The association of health anxiety with low back pain and physical inactivity in Chinese university students: a structural equation modeling study

TL;DR

This study finds that health anxiety in Chinese university students is linked to physical inactivity and low back pain, suggesting the need for combined psychological and activity-based interventions.

Contribution

This study is the first to use structural equation modeling to explore the interplay between health anxiety, physical inactivity, and low back pain in Chinese university students.

Findings

Higher health anxiety was associated with increased physical inactivity and indirectly with low back pain.

Physical inactivity was linked to more intense low back pain and higher BMI.

Participation in physical education classes was inversely associated with physical inactivity.

Abstract

Health anxiety involves excessive worry about illness and heightened vigilance toward bodily sensations. These concerns may relate to reduced physical activity and musculoskeletal symptoms such as low back pain (LBP). However, the interrelationships among health anxiety, physical inactivity, and LBP in Chinese university students remain insufficiently explored. This study examined these associations using structural equation modeling (SEM).

A cross-sectional survey was conducted between February and May 2025 among 5,607 third- and fourth-year students from 39 universities in Guangdong Province, China. Standardized instruments measured health anxiety, physical activity, participation in physical education (PE) classes, and LBP. SEM was used to evaluate direct and indirect associations while adjusting for demographic and behavioral covariates.

Among participants (64.99% female; 22.32 ± 0.67 years), 44% were classified as physically inactive and 33.93% reported LBP in the past month. Higher health anxiety was associated with a greater likelihood of physical inactivity (β = 0.291), and an indirect association with LBP through inactivity (indirect effect = 0.061). Physical inactivity was associated with greater LBP intensity (β = 0.211) and higher BMI (β = 0.157), and BMI was associated with higher LBP (β = 0.165). Participation in PE classes showed an inverse association with physical inactivity (β = −0.119), indicating that students who attended PE classes more frequently were less likely to be classified as inactive. Gender and family income showed negligible associations with health anxiety.

Health anxiety was linked to both physical inactivity and LBP, and physical inactivity partially accounted for this association. The findings underscore the importance of integrated approaches addressing both psychological concerns and activity-related behaviors among university students. Longitudinal studies are needed to clarify temporal pathways and evaluate whether interventions targeting health anxiety or sedentary behavior may help reduce LBP in young adults.

Figures