Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP study.

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke-UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases.

Introduction

Sociodemographic, environmental, and psychosocial factors can increase the probability of developing health problems [1]. Psychosocial factors such as lack of social support and loneliness have been associated with a higher mortality rate of older adults. In this population group, larger social networks are associated with up to 50% higher probability of survival [2].

Although it is not known exactly how social support affects health status, it has both direct and indirect influences. On the one hand, it seems to influence stress and affective changes through the hormonal system and, on the other hand, in behavior, conditioning people’s lifestyles [3, 4]. Certain mental health conditions are related to a low perceived social support by the individual, such as anxiety disorders and depression [5, 6]. Likewise, having lower adherence to prescribed treatment and poor health habits has been directly related to having low social support [7-9].

The conceptualization and measurement of social support is a subject of controversy among experts. Not all authors agree on the identification of its dimensions. Norbeck et al. [10] state that the dimensions of social support are so highly correlated that they are difficult to distinguish. Broadly speaking, social support can encompass two dimensions. First, the structural dimension, also called the social network, evaluates the number of links an individual has to others and their interconnections, taking into account the size, frequency of contacts, composition, density, kinship, homogeneity, and strength [11]. Authors such as Hughes et al. and Umberson et al. [12, 13] have suggested that marriage positively influences the healthy behaviors of the individual and therefore their health status. Second, the functional dimension corresponds to the perception of available support flowing through the links of the social network. Dimatteo et al. and Li et al. [7, 14] showed that the network of family and close friends offers more useful social support for the individual than the support of circumstantial friends and acquaintances. One of the most widely used instruments to study perceived functional social support is the Duke-Unk-11, Functional Social Support questionnaire (DUFSS) developed by Broadhead et al. [15]. It originally consisted of 14 items that Broadhead reduced to 11 items in its first validation, and after factor analysis the two-dimensionality of the questionnaire was confirmed. It was identified that on the one hand it measures "confidential support" (the possibility of having people to communicate with) and on the other hand it measures "affective support" (demonstrations of love, affection and empathy).

There are important sex differences in social support and in how women and men perceive it due to sex roles. Traditionally, in men, stereotypes of independence, reflection, aggressiveness, stability, strength, and competitiveness have been emphasized, them being the figure in charge of the defense, production, and economic support of the family, while in women, the stereotypes have been dependency, emotionality, sweetness, instability, weakness, and prudence, them being the family figure linked to care, reproduction, and raising children [16, 17]. According to Cable et al. [18], men report receiving more support from their partners, who are their main source of social support, affirming that marriage has a beneficial effect on psychological well-being and reduces their risk of mortality. Kaplan et al. and Walen et al. [19, 20] have seen that women, on the contrary, more strongly value the support received from their social network of friends, family, and coworkers, resorting to sources outside their partner more frequently than men do [21, 22].

Studies by Berkman and Chen suggest that the relationship between social support and health status is stronger in women [23, 24]. Over their lifetime, women have more comorbidities, multimorbidity, and polymedication and tend to report a lower health-related quality of life (HRQoL) than men of the same age, despite having a lower mortality rate and higher life expectancy [25-28]. Precisely due to their longevity, it has been seen that when women reach a certain age, they have less structural social support than men in the same situation, more often finding themselves living alone [29-32].

The study of the impact of social support, and potential sex differences, in patients with chronic conditions has focused mainly on isolated diseases. Chronicity and longevity tend to generate a need for complex care due to two converging situations in older individuals: multimorbidity, defined as two or more concurrent chronic medical conditions (the threshold of three being more specific for identifying patients with complex health needs) [33], and polypharmacy, defined as the simultaneous consumption of five or more drugs by the same person [34, 35]. The mean number of chronic problems in the in young senior patients (65–74 years) is estimated to be 2.8 [33, 36, 37], being an understudied age group with an important potential for early intervention.

The main aim of this study is to analyze sex differences in perceived (i.e. functional) social support by polymedicated old adults 65 to 74 years with multimorbidity.

Materials and methods

An observational, descriptive, cross-sectional study was conducted with an analytical approach using the baseline data of the MULTIPAP study [38]. This intervention study was conducted in 38 health centers in the regions of Andalusia, Aragon, and Madrid (Spain). Patients aged 65–74 years with multimorbidity (≥3 diseases) and polymedication (≥5 different drugs during at least the last 3 months) who had visited their family doctor at least once in the past year and provided written informed consent to participate in the MULTIPAP study [38] were included. Patients residing in nursing homes, with severe mental illness, or with a life expectancy of less than 12 months were excluded. Those patients who met the inclusion criteria were selected by cluster randomised sampling during visits with the 117 participating professionals; five patients per family doctor were enrolled.

