Social support and health related quality of life among older people in covid-19 pandemic: The mediating role of resilience.

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Learn more: PMC Disclaimer | PMC Copyright Notice PLoS One . 2026 Jun 5;21(6):e0342982. doi: 10.1371/journal.pone.0342982 Social support and health related quality of life among older people in covid-19 pandemic: The mediating role of resilience Badriyeh Karami 1 , Shahab Rezaeian 2, 3 , Mansour Bagherinia 4 , Ebrahim Shakiba 5, 6 , Raheleh Maleki 7 , Mohammadrasool Ghasemianrad 8 , Amirhossien Naghibzadeh 8 , Hamzeh Zahabi 8 , Hadi Darvishigilan 9, * Editor: Bibi Razieh Hosseini Farash 10 Author information Article notes Copyright and License information 1 Behavioral Diseases Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran 2 Infectious Diseases Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran 3 Department of Epidemiology, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran 4 School of Health, Ilam University of Medical sciences, Ilam, Iran 5 Department of Biochemistry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran 6 Behavioral Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran 7 Department of Healthcare Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Khuzestan, Iran 8 Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran 9 Social Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran 10 Mashhad University of Medical Sciences, IRAN, ISLAMIC REPUBLIC OF Competing Interests: The authors declare that they have no competing interests. ✉ * E-mail: hadidarvishi2000@yahoo.com Roles Badriyeh Karami : Conceptualization, Writing – original draft, Writing – review & editing Shahab Rezaeian : Data curation, Formal analysis Mansour Bagherinia : Conceptualization, Data curation, Writing – original draft, Writing – review & editing Ebrahim Shakiba : Conceptualization Raheleh Maleki : Conceptualization Mohammadrasool Ghasemianrad : Data curation Amirhossien Naghibzadeh : Data curation Hamzeh Zahabi : Data curation Hadi Darvishigilan : Conceptualization, Writing – original draft, Writing – review & editing Bibi Razieh Hosseini Farash : Editor Received 2024 Nov 30; Accepted 2026 Feb 1; Collection date 2026. © 2026 Karami et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13240856  PMID: 42247444 Abstract Background During emergencies and crises, comprehending the influence of various factors on the health-related quality of life (HRQoL) of older adults is crucial for enhancing it. This study aimed to investigate the mediating role of resilience in the relationship between social support and health related quality of life. Methods In this descriptive-analytical cross-sectional study, 341 older adults over 60 years participated, in 2023. Vaux’s social support questionnaire, SF-36 health-related quality of life questionnaire, and Conner and Davidson’s resilience questionnaire were used. Structural equation modeling (SEM) was used to determine the role of resilience as a mediator between social support and HRQoL. Statistical analysis of data was performed using STATA 14.2 software. Results Based on the results, a one-unit increase in social support is associated with a 0.44-unit increase in resilience (β = 0.44) and a 0.24- unit increase in HRQoL (β = 0.24) on average. Furthermore, considering the mediating role of resilience, a one-unit increase in social support contributes 0.097- units directly (β = 0.097) and 0.12- units indirectly (β = 0.12) to HRQoL on average. The total effect of social support on HRQoL was also significant (β = 0.22). Conclusion Considering the mediating role of resilience in the relationship between social support and HRQoL among older people during the Covid-19 pandemic and the possibility of emergencies and pandemics in the future, it is necessary to carry out interventions focusing on improving resilience skills to make social support more effective in the elderly and to improve the quality of life related to health. Introduction The most recent disease to be classified as a pandemic by the World Health Organization (WHO) in 2020 is Covid-19 [ 1 ]. Following the onset of epidemics, societal changes have ensued, impacting various facets of individuals’ welfare [ 2 ]. While the disease can affect individuals of any age, the elderly have been identified as the most susceptible and significantly affected demographic group [ 3 ]. “This issue is particularly important for nations experiencing population aging. Iran is one of the countries with a high rate of population aging. Iran is one of the countries with a high rate of population aging [ 4 ] and is expected to see substantial increase in the proportion of its elderly population over the next three decades [ 5 ]. Various studies indicate that the measures implemented during the Covid-19 crisis have adversely affected different aspects of health and quality of life (QoL) [ 6 – 8 ]. On the other hand, previous research findings reveal that the QoL among elderly individuals in Iran is at a moderate level, highlighting the necessity for targeted interventions [ 9 ]. QoL includes general quality of life and health-related quality of life (HRQoL) [ 10 ]. HRQoL, influenced by one’s experiences, beliefs, expectations, and personal perceptions, is rooted in health and constitutes both positive and negative health dimensions [ 11 ]. One of the key determinants of HRQoL in the elderly is social support [ 12 , 13 ]. Various research findings conducted among the elderly population amidst the Covid-19 pandemic have indicated a significant association and a direct link between social support and HRQoL [ 14 – 17 ]. Newcomb & Bentler define social support as a system of interpersonal connections that offer companionship, collaboration, emotional encouragement, and in addition to promoting health-enhancing behaviors, mitigating stressful life events, and attaining individual objectives [ 15 ]. Another determinant influencing an individual’s QoL is the capacity to navigate the novel life circumstances resulting of Covid-19 pandemic, which is called resilience. Resilience is the ability of an individual to cope with and adapt to new life circumstances, challenges, or crises [ 18 ]. Empirical research has indicated that an individual’s resilience can significantly impact their QoL [ 19 , 20 ] and exhibits a positive correlation with