Introduction
More than 20% of youths experience a mental health disorder by the end of adolescence and 45% of the global burden of disease lies in the youth age range (18–25 years). These issues have now increased due to the stress of the COVID-19 pandemic especially among students [
1]. In addition to mental health issues, physical pain has become a major health issue in this population. For instance, around 54% of university students report physical pain each year worldwide [
2]; 49% in Switzerland [
3], 66.9% in the United Kingdom [
4], 17.5% (wrist/hand pain) to 31.4% (neck pain) in the Netherlands [
5], and up to 81% in India [
6]. Previous studies evidenced that physical pain leads to lower quality of life and reduced general work productivity among university students [
7] and impairs their reward processes and the motivation to obtain a reward, which eventually weakens their academic performance [
8]. If the reward process is disrupted in students because of pain, they might also become predisposed to a greater probability of developing a disorder, or this could serve as a mutual maintenance factor for psychopathological symptoms in the future [
9]. This highlights the fact that there is an urgent need to understand factors that maintain the high frequency of physical pain symptoms in university students that could be extended to the youth population in general.
Many mental health markers and protective factors have been identified that are associated with physical pain experienced by university students. For instance, undergraduate students in Canada suffering from lower back pain (
N = 1013) experienced high rates of depression [
10]. Similarly, a study conducted on adults (
N = 655) showed positive associations between exposure to trauma and somatic symptoms, such as pain [
11]. Similarly, other studies showed a strong association between depressive and anxiety symptoms [
12], as well as higher perceived stress [
13] in people diagnosed with chronic pain and/or reporting higher pain severity. In summary, these studies suggest that depression, posttraumatic stress disorder (PTSD), anxiety, and perceived stress may function as risk factors for the development of pain symptoms. On the other hand, less is known about the protective factors that can help decrease the likelihood of physical pain. Protective factors are very important as the absence of risk factors does not predict a successful adaptation to the pain [
14]. Therefore, focusing on protective factors might help manage physical pain and promote successful adaptation. In people with pain, higher self-efficacy and social support acted as protective factors and were related to reduced pain intensity [
15,
16]. For instance, a study conducted on women (
N = 82) living in Italy and experiencing chronic pain showed that higher self-efficacy and social support from family and friends led to decreased levels of pain symptoms [
17].
Understanding risk and protective factors may help reduce pain symptoms in students around the world, however, most studies have been conducted in Western, educated, industrialized, rich, and democratic (WEIRD) societies, particularly in European countries and the United States, while only a few studies on physical pain in students were conducted in Asia, specifically Southeast Asia, despite its equally high prevalence. In that framework, a recent study conducted by our group indicated that pain impairs reward processing [
3], and it can vary across cultures [
18]. For example, investigating a sample of Swiss university students, we found a significant relationship between mood ratings and monetary reward in participants without subclinical pain symptoms compared to those with subclinical pain symptoms [i.e., university students with non-chronic yet clinically significant pain symptoms based on the cut-off from the pain subscale of Symptom Checklist-27-plus [
3,
19]. However, when replicating the same study in a non-WEIRD sample, i.e., in India, we did not see the effect of subclinical pain on reward processes in the Indian students, although pain symptoms were reported in both samples [
18]. This might be explained as the experience of pain and pain-related impairments differ across cultures, underscoring the need to expand research to non-Western cultures.
Taken together, the intercultural differences and similarities between the mental health markers and protective factors associated with physical pain among students from WEIRD and non-WEIRD samples are less known. Prior studies conducted in Western societies identified specific factors, i.e., depression, anxiety, perceived stress, PTSD, and protective factors like social support and self-efficacy associated with physical pain. However, there may be differences between countries, such as India and Switzerland. No studies have investigated mental health markers and protective factors associated with physical pain symptoms in these samples. Accordingly, we aimed to clarify the possible differences and/or similarities across non-WEIRD and WEIRD samples in the interaction between mental health markers (i.e., depression, anxiety, PTSD, perceived stress) and protective factors (i.e., social support and self-efficacy) and physical pain among university students. We used network analysis samples of Swiss and Indian university students. So far, to our knowledge, no network analysis has been conducted in this field. In addition, given the exploratory nature of the present study, no specific hypotheses were formulated.