The data were collected by previously trained professionals through an interview at the practice. Sociodemographic variables were collected: sex, age, level of education (below primary education, completed primary education, high school, or higher), and professional occupation according to the skill level required by each job through the ISCO-08 [39] (low, medium, or high level). The social class of the household was measured through the CNO-11 [40] (grouped from lowest to highest as VI, V, and I-IV) and monthly household income (≤1050 €/month, 1051–2250 €/month, or ≥2251 €/month). The following clinical variables were collected: number of chronic conditions, number of drugs prescribed, diagnosis of depressive disorder and/or anxiety state or disorder, self-reported treatment adherence through the four-item Morisky–Green–Levine Medication Evaluation Questionnaire (MGL MAQ) (0.61 Cronbach’s alpha) [41], and HRQoL measured by the EQ-5D-5L [42]. The validated version of the EQ-5D-5L questionnaire for the Spanish population was used [43], which consists of two parts. The first part consists of five questions related to mobility, self-care, daily activities, pain/discomfort, and anxiety/depression. Each one is scored from 1 to 5 points, and from these five questions, a single weighted score is obtained, the Utility Index (EQ-5D-5L Utilities). The scoring for this scale ranges from full health, with a value of 1, to death, with a value of 0, although negative values are allowed. To calculate this index, the algorithm proposed for Spain was used [44]. The second part is a visual analog scale (EQ-5D-5L VAS) that ranges from 0 (worst state) to 100 (best possible health state).

Structural social support was measured through marital status and number of cohabitants in the home. To explore the functional social support, a patient-reported measure was used, namely, the Duke UNC-11 Functional Social Support (DUFSS) questionnaire, which offers a total functional support score and two additional scores referring to the dimensions of confident and affective support [45]. We used the 11-item version with Likert responses of 1 (“much less than I would like”) through 5 (“as much as I would like”) [46]. The DUFSS questionnaire has been validated in different populations, showing differences in the distribution of the items that make up each of its dimensions. For our study, we chose the validation performed in a noninstitutionalized Spanish population over 65 years of age by Ayala et al. with 0.95 Cronbach’s alpha [47]. Its factorial analysis groups items 4, 5, 6, 7, 8, 10, and 11 into the dimension of “confident” support, with a total score of 35, and items 1, 2, 3, and 9, into the dimension of “affective” support, with a total score of 20.

Analytic plan

The characteristics of study participants and of the social support components were described as frequencies and percentages for qualitative variables and as means ± standard deviations (SD) (normally distributed) or medians and interquartile ranges (IQR) (nonnormally distributed) for quantitative variables. To analyze the associations between the different dimensions of social support and sex, Pearson’s chi-squared test was used for qualitative variables and Student’s t-test for quantitative variables. Confidence intervals were estimated at 95%.

To study the factors associated with greater functional social support, an explanatory linear regression model was constructed for women and men separately. The dependent variable was functional social support measured through the total score of the DUFSS questionnaire. The independent variables were those that showed statistical significance in the bivariate analysis or were considered relevant in the conceptual framework of the study. Since patients were recruited grouped by clusters (i.e. their family physician), all the estimations were carried out with robust estimators. The analyses were performed with STATA v.14.

The project was approved by the Clinical Research Ethics Committee of Aragon (CEICA) on September 30, 2015. It was favorably evaluated by the Research Ethics Committee of the Province of Malaga on September 25, 2015 and the Central Research Commission of Primary Care of the Community of Madrid on March 16, 2016.

Results

Of the 593 patients included in the study, 55.8% were women. The mean age of the study population was 69.7 (2.7). Among patients who had not completed their primary studies, the majority were women (64.5% vs. 35.5%, p < 0.001). Women were also highly represented among those with lower-skill occupations (83.6% vs. 16.4%, p < 0.001) and with the lowest monthly household income (68% vs. 31.8%, p < 0.001).