QoL [ 21 – 23 ]. Moreover, various studies have indicated that resilience training contributes to an enhancement in quality of life, coping mechanisms, and mental health among the elderly population [ 19 ]. Utilizing structural equation modeling, Gerino et al., elucidated the mediating role of resilience in the interplay between physical and mental QoL and feelings of loneliness among older adults [ 20 ]. Enhancing the quality of life for older individuals stands as a fundamental objective for nations worldwide [ 24 ]. Consequently, it is crucial to investigate how the various issues related to both the physical and psychological dimensions of aging impact the well-being of the elderly population. The findings from global studies indicate that research focusing on the HRQoL of the elderly during the Covid-19 pandemic has primarily investigated the HRQoL status and its correlation with psychological problems, particularly among among elderly patients [ 8 , 25 , 26 ]. In Iran, limited studies have also been conducted that have examined the status of overall QoL of the elderly and individual factors affecting it [ 27 ] and HRQoL during the Covid-19 pandemic has not been focused on. According to the findings of current research, there is no study that has explored the simultaneous relationship between HRQOL, social support, and resilience in the context of the Covid-19 pandemic among older adults. Consequently, the primary objective of this study is to examine the interconnections among these variables within the elderly people. Materials and methods Study setting This descriptive-analytical cross-sectional study was carried out, involving community-dwelling seniors aged over 60 years in Kermanshah city in the western region of Iran. Sample and sampling method To determine the sample size, the correlation coefficient of 0.22, which reflects the relationship between social support and HRQoL as reported in the study by Saber and Nosratabadi [ 28 ] was employed. Utilizing the sample size formula and 0.9 power to detect an effect, it was projected that 310 older individuals would be necessary. Considering a 10% non-response rate for the study, the final estimated sample size was determined to be 341. Given the potential impact of individuals’ residential location on HRQoL, the division of Kermanshah city into eight districts was done based on Sahebi et al.’s research [ 29 ]. In the previously mentioned study, the eight districts of Kermanshah city were classified into three categories: poor districts (3, 2, 8), medium districts (5, 1, 6), and good districts (4, 7) based on the livability index, which encompasses three dimensions: socio-cultural, economic, and environmental. Consequently, participants were chosen utilizing the cluster random sampling technique. Each district comprises multiple neighborhoods that differ greatly in terms of socio economic status. Therefore, according to the research team’s decision, two neighborhoods were randomly chosen from each district (totally 16 neighborhoods. The requirements for participating in the study included aged over 60 years, willing to participate in the study, not having sensory perception disorders or mental retardation, and the ability to speak and understand Persian or Kurdish. Questionnaires: Vaux’s social support questionnaire [ 30 ] was implemented to assess social support. This questionnaire comprises 23 items utilizing a 5-point Likert response scale.“ Within the research conducted by Afrashteh et al., in Iran [ 31 ], the alpha coefficient of this questionnaire was reported as 0.80. The social support scores ranges from 23 to 115, with a higher score indicating a greater level of social support. SF-36 health-related quality of life questionnaire [ 32 ] consists of 36 questions and encompasses 8 distinct subscales. These subscales are further categorized into 4 components related to the physical domain and 4 components related to the psychological domain. The score range for HRQoL extends from 0 to 100, with higher scores being indicative of an elevated HRQoL level. Notably, this instrument demonstrates a commendable level of reliability and validity, having been scrutinized across various nations globally [ 33 ]. In the examination conducted by Montazeri et al., the questionnaire’s reliability was assessed in Iran. The evaluation of “internal consistency” unveiled that, with the exception of the vitality subscale, the remaining components of the Persian version of SF-36 exhibit minimal standard reliability coefficients ranging from 0.77 to 0.9 [ 34 ]. To assess resilience, Conner and Davidson’s 25-item resilience questionnaire [ 35 ] was administered. The questionnaire encompasses four dimensions: goal recognition and individual control (9 items), adaptation and tolerance of individual effects (10 items), leadership and trust in instinct (action based on sense) (4 items), and spiritual knowledge of the future (2 items). This instrument employs a 5-point Likert scale with a possible score range of 25–125. Ahangarzadeh et al., conducted a study in Iran to evaluate the self-validity and reliability of this questionnaire, revealing an internal consistency of 0.82 as determined by Cronbach’s alpha [ 36 ]. In addition, in Noroozi et al., [ 37 ] and Afrashteh et al., [ 31 ]studies conducted among older people, cronbach’s alpha coefficient was calculated to be 0.79 and 0.89, respectively. Data collection Two interviewers were trained by the research team for data collection once the ethical committee of Kermanshah University of Medical Sciences (KUMS) gave the study permission to begin (ethics code IR.KUMS.REC.1402.211). Data collection was conducted at parks and recreational areas in Kermanshah, from August 15, to November 20, 2023, by interviewers. Following their explanation of the study’s objectives, participants signed a consent form and filled out the pertinent questionnaire. Trained interviewers would step in to assist if participants were incapable of completing the questionnaire due to any reasons, such as illiteracy. The process of distributing and completing questionnaires continued until all questionnaires were completed. Statistical analysis Descriptive statistics were first calculated to summarize the characteristics of the study sample, including frequencies and percentages for categorical variables and means with standard deviations (SD) for continuous variables. To examine bivariate associations between key variables, independent samples t-tests or one-way ANOVA were used for continuous outcomes, and chi-square tests were applied for categorical outcomes. Multivariable linear regression models were then fitted to evaluate the associations between independent predictors and the dependent outcome variables, while controlling for potential confounders such as gender, age, and employment status (enter method). Regression assumptions (normality, homoscedasticity, and multicollinearity) were checked and met. Furthermore, Path analysis—as a specific form of Structural equation modeling (SEM)—was conducted using Maximum likelihood estimation to test the hypothesized mediation model. Specifically, the mediating role of resilience in the association between social support (independent continuous variable) and quality of life (QoL, dependent continuous variable) was examined. The significance of indirect effects was assessed using the Bootstrapping method with 5,000 resamples to obtain bias-corrected 95% confidence intervals (CI). The proportion of the total effect of social support on QoL explained by the mediation pathway was computed by dividing the indirect effect by the total effect. All analyses were conducted at a 95% CI and a two-sided significance level of p < 0.05 using Stata version 14.2 (StataCorp, College Station, TX, USA). Results Basic characteristics of the participants According to the results of Table 1 , most of the participants were male (72.22%), in the age range of 65–75 years (46.2%) and retired (49.2%). Table 1. Demographic characteristics of participants. Variables Frequency (%) Gender Male 247 (72.22) Female 95 (27.78) Age 60-65 73 (21.35) 65-70 76 (22.22) 70-75 82 (23.98) 75-80 63 (18.42) 80-85 38 (11.11) >85 10 (2.92) Job status Retired 169 (49.42) Unemployment 167 (49.83) Employed 6 (1.75) Open in a new tab As shown in Table 2 , mean score of resilience and social support in men was 59.56 out of 125 and 80.11 out of 115, respectively, and more than women. Meanwhile, mean score of the HRQOL in women was more than men (94.23 out of 100). Also, with increasing age, the mean score of all three variables has decreased. The mean score of resilience was lower and the mean score of HRQOL in employed individuals was higher than others. Social support was more in the unemployed group than others. Table 2. Descriptive analysis of main variables based on demographic characteristics. Demographic characteristics Variables Resilience Social support Quality of life Mean SD Mean SD Mean SD Gender Female 54.77 11.8 73.69 10.35 94.23 7.44 Male 59.56 10.84 80.11 12.42 92.72 10.16 Age 60-65 61.91 11.15 81.67 13.09 93.37 10.46 65-70 60.5 10.94 79.61 11.64 93.47 10.1 70-75 57.79 9.26 77.51 11.04 93.68 9.46 75-80 55.65 11.37 76.74 10.54 93.22 7.54 80-85 52.5 10.15 74.1 12.9 91.73 8.6 >85 55.9 20.5 77 19.99 89.3 12.74 Job status Employed 57.37 11.31 76.37 11.82 93.45 8.78 Retired 57.26 11.18 81.05 11.54 93.37 9.92 Unemployment 53.16 3.65 66.16 11.77 94.5 6.25 Total 58.23 11.31 78.33 12.21 93.14 9.5 Open in a new tab Testing research hypotheses Relationship between social support and resilience. As shown in Table 3 , after adjusting for gender, age, and job status, a one-unit increase in social support is associated with a 0.44 increase in resilience on average (β = 0.44, p = 0.001). Table 3. Linear regression analysis assessing the relationships between social support, resilience, and HRQoL adjusted for gender, age, and job status. Variables Resilienc HRQoL Coef. SE T-value P-value CI Coef. SE T-value P-value CI Social support 0.44 0.04 10.19 0.001 0.35,0.53 0.24 0.04 5.85 0.001 0.85, 5.31 Resilience 0.34 0.04 7.66 0.001 0.25, 0.42 Open in a new tab Relationship between social support and HRQOL. As shown in Table 3 , after controlling for gender, age, and job status, a one-unit increase in social support is associated with a 0.24 increase in HRQoL on average (β = 0.24, p = 0.001). Relationship between resilience and HRQOL. As shown in Table 3 , after adjusting for gender, age, and job status, a one-unit increase in resilience is associated with a 0.34 increase in HRQoL on average (β = 0.34, p = 0.001). Relationship between social support, resilience and HRQOL. As shown in Table 4 , resilience and social support simultaneously explain the HRQoL in participants. Table 4. Linear regression analysis assessing the relationships between social support, resilience and HRQoL, simultaneously. Variables HRQoL Coef. SE* T-value P-value CI Resilienc 0.27 0.05 5.46 0.000 0.17, 0.37 Social Support 0.12 0.04 2.68 0.008 0.03, 0.21 Gender 3.64 1.09 3.34 0.001 1.49, 5.79 Age 0.33 0.35 0.96 0.33 − 0.35,1.02 Retired − 0.16 0.43 − 0.39 0.69 − 01.01, 0.67 Open in a new tab *SE: Standard Error. The research hypothesis of our study is displayed in Fig 1 . In the research hypothesis, a mediation model was fitted where social support was set as independent variable, resilience as a mediator, and quality of life as dependent variable. Results shows that the social support had a significant direct effect (β = 0.097) and an indirect effect through resilience (β = 0.12) on the quality of life. We also found a significant total effect of social support (β = 0.22) on the quality of life ( Table 5 ). The model showed that a proportion of 55.8% of the total effect is explained by the mediator. Fig 1. Pathways between, social support, resilience, and Health related Quality of life (*Social S: social support, QoL: Health Related Quality of life)‌‌. Open in a new tab Table 5. Direct, indirect, and total effects of social support on HRQoL. Pathways Coefficient SE* P-value Direct effects Resilience →HRQoL 0.25 0.05 0.001 Social support →HRQoL 0.097 0.05 0.034 Social support → Resilience 0.49 0.04 0.001 Indirect effects Social support →HRQoL 0.12 0.03 0.001 Total effects Social support →HRQoL 0.22 0.04 0.001 Open in a new tab *SE: Standard Error. Discussion Main findings In this specific cross-sectional study, the focus was on examining the mediating role of resilience in the relationship between social support and HRQoL among elderly during Covid-19 pandemic. The results indicated that the availability of appropriate social support is a key factor in improving both resilience and HRQoL. Notably, these effects remained significant even after accounting for