Introduction
In December 2019, a new flu-like virus emerged in China [1]. All people are exposed to COVID-19, but the probability of infection and death is higher in the elderly [2]. 
The World Health Organization (WHO) advised the elderly to observe social distancing to prevent infection. Isolation of the elderly increases the risk of mental health disorders in them [3].
Considering the number and variety of stresses that the elderly face, it has become a necessity to pay attention to mental health and resilience. Resilience is defined as the capacity to return from a difficult and continuous situation and the ability to restore oneself [8].
Maintaining and improving the mental well-being of the general public, especially the elderly, during epidemics is as important as curbing the spread of epidemics. Therefore, this study was conducted to determine the relationship between the resilience and mental health of the elderly in Ahar City during the COVID-19 pandemic in 2021.

Methods
This cross-sectional study (descriptive-analytical) was done on 271 elderly (according to Nabavi [11], the sample size for obtaining the correlation coefficient in the target population was estimated with 80% power (z=0.85) and a 95% confidence level (z=1.96)) over 60 years old covered by the health centers of Ahar city in 2021. Ahar city with a population of 136,000 people and an area of 3074 km2 (6.7% of the area of the province) is located 110 km from Tabriz. Sampling was done using the random cluster method. The inclusion criteria included being at least 60 years old, having consent to participate in the study, having no history of cognitive, mental, and memory disorders in the electronic file of the SIB system, living in Ahar city, and not living in a nursing home. The exclusion criteria included incomplete or distorted questionnaires, refusal to continue cooperation, or death before the completion of the study. 
After filling out the demographic questionnaire, the General Health Questionnaire (GHQ) and Connor and Davidson Resilience Questionnaire (CD-RISC) were completed by the elderly. Data were analyzed using SPSS statistical software, version 23 at a significance level of 0.05 by descriptive statistics and chi-square, Mann-Whitney, Kruskal-Wallis tests, and Spearman correlation coefficient. The Kolmogorov-Smirnov test was used to check the normality of the research variables.

Findings
A total of 265 elderly with an average age of 70.20±7.38 years participated in this study. The mean total resilience score was 64.38±16.42 and the mean general health score was 24.56±10.05. The average total resilience in people with different educations (based on Tukey’s test, only in illiterate and high school students) showed a significant difference (P<0.05) so that with the increase in education, people’s resilience increased. The dimensions of positive acceptance, resilience control, and physical symptoms of general health had significant differences with marital status (P<0.05), indicating that married elderly are more resilient than other elderly people. The dimensions of positive change, resilience control, physical symptoms, and general health showed a significant relationship with marital status so that married elderly are more resilient than other elderly. The dimension of positive acceptance of changes, secure relationships, and the dimension of control of total resilience, general health, and the dimension of physical symptoms and impairment in social functioning showed a significant relationship with those living with the elderly (P<0.05), indicating that the elderly who lived with their spouses and children had better general health and resilience than the rest of the elderly (Table 1).


The result of Spearman’s correlation coefficient showed a weak negative relationship between the history of residence with total resilience, trust in individual instincts, tolerance of negative emotions, positive acceptance of changes, secure relationships, and control, indicating that with an increase in the score of residence, these variables decrease.
According to the fitted model for general health, the total score of resilience and lifestyle had a significant relationship with general health. As the resilience score increases, the average score of general health decreases (a lower score means better general health). The average score of resilience increases with the decrease of the general health score (lower score means better general health).

Conclusion
The present study was conducted to determine the relationship between resilience and the mental health of the elderly in Ahar City during the COVID-19 pandemic in 2021. The results showed that the resilience of the majority of the elderly was higher than the cut-off point (50) and their average resilience score (64.38) was at the optimal level, and these results are in line with the results of Shahristanki et al. [18]. 
In this study, there was a significant relationship between resilience score and education. In the present study, the average overall score of general health was 24.56. Also, 53.6% of the elderly had good mental health (score ≤23) and 46.4% of people had bad mental health (score > 23), which indicates the appropriate state of mental health in the studied elderly. Rashidi et al. performed a similar study to ours [5]. The reason why the results of this research are inconsistent with the results of some studies (Pasha et al. and Tehrani et al.) [24, 25] can be attributed to their different statistical sample (elderly living in nursing homes).

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1400.333). All ethical principles were considered in this research.

Funding
This article was extracted from the master’s thesis of Asghar Shahbazi in geriatric health, at the Department of Gerontology, University of Social Welfare and Rehabilitation Sciences. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
All authors participated in the design, implementation, and writing of all parts of this research.

Conflicts of interest
The authors reported no conflicts of interest.

Acknowledgments
The authors would like to thank the comprehensive health service centers and the elderly who participated in this research for their cooperation.