Discussion
This study aimed to explore the interaction between specific mental health markers and specific protective factors correlated with physical pain in university students as well as to elucidate the possible similarities and differences across non-WEIRD and WEIRD samples in India and Switzerland. To our knowledge, this is the first study to test for possible similarities and differences using a network analysis approach.
Interestingly, the exploratory analysis revealed that the two countries showed significant statistical group differences regarding perceived stress, depression, and social support. Surprisingly, our study found that perceived social support (i.e., the resources perceived as being available from others like family and friends in our social networks) seemed higher in Swiss students than in Indian students. This contradicts the intuitive prediction based on the relationships between WEIRD and non-WEIRD countries. This counterintuitive cultural pattern may be explained as, in Western countries, relationships are seen as promoting individual goals. For instance, one may seek help from their immediate environment to achieve personal goals [
33,
34], whereas in collectivistic cultures, a person is fundamentally connected to others, and the emphasis is placed on group harmony, and any efforts made to bring personal problems to the attention of the others may harm the group harmony [
35]. This might lead people from non-WEIRD societies not to seek help from their immediate environment. One of the studies conducted on Korean students (
N = 56) and American students (N = 56) showed similar results. American students were more likely to mention using social support than Koreans [
36]. However, in the current study, we reported the differences in the total MSPSS score [
26]. However, additional analyses, not reported in this paper’s objective, showed that when the dimensions of the MSPSS were used, the difference between Switzerland and India in family support was nonsignificant, whereas the differences in friend and significant others support were significant. Thus, it may be possible that the groups in which the support is perceived make a difference, and it may be important to consider them, especially in cross-cultural studies. Also, our study found that Swiss students had higher stress levels than Indian students, whereas Indian students reported higher levels of depression than Swiss students. This highlights that mental health is a major health concern in developing and developed nations, although mental health markers might differ across countries. Also in our study, we found a strong positive relationship between mental health markers (i.e., depression, anxiety, perceived stress, and PTSD) with physical pain. This shows that mental health markers might make a person vulnerable to developing chronic pain in the future, which aligns with many previous studies [
37‐
39]. In addition to this, we also found protective factors (i.e., self-efficacy and social support) were negatively related to physical symptoms of pain, which shows that higher levels of protective factors might be associated with a reduced likelihood of experiencing physical symptoms of pain and might lead to better daily physical function and a better quality of life in the lives of the student [
40].
The results of our network analyses reveal the association between stress symptoms, PTSD symptoms, anxiety, and depression appeared to be particularly important for physical pain in both countries in students. The edges connecting these three mental health markers (i.e., stress, PTSD, anxiety, and depression) were among the strongest edges of the network, indicating that the association between these symptoms is a core feature of physical pain across two countries. Notably, interventions designed to weaken the association between these three mental health markers in students might decrease physical pain symptoms. However, there were no significant differences between the two countries’ network structure and global strength. Anxiety was the most central symptom for both countries as indexed by the magnitude of association with physical pain, consistent with other research on young adults (18–25 years old) [
41‐
44] and anxiety might be an important factor in predicting youth who are at greatest risk for increased impairment because of pain symptoms [
45]. Indeed, anxiety is emerging as a potent risk factor for physical pain risk in young adults [
46]. Several human brain imaging studies have provided better support for clinical observations of the interaction between pain and anxiety and showed that anxiety enhances the experience of pain [
44,
47,
48]. This suggests potential targets for treating anxiety. In addition, social support was the important protective factor negatively related to physical pain in our network for both countries. Many studies have shown that people with chronic pain who report high levels of social support experience less distress and less severe pain, with higher levels of support associated with better adjustment in daily life despite the pain-related challenges [
49,
50].