potential confounding variables such as demographic characteristics. Available evidence on the association of social support and resilience with HRQoL Existing literature provides insight intocorrelation between social support, resilience, and HRQoL. Our analysis revealed a direct impact of social support on HRQoL amounting to 0.44 (p < 0.001). Prior research has illustrated the capacity of social support to influence HRQoL during the Covid-19 outbreak [ 17 , 14 , 16 ]. Noteworthy is the intervention research conducted by Ajh et al., which underscored the nexus between social support and the enhancement of elderly individuals’ quality of life, resulting in a noticeable augmentation in both mental and physical dimensions post-intervention [ 38 ]. Additionally, antecedent studies indicate that social elements such as social engagement, familial affiliation, level of familial reverence for seniors, amicable ties with neighbors, contentment with residential environment, participation in communal activities, and satisfaction derived from interpersonal interactions significantly impact their overall quality of life [ 39 , 40 ]. In this investigation, a positive and statistically significant correlation between resilience and quality of life has been validated, aligning with previous findings by Fam [ 41 ], Gerino [ 42 ], and Silverman [ 43 ]. The outcomes highlight resilience as a protective element, capable of enhancing quality of life through mitigation of adverse impacts stemming from unfavorable circumstances. Furthermore, they underscore the significance of assessing an individual’s capacity to navigate challenging situations, thereby influencing quality of life [ 44 ]. Consequently, the identification of older adults most vulnerable to detrimental effects of the pandemic on quality of life is crucial, necessitating the development of a tailored health intervention. Furthermore, the present study results demonstrate that both resilience and social support serve as significant predictors of HRQoL among elderly during Covid-19 pandemic. These findings are in agreement with the studies of Mikayili et al., [ 45 ], Salonenet et al., [ 46 ], Behnam Moghadam et al., [ 47 ], Patel et al., [ 48 ], Zhou et al., [ 49 ] which conducted before the Covid-19 outbreak. According to the results of our study, social support has a moderate direct effect on the resilience of the elderly (β = 0.49). However, the direct effect of social support on HRQoL is weaker than the direct effect of resilience. This means that to improve the HRQoL of the elderly, planning and interventions should focus on improving the resilience of the elderly. In our study, effect of resilience on HRQOL (as mediator variable) was moderate effect (β = 0.49). This finding is not in line with the results of Kong’s et al., study among migrant older adults prior to the onset of the Covid-19 pandemic [ 50 ]. The findings derived from the mentioned study conducted demonstrated that resilience served as a partial mediator in the association between social support and both dimensions of HRQOL. These results enhance our comprehension of the interplay between social support and psychological resilience in shaping HRQOL, thereby offering valuable insights for designing interventions aimed at improving HRQOL among older adults residing in community settings [ 50 ]. In the research conducted by Wu et al., [ 51 ] encompassing a sample of 205 elderly individuals residing in nursing homes, the effect of social support on HRQOL was stronger than that effect in our study (β = 0.30, p < 0.001), but the effect of resilience as mediating role in the relationship between social support and HRQOL was smaller (β = 0.13, p = 0.008). To justify these findings, it can be stated that elderly individuals residing in nursing homes obtain more substantial social support from their caregivers than those living in the community. However, this social support does not significantly enhance resilience among these individuals. It is essential that this support is structured to bolster the elderly’s ability to adapt and confront the challenges associated with living in nursing homes, thereby improving resilience and ultimately enhancing their HRQOL. It is also necessary to identify other variables that can have a stronger effect on the relationship between social support and quality of life in these individuals, so that effective interventions can be taken to improve the HRQoL of these individuals. Finally, individuals with higher levels of resilience exhibit increased satisfaction and quality of life through the attenuation of negative emotions and fostering positive interpretations of experiences. Moreover, those with greater social support tend to enjoy enhanced quality of life, with social support playing a role in bolstering mental well-being by alleviating stress and anxiety. Consequently, the enhancement of resilience and social support is conducive to improving HRQoL [ 52 ]. Strengths and limitations This research exhibited several notable strengths. Initially, it identified the correlation between social assistance and HRQoL among the elderly populace amid the Covid-19 crisis. Furthermore, it scrutinized the intermediary function of resilience in the correlation between social support and HRQoL. The outcomes of this study hold the potential to guide the focal point of strategizing for policymakers and administrators. The study encompassed 341 elderly individuals residing within the community, thereby enhancing the external validity of our findings within the Iranian context. Nonetheless, it is imperative to acknowledge that HRQoL is influenced by a multitude of factors including place of habitation, cultural disparities, and various socio-economic aspects. To address these considerations, research participants should be recruited from diverse urban settings, while controlling for these variables to scrutinize the interrelation of the variables under study. It is advisable for future researchers to explore other conceivably influential factors in the association between social support and HRQoL, bearing in mind the aforementioned aspects for subsequent investigations. Conclusion Drawing from the findings of this investigation, resilience emerged as a pivotal mediator in the nexus between social support and HRQoL among the elderly during the Covid-19 pandemic, underscoring