References

1. Habibi N, Uddin S, Al-Salameen F, Amad S, Kumar V, Otaibi M. Identification and characterization of novel corona and associated respiratory viruses in aerosol. Kuwait: Kuwait Institute for Scientific Research; 2021. [Link]
2. Esmaeili ED, Azizi H, Sarbazi E, Khodamoradi F. The global case fatality rate due to COVID-19 in hospitalized elderly patients by sex, year, gross domestic product, and continent: A systematic review, meta-analysis, and meta-regression. New Microbes and New Infections. 2023; 51:101079. [PMID]
3. Rostami Z, Abbasian M, Sarbazi E, Soleimanpour H, Mostafaei H, Ghasemi M, et al. Features influencing older adults’ quality of life and their association with loneliness and activities of daily living: A cross-sectional study in Iran. International Journal of Aging. 2023; 1:2. [Link]
4. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. General Psychiatry. 2020; 33(2):e100213. [DOI:10.1136/gpsych-2020-100213] [PMID] [PMCID]
5. Rashedi V, Asadi-Lari M, Foroughan M, Delbari A, Fadayevatan R. Mental health and pain in older adults: Findings from urban HEART-2. Community Mental Health Journal. 2017; 53(6):719-24. [DOI:10.1007/s10597-017-0082-2] [PMID]
6. Padayachey U, Ramlall S, Chipps J. Depression in older adults: prevalence and risk factors in a primary health care sample. South African Family Practice. 2017; 59(2):61-6. [DOI:10.4102/safp.v59i2.4536]
7. Soleimanpour H, Ghaffari-fam S, Sarbazi E, Gholami R, Azizi H, Daliri M, et al. The association between self-care and quality of life among Iranian older adults: Evidence from a multicenter survey. Journal of Rehabilitation Sciences & Research. 2023. [Link]
8. Payami Bousari M, Ebrahimi H, Ahmadi F, Abedi H A. Types and major causes of conflicts experienced by nurses: A qualitative analysis. Journal of Advances in Medical and Biomedical Research. 2008; 16(65):61-76. [Link]
9. Connor KM, Davidson JR. Development of a new resilience scale: The connor-davidson resilience scale (CD-RISC). Depression and Anxiety. 2003; 18(2):76-82. [DOI:10.1002/da.10113] [PMID]
10. Mohamadzadeh M, Rashedi V, Hashemi M, Borhaninejad V. [Relationship between activities of daily living and depression in older adults (Persian)]. Salmand. 2020; 15(2):200-11. [DOI:10.32598/sija.13.10.180]
11. Nabavi SH, Alipour F, Hejazi A, Rabani E, Rashedi V. [Relationship between social support and mental health in older adults (Persian)]. Medical Journal of Mashhad University of Medical Sciences. 2014; 57(7):841-6. [DOI:10.22038/MJMS.2014.3756]
12. Rafie AH,Jazayeri AR, Mohammadi M, Pourshahbaz A, Joukar B. [Resilience factors in individuals at risk for substance abuse  (Persian)]. Journal of Psychology. 2006; 1(2-3):203-24. [Link]
13. Khalili Z, Gholipour F, Habibi Soola A. [Evaluation of resilience and its related factors in the elderly of Ardabil city (Persian)]. Journal of Health and Care. 2021; 22(4):286-94. [DOI:10.52547/jhc.22.4.286]
14. Nourbala A, Mohammad K, Bagheri Yazdi SA. [The validation of general health questionnaire-28 as a psychiatric screening tool (Persian)]. Hakim Research Journal. 2009; 11(4):47-53. [Link]
15. Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychological Medicine. 1979; 9(1):139-45. [DOI:10.1017/S0033291700021644] [PMID]
16. Hemmati Alamdarlou G, Dehshiri G, Shojaie S, Hakimi Rad E. [Health and loneliness status of the elderly living in nursing homes versus those living with their families (Persian)]. Salmand. 2008; 3(2):557-64. [Link]
17. Shahrestanaki M, Alaee N, Heravi karimooi M, Zaeri F. [The burden of caring for family caregivers of the elderly with chronic diseases in Tehran, 1398 (Persian)]. Journal of Geriatric Nursing. 2018; 5(1):28-40. [Link]
18. Karami J, Moradi A, Hatamian P. [The effect of resilience, self-efficacy, and social support on job satisfaction among the employed, middle-aged and elderly (Persian)]. Salmand. 2017; 12(3):300-11. [DOI:10.21859/sija.12.3.300]