In relation to health status, women had a higher frequency of depressive disorder (82% vs. 18%, p < 0.001) and anxiety disorder (77% vs. 23%, p < 0.001) than men. No statistically significant difference was found in the number of diagnosed diseases or the number of prescribed drugs. Regarding HRQoL measured by the VAS, women reported a health status 7 points lower than men (69.5 ± 20 vs. 62.5 ± 20.4, p < 0.001). Moreover, women more often presented some type of problem in any of the dimensions of HRQoL: mobility (61% vs. 39%, p = 0.01); daily activities (73% vs. 27%, p < 0.001); pain/discomfort (40.4% vs. 59.6%, p = 0.001); and anxiety/depression (29.5% vs. 70.5%, p < 0.001). Women had a lower score in utilities than men (0.73 ± 0.2 vs. 0.82 ± 0.2). Table 1 describes the characteristics of the sample according to sex.

Table 1

Characteristics of the sample according to sex.

	Total n (%)	Men n (%)	Women n (%)
	593(100)	262(44.2)	331 (55.8)
Sociodemographic
Age m (SD)	69.7(2.7)	69.8(2.6)	69.7(2.7)
Educational level
Did not complete primary studies	279(47.1)	99(37.8)	180(54.4)
Completed primary studies	196(33.1)	82(31.3)	114(34.4)
Bachelor or higher	118(19.9)	81(30.9)	37(11.2) ***
Occupation skill level
Level 1	232(39.1)	38(14.5)	194 (58.6) ***
Level 2	249(42)	158 (60.3)	91 (27.5)
Level 3	80(13.5)	41(15.7)	39(11.8)
Level 4	32(5.4)	25(9.5)	7(2.1)
Social class of the household
VI	142(24)	58(22.1)	84(25.4)
V	217(36.6)	84(32.1)	133(40.2)
IV-I	234(39.5)	120(45.8)	114(34.4) *
Monthly household income
< = 1.050 €/month	170(28.7)	54(20.6)	116(35.1)
1.051–2.250 €/month	342(57.7)	160(61.1)	182(54.9)
≥2.251 €/month	59(10)	39(14.9)	20(6.0) ***
NS/NC	22(4)	9(3.4)	13(3.9)
Clinical
Median number of diseases (IQR)	5(4–7)	5(4–7)	5(4–7)
Depressive disorder	110(18.6)	20(18.2)	90(81.8) ***
Anxiety state or disorder	88(914.8	20(22.7)	68(77.3) ***
Median number of drugs (IQR)	7(6–9)	7(5–9)	7(6–9)
MGL MAQ m (SD)	351(59.2)	155(44.2)	196(55.8)
HRQoL
EQ5D5 L VAS m (SD)	65.5(20.5)	69.5(20)	62.4(20.5) ***
EQ5D5 L Utilities m (SD)	0.77(0.2)	0.82(0.2)	0.73(0.2) ***
Mobility
No problems	293 (49.4)	145 (55.3)	148 (44.7) **
Some type of problem	300 (50.6)	117 (44.7)	183 (55.3)
Personal care
No problems	505 (85.2)	227 (86.6)	278 (84.0)
Some type of problem	88 (14.8)	35 (13.4)	53 (16.0)
Daily activities
No problems	411 (69.3)	213 (81.3)	198 (59.8)
Some type of problem	182 (30.7)	49 (18.7)	133 (40.2) ***
Pain/discomfort
No problems	145 (24.5)	81 (30.9)	64 (19.3)
Some type of problem	448 (75.6)	181 (69.1)	267 (80.7) **
Anxiety/depression
No problems	308 (51.9)	178 (67.9)	130 (39.3) ***
Some type of problem	285 (48.1)	84(32.1)	201(60.7)

Note: m = median; SD = standard deviation; IQR = interquartile range.

* p < .05

** p < .01

*** p < .001

Of the 593 patients, 106 (17.9%) lived alone, of whom 79.3% were women. Men lived in households with three or more cohabitants more frequently than women (59.7% vs. 40.3%, p = 0.009). Sixteen percent of the patients were widowers, and 89.4% of them were women. The mean score of functional social support was 43.7 ± 8.8, with women scoring 2 points lower than men (p = 0.004). Table 2 describes the components of social support by sex. The difference in score between the dimensions of functional support for men and women was 1.3 points in the “confident” support dimension and 0.8 points in the “affective” dimension, both scores being lower in women. Table 3 describes the distribution of the DUFSS questionnaire scores by sex. Significant differences by sex appeared regarding the category "Much less/less than I would like" in the items: I get chances to talk to someone about problems at work or with my housework (7.3% vs. 14.2%, p = 0.008); I get chances to talk about money matters (7.6% vs. 13.9%, p = 0.03); I get help when I´m sick in bed (5.7% vs. 13.6%, p = 0.002); I get help around the house (29.8% vs. 37.8%, p = 0.04); I get praise for a good job (16.0% vs. 25.1%, p = 0.007).