the necessity to enhance the HRQoL of older individuals during crises, particularly within aging and elderly communities. In addition to emphasizing social support, enhancing resilience through imparting skills such as problem-solving and self-awareness is recommended to enhance the quality of life for this demographic, especially during their later years. In addition, through the implementation of spiritual therapy techniques, facilitating participation in group sessions focused on spiritual therapy, and fostering the exchange of thoughts and ideas, policymakers in the aging sector can enhance the capacity and consciousness of the elderly, reinforcing the notion that life invariably holds significance and that meaning and purpose can be discovered in every experience. Supporting information S1 File. Data underlying the findings described in our manuscript. (PDF) pone.0342982.s001.pdf (479.5KB, pdf) Abbreviations WHO World Health Organization HRQOL health-related quality of life QOL quality of life SEM structural equation model SE standard error Data Availability All relevant data are within the paper and its Supporting Information files. Funding Statement The author(s) received no specific funding for this work. References 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. 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[ Google Scholar ] PLoS One. doi: 10.1371/journal.pone.0342982.r001 Decision Letter 0 Bibi Razieh Hosseini Farash Author information Copyright and License information Roles Bibi Razieh Hosseini Farash : Academic Editor © 2026 Bibi Razieh Hosseini Farash This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 8 Sep 2025 -->PONE-D-24-51857-->-->Social Support and Health Related Quality of Life among Older People in Covid-19 Pandemic: The Mediating Role of Resilience-->-->PLOS ONE Dear Dr. Darvishigilan, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. 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Enhance Statistical Analysis: Providing detailed descriptions of the statistical methods used and presenting comprehensive analysis results would increase transparency and scientific validity. 4. Improve Results Structure: Organizing and structuring the results section more coherently would enhance readability and comprehension. Reviewer #2: Dear Editor Thank you for the opportunity to review. The review of manuscript PONE-D-24-51857, entitled “Social Support and Health Related Quality of Life among Older People in Covid-19 Pandemic: The Mediating Role of Resilience” done and sent for you. Comments to authors Abstract - Several grammatical errors are present, such as line 42 "341 older people over 60 years were participated," which should be corrected to "341 older adults over 60 years participated". - In line 39, Phrasing such as "it will be possible to improve…" is vague and speculative. A more assertive tone is recommended. - In line 48, there are misplaced commas (e.g., β = 0.44,). - In lines 48 and 49, the statistical findings are not contextualized—what does a β = 0.097 mean in practical terms for HRQoL? - I recommended briefly mention prior studies and highlight the novelty of this research. Introduction - I would suggest to summarize the introduction section. - Definitions and relationships between HRQoL and social support are repeated unnecessarily. - The concept of resilience is introduced multiple times with overlapping definitions and citations, which disrupts the flow and dilutes impact. - The paragraph transitions are abrupt, and the logical progression of ideas is weak. For example, demographic data about Iran’s aging population is inserted without a clear link to the preceding or following content. - The final paragraph claims novelty in examining the three variables concurrently but does not adequately support this claim with references or a synthesis of existing gaps in the literature. In line 100, the writing is overly formal and verbose in places, which may hinder readability. Phrases such as "engendered by the emergence of this recent epidemic" could be simplified. Materials and Methods - Please explain the demographic factors. - In line 137, Please replace the word "Instrument" in this sentence with "The questionnaires". - Authors should be summarized the parts mentioned in lines 138-169. - The study uses cluster random sampling across 16 neighborhoods, but the rationale for selecting two neighborhoods per district is not fully explained. - It is recommended to clarify how the sample size was determined and whether power analysis was conducted to justify the inclusion of 341 participants. - The method of replacing non-respondents with others from the same age group and neighborhood may introduce selection bias so, it is recommended to discuss the potential impact of this substitution on sample representativeness and data validity. - While reliability coefficients are reported for all instruments, the validity of the resilience questionnaire in the elderly population is not discussed. It is recommended to provide more detail on the cultural and age-specific validation of the Conner-Davidson resilience scale in Iranian elderly populations. - The authors mention controlling for gender, age, and employment status, but do not specify how these were included in the regression or SEM models. - Include a statement confirming ethical clearance from an institutional review board and the process for obtaining participant consent. - Clarify whether missing data were present and how they were handled. Results - In lines 185 and 188, tables and 2 change to Tables 1 and 2. - In line 206, the relationship between resilience and HRQoL is reported with two different β values (0.34 and 0.24), which creates confusion. - Differences in mean scores between demographic groups (e.g., gender, employment status, age) are described, but no statistical tests (e.g., t-tests, ANOVA) are reported to determine significance. - The scales used for resilience (out of 125), social support (out of 115), and HRQoL (out of 100) are mentioned, but the instruments are not identified. - The phrase "considering demographic variables" is used repeatedly, but it is unclear which variables were controlled for and how they were incorporated into the models. - Some reported β values (e.g., 0.097 for direct effect) are statistically significant but small. The practical relevance