Interestingly, PTSD seemed to be the most central mental health marker related to physical pain symptoms in the network for Indian students. Previous studies have revealed that exposure to traumatic events is quite prevalent in India [
51,
52], with findings from the largest-ever representative survey [
53] of the prevalence of child abuse and neglect in India showing how 2 out of every 3 youth have experienced physical abuse, sexual or emotional abuse once in their lives. One study conducted by Bhat and Rangaiah [
54], showed that 49.81% of young adults (19–24 years) (
n = 797) encountered at least one traumatic event, with the most common event being the death of a close one, serious illness, witnessing the injury or killing of others, and coming close to being injured or killed. Substantial literature has revealed that traumatic events are one of the risk factors leading to chronic pain [
55‐
57]. In one of the studies conducted in the Norway reported that the exposure to traumatic events and PTSD were significantly associated with more severe physical pain, and PTSD significantly moderated the relationship between trauma exposure and pain [
58] and in one of the cohort studies that included 2021 participants from the USA observed over time that after traumatic stress exposure, identified individuals with greater pain severity [
59]. In our study, this was shown in the network of Indian students suggesting a potential target for an intervention designed for young people in India for the prevention of issues related to physical pain that might become chronic in the future. Perceived stress is quite common among the university students, in Malaysia 38% of the students [
60], in Saudi Arabia 52% of the students [
61] and among Italian students, 8 to 31.4% [
62] suffers from it. In Swiss students, stress was the most important mental health marker. Stress is quite commonly seen in university students as they are in a major transitional phase of moving out, managing their household, financing, and becoming independent from their parents [
63]. This puts a lot of pressure on them leading to social, emotional, and academic challenges. Roughly half of Swiss students, 46% of them suffer from perceived stress in which personal resources are no longer able to address daily challenges [
64]. One of the systematic reviews found that stress plays an important role in the development of pain-related issues in young adults [
65], consistent with our findings. Our study suggests that stress would be a potential target for an intervention designed for young people in Switzerland for the prevention of issues related to physical pain that might become chronic in the future.
Our study highlights the central symptoms and associations related to physical pain and provides us with an important direction to examine the dynamics of activating and deactivating those central mental health markers and protective factors and associations [
66]. For example, potential treatments that deactivate a central symptom or association could lead to the spreading deactivation of other less central elements and be more effective in treating physical pain-related issues among students before they become chronic [
67]. So, interventions that specifically target stress, PTSD, anxiety, and depression might efficiently and effectively reduce physical symptoms, increase the likelihood of social support, and possibly reduce the risk of relapse. However, these possibilities remain open to empirical questions. Also, these symptoms and associations between symptoms can be prioritized in theoretical models of physical pain and could also serve as important treatment targets for pain interventions among students before it becomes chronic in the future for both countries. Katz and Selzer [
68] mentioned that the transition from acute to chronic pain may reveal important cues that predict whose acute pain will become chronic. However, Lee et al., [
69] showed that factors like social support that promote pain adaptation can protect the individual from transitioning to chronic pain from acute pain. Based on our study, we can identify those specific risk factors and protective factors for Indian students and Swiss students and target those factors in the future studies.
The above results also make us question the fact that what could be the reason behind the similarities of the networks in the two countries though keeping in mind that our sample represents the part of the country. This might be explained as many studies have focused primarily on East–West differences in individualism–collectivism or independent–interdependent constructs though these are important [
70]. At the same time, we forget that we live in a globalized world. According to Ralston [
71], there is a “cross-vergence” of cultures which means there is a shortening of cultural distances between countries. Also, our sample comprised a young population (18–25 years of age) who uses social media the most, and due to the convergence of social media and globalization, the world has shrunk into a much smaller interactive field [
72]. Social media has brought people from different cultures together in the “global village” [
73]. Young people use social media to learn about other countries, establish and maintain relationships, and stay informed about events happening in different countries [
74]. Therefore, it leads to broad similarities in underpinning risk and protective mechanisms related to mental health, although these are often influenced by cultural and other contextual factors that might differ across or within countries [
75].
Several limitations deserve mention. First, self-report instruments may underestimate symptom severity in cultures that stigmatize psychopathology. Second, the cut-off used in the study was for a Western population, which might not be representative of Indian reality and a lack of validation of instruments in the Indian population. Future studies should seek to validate these instruments in Indian and non-WEIRD samples and determine specific cut-offs for these populations. Third, our study only represents a part of the country, and it might be helpful to include samples from different regions within the same country to first understand the within-country differences and similarities and then expand it further across different countries.
In conclusion, our findings provide promising evidence of mental health markers and protective factors related to physical pain in the two countries and some cultural variations between them. Our study is the first to explore this relationship using the network analysis approach. This relationship with the university students provides the first insight into the development of culturally specific preventive interventions in students.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.