Table 2

Components of social support by sex.

	Total n (%)	Male n (%)	Female n (%)
	593(100)	262(44.2)	331 (55.8)
Structural Social Support
Living alone	106(17.9)	22(8.4)	84(25.4) ***
Living with
2 people	368(75.6)	169(70.4)	199(80.6) **
≥ 3 people	119(24.4)	71(29.6)	48(19.4)
Marital status
Single	23(3.9)	11(4.2)	12(3.6)
Married	447(75.4)	228(87.0)	219(66.2)
Separated	29(4.9)	13(5.0)	16(4.8)
Widower	94(15.9)	10(3.8)	84(25.4) ***
Functional Social Support (DUFSS)
Total score, m (SD)	43.7(8.8)	44.9(8.3)	42.8(9) **
1st tertile (low)	190(32)	70(26.7)	120(36.3)
2nd tertile (medium)	191(32.2)	88(33.6)	103(31.1) *
3rd tertile (high)	212(35.8)	104(39.7)	108(32.6)
“Confident” score, m (SD)	29.5(5.9)	30.2(5.7)	28.9(6.1) **
“Affective” score, m (SD)	14.2(3.7)	14.7(3.5)	13.9(3.7) *

Note: m = mean; SD = standard deviation; IQR = interquartile range.

* p < .05

** p < .01

*** p < .001

Table 3

DUFSS questionnaire score by sex.

	Total n (%) 593(100)	Male n (%) 262(44.2)	Woman n (%) 331 (55.8)	p
Confident Dimension
Item 4. I get people who care what happens to me
Much less/less than I’d like	49(8.3)	21(8.0)	28(8.5)
Neither a lot nor little/almost/as much as I would like	544(91.7)	241(92)	303(91.5)
Item 5. I get love and affection
Much less/less than I would like	59(10)	21(8.0)	38(11.5)
Neither a lot nor little/almost/as much as I would like	534(90.1)	241(92)	293(88.5)
Item 6. I get chances to talk to someone about problems at work or with my housework
Much less/less than I would like	66(11.13)	19(7.3)	47(14.2)	**
Neither a lot nor little/almost/as much as I would like	527(88.9)	243(92.8)	284(85.8)
Item 7. I get chances to talk to someone I trust about my personal and family problems
Much less/less than I would like	70(11.8)	25(9.5)	45(13.9)
Neither a lot nor little/almost/as much as I would like	523(88.2)	237(90.5)	286(86.4)
Item 8. I get chances to talk about money matters
Much less/less than I would like	66(11.1)	20(7.6)	46(13.9)	*
Neither a lot nor little/almost/as much as I would like	527(88.9)	242(92.4)	285(86.1)
Item 10. I get useful advice about important things in life
Much less/less than I would like	61(10.3)	25(9.5)	36(10.9)
Neither a lot nor little/almost/as much as I would like	532(89.7)	237(90.5)	295(89.1)
Item 11. I get help when I´m sick in bed
Much less/less than I would like	60(10.1)	15(5.7)	45(13.6)	**
Neither a lot nor little/almost/as much as I would like	533(89.9)	247(94.3)	286(86.4)
Affective Dimension
Item 1. I get visits with friends and relatives
Much less/less than I would like	140(23.6)	55(21)	85(25.7)
Neither a lot nor little/almost/as much as I would like	453(79)	207(45.7)	246(74.3)
Item 2. I get help around the house
Much less/less than I would like	203(34.2)	78(29.8)	125(37.8)	**
Neither a lot nor little/almost/as much as I would like	390(65.8)	184(70.2)	206(62.2)
Item 3. I get praise for a good job
Much less/less than I would like	125(21.1)	42(16.0)	83(25.1)	**
Neither a lot nor little/almost/as much as I would like	468(78.9)	220(48)	248(74.9)
Item 9. I get invitations to go out and do things with other people
Much less/less than I would like	116(19.6)	48(18.3)	68(20.5)
Neither a lot nor little/almost/as much as I would like	477(80.4)	214(81.7)	263(79.5)