of these findings is not discussed. - The finding that unemployed individuals had higher social support than employed ones contradicts common assumptions and prior literature. Discussion - The reported direct effect of social support on HRQoL (β = 0.04) is statistically significant but extremely small. The discussion does not address whether this effect is practically meaningful. - While the authors cite numerous studies, the discussion lacks critical analysis of conflicting findings, methodological differences, or contextual limitations. - The mediating role of resilience is reiterated multiple times without adding new insights or elaborating on mechanisms. It is recommended to consolidate repetitive statements and expand on how resilience functions as a mediator in practical terms. - The manuscript suggests that findings can inform policy but does not specify how interventions might be designed or implemented. Offer concrete examples of resilience-building or social support strategies that could be applied in community or clinical settings. References - Please correct the errors in throughout the References. However, Authors must use the abbreviation for journal name. Articles rewrite according to "PLOS ONE" format. - In line 355, "WH" change "WHO". - Please delete "" in line 377. - In lines 406 and 409, articles with more than 6 authors must also rewrite according to "PLOS ONE" format. - In line 423, please delete ".", ":" and ";". - In line 424, Karimi Y KM HY should be corrected. - 2006;5(1):0-. in line 431, rewrite. - Please delete "," in line 434. - In line 444, authors should be corrected. - In line 450, please delete space and ",". - In lines 466 and 472, authors should be corrected. Tables - Authors should explain "*" in Table 5. ********** -->6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #2: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachment Submitted filename: PONE-D-24-51857.docx pone.0342982.s002.docx (20.9KB, docx) PLoS One. 2026 Jun 5;21(6):e0342982. doi: 10.1371/journal.pone.0342982.r002 Author response to Decision Letter 1 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 27 Sep 2025 respose to reviewers comment was uploaded. ID number: PONE-D-24-51857 Dear editor of journal of PLOS One Thanks for providing the comments of the respectful reviewer to us. We tried to revise the manuscript, titled “Social Support and Health Related Quality of Life among Older People in Covid-19 Pandemic: The Mediating Role of Resilience”, based on the comments and respond them in the following table. Revisions has been highlighted in green color in the manuscript. Hope the revisions are satisfactory. We welcome any further constructive comments if required. Dr. Hadi Darvishigilan Corresponding author Comment Response Reviewer #1 1. If the basis for dividing regions into weak, good, and strong categories is mentioned in the text of the article, specifying the criteria for these divisions (such as income, education, etc.) can enhance the reader's understanding. Many thanks for your comment. More explanation was added to the material and methods; Sample and sampling method section. Pages 4 and 5, lines 119-124. 2. Additionally, the data analysis should be presented in a more detailed manner, for example, stating how reliability and validity coefficients were calculated." Thank you for your comment. The questionnaires used in this study have been previously validated and shown to have good reliability in prior research. Therefore, we relied on these established instruments for measuring the constructs in our study. We have added these details and references to the material and methods; questionnaire section to clarify the reliability and validity of the measures. Pages 5 and 6, lines 132-156. More explanation about data analysis was presented in a more detailed manner in material and methods; statistical analysis section. Pages 6 and 7, pages 168-186. 3. Enhance Statistical Analysis: Providing detailed descriptions of the statistical methods used and presenting comprehensive analysis results would increase transparency and scientific validity. We have clarified this point in the material and methods; statistical analysis section of the revised manuscript. Pages 6 and 7, pages 168-186. 4. Improve Results Structure: Organizing and structuring the results section more coherently would enhance readability and comprehension. Thank you. It was done. Pages 7 and 8, lines 188- 223. Reviewer #2 Abstract 1. Several grammatical errors are present, such as line 42 "341 older people over 60 years were participated," which should be corrected to "341 older adults over 60 years participated". Many thanks for your comment. Grammatical errors were corrected. Page 2, line 43. 2. In line 39, Phrasing such as "it will be possible to improve…" is vague and speculative. A more assertive tone is recommended. Many thanks for your comment. The mentioned sentence was revised. Page 2, lines 39-40. 3. In line 48, there are misplaced commas (e.g., β=0.44,). Many thanks for your attention. It was deleted. Page 2, line 49. 4. In lines 48 and 49, the statistical findings are not contextualized—what does a β = 0.097 mean in practical terms for HRQoL? Many thanks for your comment. More explanation was added to the result section of the abstract. Page 2, lines 48-52. Introduction 1. I would suggest to summarize the introduction section. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 2. Definitions and relationships between HRQoL and social support are repeated unnecessarily. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 3. The concept of resilience is introduced multiple times with overlapping definitions and citations, which disrupts the flow and dilutes impact. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 4. The paragraph transitions are abrupt, and the logical progression of ideas is weak. For example, demographic data about Iran’s aging population is inserted without a clear link to the preceding or following content. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 5. The final paragraph claims novelty in examining the three variables concurrently but does not adequately support this claim with references or a synthesis of existing gaps in the literature. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 6. In line 100, the writing is overly formal and verbose in places, which may hinder readability. Phrases such as "engendered by the emergence of this recent epidemic" could be simplified. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. 7. I recommended briefly mention prior studies and highlight the novelty of this research. Many thanks for your comment. The introduction section was revised. Pages 3 and 4, lines 65-107. Materials and Methods 1. Please explain the demographic factors. Many thanks for your comment. More explanations was added to the material and methods; Study setting and Sample and sampling method section. Page 4, line 111. Page 5, lines 128-130. 2. In line 137, Please replace the word "Instrument" in this sentence with "The questionnaires". Many thanks for your comment. It was edited. Page 5, line 132. 3. Authors should be summarized the parts mentioned in lines 138-169. Many thanks for your comment. This part was summarized. Pages 5 and 6, lines 132-156. 4. The study uses cluster random sampling across 16 neighborhoods, but the rationale for selecting two neighborhoods per district is not fully explained. Many thanks for your comment. More explanation was added to the material and methods; Sample and sampling method section. Pages 4 and 5, lines 119-124. 5. It is recommended to clarify how the sample size was determined and whether power analysis was conducted to justify the inclusion of 341 participants. Many thanks for your comment. The procedure for determining the sample size was described comprehensively. Page 4, lines 115-119. 6. The method of replacing non-respondents with others from the same age group and neighborhood may introduce selection bias so, it is recommended to discuss the potential impact of this substitution on sample representativeness and data validity. Many thanks for your comment. The sampling method was explained more clearly in the method section. Pages 4 and 5, lines 115-130. Given that the participants were community-dwelling seniors aged over 60 years, the interviewers accessed the samples by visiting parks and recreational areas in the neighborhoods, and this process continued until the total number of questionnaires was completed, there is no selection bias. 7. While reliability coefficients are reported for all instruments, the validity of the resilience questionnaire in the elderly population is not discussed. It is recommended to provide more detail on the cultural and age-specific validation of the Conner-Davidson resilience scale in Iranian elderly populations. Thank you for your comment. The questionnaires used in this study have been previously validated and shown to have good reliability in prior research [1, 2]. Therefore, we relied on these established instruments for measuring the constructs in our study. We have added these details and references to the methods section to clarify the reliability and validity of the measures. More explanation added to the methods; questionnaire section. Pages 5 and 6, lines 132-156. 8. The authors mention controlling for gender, age, and employment status, but do not specify how these were included in the regression or SEM models. We appreciate the reviewer’s valuable comment. In our regression analyses, the covariates (gender, age, and employment status) were included as control variables using the enter method, meaning they were entered simultaneously in a single block along with the main independent variables. This approach allowed us to adjust for their potential confounding effects on the outcome variable. 9. Include a statement confirming ethical clearance from an institutional review board and the process for obtaining participant consent. In the method; data collection and declaration sections, the process of obtaining the ethics code from Kermanshah University of Medical Sciences is mentioned, and the ethics code is also included. Page 6, lines 158-166. Page 12, lines 324-329. 10. Clarify whether missing data were present and how they were handled. We appreciate the reviewer’s comment. There were no missing data in our dataset; therefore, no imputation or special handling procedures were required. We have clarified this point in the Methods section of the revised manuscript. Results 1. In lines 185 and 188, tables and 2 change to Tables 1 and 2. Many thanks for your attention. It was edited. Page 7, lines 190-193. 2. In line 206, the relationship between resilience and HRQoL is reported with two different β values (0.34 and 0.24), which creates confusion. Many thanks for your attention. It was corrected. Page 8, lines 209-211. 3. Differences in mean scores between demographic groups (e.g., gender, employment status, age) are described, but no statistical tests (e.g., t-tests, ANOVA) are reported to determine significance. Thank you for your comment. The table was intended to provide a descriptive overview of mean differences across demographic groups. Inferential statistical analyses (e.g., Linear regression) was conducted in subsequent analyses, and the results are reported in Table 3 and 4. Page 18. 4. The scales used for resilience (out of 125), social support (out of 115), and HRQoL (out of 100) are mentioned, but the instruments are not identified. Many thanks for your attention. Detailed explanations of the questionnaires used are provided in the method section, and the score obtained from each questionnaire is stated in the Results section. Pages 5 and 6. Lines 132-156. 5. The phrase "considering demographic variables" is used repeatedly, but it is unclear which variables were controlled for and how they were incorporated into the models. Thank you for your comment. We have clarified which demographic variables were included in the analyses. Page 6. Lines 174-177. Specifically, gender, age, and job status were controlled for in all models. Accordingly, the text in the Results section has been revised to specify that the reported associations are adjusted for these variables. Pages 7 and 8. Lines 200-211. 6. Some reported β values (e.g., 0.097 for direct effect) are statistically significant but small. The practical relevance of these findings is not discussed. The Results section has been revised. The Discussion section has been revised and the interpretation of the results is provided in the Discussion section. 