modest by classical psychometric standards, is theoretically congruent with the structural properties of health adherence checklists in behavioral medicine.

In psychometrics, preventative health behaviors frequently function as causal or formative indicators rather than purely reflective indicators. Individual adherence behaviors (e.g., surface decontamination versus outdoor mask wearing) do not necessarily share a single continuous psychological engine; an individual may strictly sanitize groceries while finding complete home confinement impossible due to occupational obligations. Consequently, lower inter-item correlations are widely documented across epidemiological behavioral inventories without undermining the structural validity or ecological utility of the tool. Nonetheless, researchers conducting structural equation modeling with the CB-19 are advised to model Health Behaviors with due consideration of measurement error or to inspect composite reliability (McDonald’s omega) in prospective cross-cultural cohorts.

9. Factor Analysis

The latent dimensionality of the CB-19 was established through rigorous Exploratory Factor Analysis (EFA), followed by structural evaluation to determine the most parsimonious and theoretically robust factor solution.

Exploratory Factor Structure

During the quantitative refinement phase, the 17 refined candidate items were subjected to factor extraction techniques using community data from Mashhad residents. Factor extraction criteria—guided by eigenvalue examination (Kaiser-Guttman criterion, eigenvalues > 1.0), scree plot inspection, and theoretical interpretability—consistently pointed to a two-factor latent framework. Three candidate items that displayed substantial cross-loadings, weak primary loadings (< .30), or conceptual redundancy were systematically eliminated, producing a finalized, balanced 14-item instrument.

Factor Loadings and Structural Organization

The final factor solution organized the 14 items symmetrically across two distinct latent dimensions, with seven items loading decisively onto each factor:

• Factor 1: Health-Related Behaviors (Items 1 through 7): Items clustered onto this dimension capture concrete, protective non-pharmaceutical interventions. This includes frequent handwashing with soap or alcohol sanitizer, avoiding facial mucosal touching, public mask wearing, physical distancing (1.5–2 meters), crowd avoidance, surface and grocery disinfection, and compliance with stay-at-home restrictions.
• Factor 2: Psychological-Related Behaviors (Items 8 through 14): Items loading onto this dimension reflect affective, cognitive, and somatic hypervigilance. This includes compulsive news monitoring, acute anxiety in response to coronavirus updates, somatic symptom scanning, obsessive thoughts of familial infection, interpersonal anxiety in public spaces, obsessive verbal discussions concerning the virus, and threat-related sleep disturbances or daily routine disruption.

Model Fit and Structural Parameterization

Structural validation confirmed that the two-factor paradigm exhibited superior goodness-of-fit relative to unidimensional alternatives. The empirical fit parameters satisfied standard structural equation modeling benchmarks:

These robust indices confirm that the observed data matrix corresponds closely with the two-factor conceptualization, establishing that Health Behaviors and Psychological Behaviors represent distinct structural dimensions rather than a single generalized behavioral trait.

10. Instrument / Measurement Tool

The operational specifications of the COVID-19-related Behaviors Scale (CB-19) are summarized below:

• Instrument Name: COVID-19-related Behaviors Scale
• Acronym: CB-19
• Test Type: Original Psychometric Self-Report Questionnaire / Behavioral Rating Scale
• Target Population: General community populations, young adults, and clinical cohorts (originally validated in individuals with a mean age of 26.51 years; applicable across male and female adults)
• Administration Format: Individual self-report; suitable for digital (online survey engines), paper-and-pencil, or clinical face-to-face administration
• Completion Time: Approximately 3 to 5 minutes
• Item Count: 14 items
• Latent Dimensions / Subscales:
  • Factor 1: Health Behaviors (Items 1 to 7)
  • Factor 2: Psychological Behaviors (Items 8 to 14)
• Response Scale: The response scale items are ordinal.
• Scoring Methodology: Subscale scores are obtained by calculating the sum of the ordinal ratings for the designated items within each dimension:
  • Health Behaviors Score: Sum of Items 1, 2, 3, 4, 5, 6, and 7. Higher scores denote elevated adherence to non-pharmaceutical infection prevention and hygiene protocols.
  • Psychological Behaviors Score: Sum of Items 8, 9, 10, 11, 12, 13, and 14. Higher scores reflect elevated health anxiety, threat-related hypervigilance, and disruptive psychological reactivity.
  • Total Composite Score: Calculated by summing all 14 items, reflecting total behavioral engagement and psychological preoccupation surrounding the pandemic.
• Reverse Scoring Rules: The scale comprises two factors: Health Behaviors (Items 1 to 7) and Psychological Behaviors (Items 8 to 14). Total scores are calculated by summing the item ratings. None of the items are reverse-scored; all items are coded in the direct theoretical direction of behavioral frequency.

11. Permissions & Fee and Test Year

The COVID-19-related Behaviors Scale (CB-19) was developed and published in the academic literature in 2023 (incorporating validation data collected during the outbreak period in 2020). The administrative parameters governing its intellectual property and usage include:

• Test Year: 2023
• Commercial Status: Non-commercial; the instrument is dedicated to scientific advancement and public health surveillance.
• Fee: None. The scale is freely accessible for non-profit scholarly research, epidemiology, and clinical assessment.
• Permissions: Researchers wishing to utilize, translate, adapt, or administer the CB-19 in clinical trials or academic studies should contact the corresponding author to obtain formal authorization and maintain cross-cultural psychometric tracking:
  • Corresponding Contact: Seyedeh-Maryam Moshirian-Farahi / Seyed-Mohammad-Mahdi Moshirian-Farahi
  • Affiliation: Department of Psychology, Imam Reza International University, Mashhad, Islamic Republic of Iran
  • Email: [email protected]

12. References

The development, validation, and theoretical context of the CB-19 are documented in the following peer-reviewed literature:

• Moshirian-Farahi, S.-M.-M., Hoshirian-Farahi, S.-M., & Ghazaei, M. (2023). The prevalence of psychological distress and its associations with attentional control and COVID-19 related behaviors in an Iranian sample. International Journal of Behavioral Sciences, 17(1), 46–51. https://doi.org/10.22037/ijbs.v17i1.35061
• Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461–470. https://doi.org/10.1016/0005-7967(86)90011-2
• Eysenck, M. W., Derakshan, N., Santos, R., & Calvo, M. G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7(2), 336–353. https://doi.org/10.1037/1528-3542.7.2.336
• Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U
• Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. The Journal of Psychology, 91(1), 93–114. https://doi.org/10.1080/00223980.1975.9915803
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403
• Salkovskis, P. M., & Warwick, H. M. C. (1986). Morbid obsessions, health anxiety, and reassurance seeking: A cognitive-behavioural approach. Behavioural and Cognitive Psychotherapy, 14(3), 193–202. https://doi.org/10.1017/S014134730001490X

13. Items of the Scale