Note

* p < .05

** p < .01

*** p < .001

For both sexes, the variable most strongly associated with functional social support was the one referring to utilities in the HRQoL. Table 4 shows the factors associated with functional social support in women and men. For every 1-point increase in the utility score, functional social support increased 11.5 points (95% CI 7.09; 15.85) in women and 9.4 points (95% CI 3.18; 15.59) in men. Being married or partnered was also associated to perceived social support in both women and men, but more strongly in the latter (4.2 points, 95% CI 1.26; 7.07 vs. 3.3 points, 95% CI 0.29; 6.24). The rest of the variables associated to functional social support were different for each sex. In women, the functional social support score increased by 5 points (95% CI 1.91;7.94) in those who had completed high school or higher education; 2 points (95% CI 0.08;3.78) in those adhering to the prescribed treatment; and 5.6 points (95% CI 2.42;8.83) in those who lived alone. In men, the functional social support score increased by 3 points (95% CI 0.74; 5.70) in those with a household income between 1.051–2.250 €/month and 0.5 points (95% CI 0.03; 0.90) for each prescribed drug. Fig 1 shows the magnitude of the association for each of the variables that the final model yielded for both sexes.

Table 4

Factors associated with functional social support in women and men.

Women
	Coef. (95% CI)	p value
Educational level
Completed primary studies	2.33(0.34;4.32)	0.022
Bachelor or higher	4.92(1.91;7.94)	0.001
Adherence, compliance (Morisky-Green)	1.93(0.08;3.78)	0.041
Utility index	11.47(7.09;15.85)	0.000
Live alone	5.63(2.42;8.83)	0.001
Married or partnered	3.27(0.29;6.24)	0.031
R2	0.1604
Men
	Coef. (95% CI)	p value
Monthly household income
1.051–2.250€/month	3.22(0.74;5.70)	0.011
≥2.251€/month	2.30(-1.04;5.65)	0.176
Number of diseases	-0.42(-0.87;0.30)	0.067
Number of drugs	0.47(0.03;0.90)	0.036
Utility index	9.38(3.18;15.59)	0.003
Married or partnered	4.16(1.26;7.07)	0.005
R2	0.1108

Fig 1

Differences by sex found in the final model.

Discussion and conclusions

There are important sex differences in the social support perceived by polymedicated young-old patients with multimorbidity. These differences must be interpreted bearing in mind the age range studied, i.e. those born in Spain in the 1940s and 1950s, when social differences between men and women were still quite marked [48].

The functional social support score reported by women was lower than that reported by men, coinciding with previous studies conducted in similarly aged populations from Spain and Brazil [21, 43]. Being the main source of care and support for others can hinder women’s role as a recipient of support from others, which could explain why women, unlike men, have stated that they would like to be better listened to about their problems, hear more praise when they do something well, and get more help when they are sick [29].

The lower social support score perceived by women could also be explained by the fact that social networks are importantly influenced by sex inequalities within social structures. Women with worse educational and occupational level tend to perceive lower social support [25, 45]. In contrast, in men, the perception of social support seems to be related to their income level. Accordingly, a German study found that living in the most socially disadvantaged municipalities was associated with low social support in men, but not in women, which suggests that for men the perception of social support is related to their success in their role as household economic providers, represented in our study by income [49].

For both sexes, being married or partnered increased the perception of social support, observing a stronger association in the case of men, as described by other authors who have found that men’s main sources of support are their partners [50]. The increasing feminization of old age has meant that widowhood is a mostly female experience [51]. More and more widowed men and women are living alone, but women do so more often than men, who usually live with someone [52]. Women, when widowed, may feel very supported by social networks that, until then, had not been their main source of support, such as children, other family members, and friends, and may thus perceive greater social support in this new situation [18].

Perceived social support was directly correlated with the utility index of HRQoL in both sexes. In women this relationship was most intense, and they reported worse scores in all dimensions of HRQoL, along the lines of previous research [53]. Different authors have linked family demands with a worse quality-of-life score, especially in women with lower socioeconomic status [54].

Regarding polypharmacy, in men, better perceived social support was associated with a higher number of prescribed drugs and, in women with better adherence to treatment. This association could be explained by the effectiveness of the treatment, which may improve their health status and symptoms, allowing them to carry out social activities. In the case of women, such an association might be explained by the acceptance and social recognition that they can experience when performing self-care in a socially accepted way [29].

Perceived support is a multidimensional construct subject to different interpretations by experts in the field, for which a consensus is not reached with respect to the dimensions that compose it or how to measure it. Different validations have been carried out on the questionnaire used in this study (DUFSS) in very specific populations, such as caregivers [55], mental health patients [56], or socioeconomically disadvantaged people, and they were mostly women [11, 41]. In our study, we chose to use the most recent validation performed by Ayala et al. [47], who obtained a Cronbach’s alpha of 0.94 in noninstitutionalized people aged 60 or over; their population was similar to ours and allows better comparisons with our results.