7. The finding that unemployed individuals had higher social support than employed ones contradicts common assumptions and prior literature. After reviewing the research findings by the study's statistical consultant, it was determined that an error had occurred in entering the information in the relevant table. The findings were reviewed and the correct finding was entered in Table 2. Page 17. Discussion 1. The reported direct effect of social support on HRQoL (β = 0.04) is statistically significant but extremely small. The discussion does not address whether this effect is practically meaningful. Thank you for your comment. The discussion section was revised based on the comments of the respected reviewers. Pages 8, 9, and 10. Lines 227-288. 2. While the authors cite numerous studies, the discussion lacks critical analysis of conflicting findings, methodological differences, or contextual limitations. Thank you for your comment. The discussion section was revised based on the comments of the respected reviewers. Pages 8, 9, and 10. Lines 227-288. 3. The mediating role of resilience is reiterated multiple times without adding new insights or elaborating on mechanisms. It is recommended to consolidate repetitive statements and expand on how resilience functions as a mediator in practical terms Thank you for your comment. The discussion section was revised based on the comments of the respected reviewers. Pages 8, 9, and 10. Lines 227-288. 4. The manuscript suggests that findings can inform policy but does not specify how interventions might be designed or implemented. Offer concrete examples of resilience-building or social support strategies that could be applied in community or clinical settings. Thank you for your comment. The discussion section was revised based on the comments of the respected reviewers. Pages 8, 9, and 10. Lines 227-288. References 1. Please correct the errors in throughout the References. However, Authors must use the abbreviation for journal name. Articles rewrite according to "PLOS ONE" format. The PLOS One journal reference style has been followed. 2. In line 355, "WH" change "WHO". This reference was deleted in the revised manuscript. 3. Please delete "" in line 377. It was corrected. 4. In lines 406 and 409, articles with more than 6 authors must also rewrite according to "PLOS ONE" format. The PLOS One journal reference style has been followed. 5. In line 423, please delete ".", ":" and ";". It was edited. 6. In line 424, Karimi Y KM HY should be corrected. It was edited. 7. 2006;5(1):0-. in line 431, rewrite. It was edited. 8. Please delete "," in line 434. It was edited. 9. In line 444, authors should be corrected. It was edited. 10. In line 450, please delete space and ",". It was edited. 11. In lines 466 and 472, authors should be corrected It was edited. Tables 1. Authors should explain "*" in Table 5. It was added. 1. Noroozi Homayoon M, Sadeghi M, Sadri Damirchi E, Hatami Nejad M. The relationship between sense of coherence and perceived social support with resilience: The mediating role of adaptive cognitive-emotional regulation strategies in older adults. Aging Psychology. 2024;10(4):427-05. 2. Yousefi Afrashteh M, Moradi M. The Spiritual Health and Social Support with Quality of Life in the Rural Elderly: The Mediating Role of Resilience and Hope. Aging Psychology. 2022;8(3):266-51. Attachment Submitted filename: Comment Respons..docx pone.0342982.s004.docx (34.8KB, docx) PLoS One. doi: 10.1371/journal.pone.0342982.r003 Decision Letter 1 Bibi Razieh Hosseini Farash Author information Copyright and License information Roles Bibi Razieh Hosseini Farash : Academic Editor © 2026 Bibi Razieh Hosseini Farash This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 2 Feb 2026 Social Support and Health Related Quality of Life among Older People in Covid-19 Pandemic: The Mediating Role of Resilience PONE-D-24-51857R1 Dear Dr. Hadi Darvishi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #2: Yes Reviewer #3: Yes ********** -->6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)--> Reviewer #2: Dear Authors Some minor corrections need to be made in manuscript as follows: Page 2, line 67: "the advent of epidemics" can be replaced to "the onset of epidemics" Page 2, line 68: "While the disease can impact" can be replaced to "While the disease can affect" Page 2, line 70: "This matter holds significant importance for nations experiencing population aging. Iran is one of the countries with a high rate of population aging [4]. Iran is poised to witness a substantial rise in the proportion of its elderly population over the next three decades [5]." Should be replaced by "This issue is particularly important for nations experiencing population aging. Iran is one of the countries with a high rate of population aging [4] and is expected to see substantial increase in the proportion of its elderly population over the next three decades [5]. Page 4, Line 111: carried out Pages 8, 9, lines 228-233: In this specific cross-sectional study, the focus was on examining the mediating role of resilience in the relationship between social support and HRQoL among the elderly during the Covid-19 pandemic. The results indicated that the availability of appropriate social support is a key factor in improving both resilience and HRQoL. Notably, these effects remained significant even after accounting for potential confounding variables such as demographic characteristics. Page 9, lines 236: Existing literature provides insight into... Reviewer #3: Thank you for your cooperation and kindness . All the points I had suggested have been corrected. Recommendations: 1. If the basis for dividing regions into weak, good, and strong categories is mentioned in the text of the article, specifying the criteria for these divisions (such as income, education, etc.) can enhance the reader's understanding. 2. Additionally, the data analysis should be presented in a more detailed manner, for example, stating how reliability and validity coefficients were calculated." 3. Enhance Statistical Analysis: Providing detailed descriptions of the statistical methods used and presenting comprehensive analysis results would increase transparency and scientific validity. 4. Improve Results Structure: Organizing and structuring the results section more coherently would enhance readability and comprehension. ********** -->7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? 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