19. Meng M, He J, Guan Y, Zhao H, Yi J, Yao S, et al. Factorial invariance of the 10-item connor-davidson resilience scale across gender among Chinese elders. Frontiers in Psychology. 2019; 10:1237. [DOI:10.3389/fpsyg.2019.01237] [PMID] [PMCID]
20. Jafari M, Alipour F, Raheb G, Mardani M. [Perceived stress and burden of care in elderly caregivers: The moderating role of resilience (Persian)]. Salmand. 2022; 17(1):62-75. [DOI:10.32598/sija.2021.2575.2]
21. Pessotti CFC, Fonseca LC, Tedrus GMAS, Laloni DT. Family caregivers of elderly with dementia relationship between religiosity, resilience, quality of life and burden. Dementia & Neuropsychologia. 2018; 12(4):408-414. [DOI:10.1590/1980-57642018dn12-040011] [PMID] [PMCID]
22. Tourunen A, Siltanen S, Saajanaho M, Koivunen K, Kokko K, Rantanen T. Psychometric properties of the 10-item Connor-Davidson resilience scale among Finnish older adults. Aging & Mental Health. 2021; 25(1):99-106. [DOI:10.1080/13607863.2019.1683812] [PMID]
23. Manzini CSS, Bregola A, Pavarini SCI, Vale FAC. Factors associated with the resilience of family caregivers of persons with dementia: A systematic review. Revista Brasileira de Geriatria e Gerontologia. 2016; 19(4):703-14. [DOI:10.1590/1809-98232016019.150117]
24. Pasha GR, Saffar Zadeh S, Mashak R. [General health and social support in two groups of elders living in nursing homes and with families (Persian)]. Journal of Family Research. 2007; 3(1):503-17. [Link]
25. Tehrani H, Vahedian Shahroodi M, Fadayevatan R, Abusalehi A, Esmaeili H. [Mental health status and its related factors in elderly people residing in nursing homes of Mashhad, Iran (Persian)]. Health and Development Journal. 2017; 6(3):171-81. [Link]
26. Negarestani M, Rashedi V, Mohamadzadeh M, Borhaninejad V. [Psychological effect of media use on mental health of older adults during the COVID-19 Pandemic (Persian)]. Salmand. 2021; 16(1):74-85. [DOI:10.32598/sija.16.1.1116.6]
27. Rashedi V, Gharib M, Yazdani AA. Social participation and mental health among older adults in Iran. Iranian Rehabilitation Journal. 2014; 12(1):9-13. [Link]
28. Niknami S, Izadi Rad H. Social support and mental health among older women in Iranshahr, Iran. Elderly Health Journal. 2017; 3(2):94-8. [Link]
29. Alavi M, Jorjoran Shushtari Z, Noroozi M, Mohammadi Shahboulaghi F. [Mental health and related factors in old population in Tehran 2014-2015 (Persian)]. Journal of Mazandaran University of Medical Sciences. 2018; 27(158):112-22. [Link]
30. Simon MA, Chen R, Dong X. Gender differences in perceived social support in US Chinese older adults. Journal of Gerontology & Geriatric Research. 2014; 3(4):163-72. [DOI:10.4172/2167-7182.1000163]
31. Inder KJ, Lewin TJ, Kelly BJ. Factors impacting on the well-being of older residents in rural communities. Perspectives in Public Health. 2012; 132(4):182-91. [DOI:10.1177/1757913912447018] [PMID]
32. Li F, Luo S, Mu W, Li Y, Ye L, Zheng X, et al. Effects of sources of social support and resilience on the mental health of different age groups during the COVID-19 pandemic. BMC Psychiatry. 2021; 21(1):16. [DOI:10.1186/s12888-020-03012-1] [PMID] [PMCID]
33. Bonanno GA, Galea S, Bucciarelli A, Vlahov D. Psychological resilience after disaster: New York City in the aftermath of the September 11^th terrorist attack. Psychological Science. 2006; 17(3):181-6. [DOI:10.1111/j.1467-9280.2006.01682.x] [PMID]
34. Revicki DA, Mitchell JP. Strain, social support, and mental health in rural elderly individuals. Journal of Gerontology. 1990; 45(6):S267-74. [DOI:10.1093/geronj/45.6.S267] [PMID]
35. van Tilburg TG, Steinmetz S, Stolte E, van der Roest H, de Vries DH. Loneliness and mental health during the covid-19 pandemic: A study among dutch older adults. The Journals of Gerontology. 2021; 76(7):e249-55. [DOI:10.1093/geronb/gbaa111] [PMID] [PMCID]
36. Shahabifam L,  Lotfinia H. [The effectiveness resilience training on quality of life, coping strategies and mental health of the elderly living in Mehr Tabriz nursing home (Persian)]. Journal of Modern Psychological Researches. 2022; 17(65):174-81. [Link]