Behavioral and psychosocial correlates of multisite musculoskeletal symptoms in university students: green-space use, physical activity, and perceived stress

Aims: This study examined behavioral, psychosocial, and environmental correlates of recent multisite musculoskeletal symptom burden among university students, with particular attention to green-space access and use, physical activity, and perceived stress. Methods: This cross-sectional study included 619 students aged 18–30 years at Selçuk University in Konya, Turkiye. Data were collected in March–April 2026 using an anonymous online questionnaire. The primary outcome was the number of anatomical regions with symptoms during the previous 4 weeks. Perceived green-space access was assessed using a four-item composite, and recent green-space use was measured as the number of visit days during the previous 7 days. Direct associations were evaluated using negative binomial regression, with zero-inflated negative binomial models as sensitivity analyses. Exploratory pathway-oriented analyses estimated indirect statistical associations through physical activity and perceived stress. Results: Overall, 353 students (57.0%) reported at least one 4-week musculoskeletal symptom. The neck (34.6%), low back (24.7%), shoulders (23.7%), and upper back (23.4%) were the most frequently affected regions. Neither perceived green-space access nor visit frequency was directly associated with symptom burden. Green-space visit frequency was positively associated with log-transformed total physical activity (β = 0.296; p < 0.001). Log-transformed physical activity (IRR = 1.11; p = 0.002) and perceived stress (IRR = 1.05; p < 0.001) were positively associated with symptom burden. A positive indirect statistical association through physical activity was observed (estimate = 0.0306; 95% CI, 0.0114–0.0538; p < 0.001), whereas the indirect association through perceived stress was not significant. Conclusion: Multisite musculoskeletal symptom burden was common among university students. Green-space access and visit frequency were not directly associated with symptom burden, whereas physical activity and perceived stress showed positive cross-sectional associations. Student musculoskeletal health assessments should therefore consider activity context and psychosocial factors rather than assume a direct protective effect of green-space access or use.