Limitations and strengths

The study of social support presents difficulties in relation to conceptualisation and measurement. In this study, structural social support has been studied through a proxy of the social network such as marital status and the number of cohabitants in the household. This is undoubtedly a limitation, since the structural perspective studies social networks, including all the individual’s contacts and providing information on their dimensions, and not only the variables available in this research. However, despite this limitation, this proxy allows us to cover part of the structural social support, following the recommendations of the authors who state that it is more appropriate to study both types of support, functional and structural.

The data used in this study are the baseline data from a randomised clinical trial, MULTIPAP STUDY [38]. It is a pragmatic cluster randomised controlled clinical trial with 12 months follow-up. The unit of randomisation was the family doctor and the unit of analysis was the patient. Although this was a cross-sectional study, its external validity was increased through systematic random sampling drawn from a representative sampling frame. The sample was drawn from a heterogeneous sample that is representative of the general multimorbid and polymedicated population… This was achieved by selecting patients from the health centers, by their family physicians, under clinical practice conditions, giving a pragmatic outlook to the study. The restriction of the sample to the age group of young older adults aged 65 to 74 years makes the sample size difficult, but, at the same time, offers greater knowledge about this group, which is rarely studied on its own but increasingly prominent in our society.

Important sex differences exist in the social support perceived by older multimorbid adults, which should be considered in future public health and health promotion interventions.

16 Feb 2022

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Project.

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“This study was funded by Instituto de Salud Carlos III (ISCIII) [grant references PI15/00276, PI15/00572, PI15/00996, PI18/01812, PI18/01303, PI18/01515, RD16/0001/0004, RD16/0001/0005, RD16/0001/0006] and co-funded by the European Regional Development Fund “A way to shape Europe; Research, Development and Innovation National Plan 2013-2016”. CMLH has received a grant from the Fundación para la Investigación e Innovación Biosanitaria de Atención Primaria (FIIBAP) for translation.”

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. 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 #1: This manuscript uses survey data from Spanish health centers to assess the sex differences in social support among older polymedicated adults. Overall, it is fairly well written and easy to follow. Please see below for my comments.

1. For the most part, the authors do well to use politically correct language when referring to older adults. However, on line 45, per the Gerontological Society of America’s policy on language regarding the older population, I suggest replacing the term ‘eldery people’ with a more neutral term (e.g., older adults, older people). See for (Lundebjerg et al., 2017) for details on this policy.

CITED SOURCE: Lundebjerg, Nancy E., Daniel E. Trucil, Emily C. Hammond, and William B. Applegate. 2017. “When It Comes to Older Adults, Language Matters: Journal of the American Geriatrics Society Adopts Modified American Medical Association Style.” Journal of the American Geriatrics Society 65(7):1386–88. doi: 10.1111/jgs.14941.

2. The authors do well to distinguish between social networks and social support (lines 56-65). However, after introducing the concept of networks (including size, density, homogeneity, etc) in the Introduction, it was a little disappointing to see structural social support later operationalized simply as marital status and number of cohabitants in the home (lines 122-123). While these measures are often indicative of social support, their mere presence does not automatically guarantee social support. For instance, poor marriages might actually cause more strain than support (de Jong Gierveld et al. 2009). I realize that data limitations are always going to be an issue, but it seems that it is at least acknowledging the lack of social network data and marital quality as limitations in this study.

CITED SOURCE: Jenny de Jong Gierveld, Marjolein Broese van Groenou, Adriaan W. Hoogendoorn, Johannes H. Smit, Quality of Marriages in Later Life and Emotional and Social Loneliness, The Journals of Gerontology: Series B, Volume 64B, Issue 4, July 2009, Pages 497–506, https://doi.org/10.1093/geronb/gbn043

3. In the Materials and Methods section, the authors choose to separate functional support into ‘confident support” and “affective support” (lines 131-133). If they are going to make this distinction methodologically, it should be preceded with conceptual justification in the Introduction section.

4. I don’t understand the values given in lines 175-178). They do not seem to match those in Table 3. The bivariate comparisons given in the text do not make sense to me because they are not dichotomous outcomes. Rather there appears to be three response categories to each outcome.

5. I am confused by the sentence on line 215 that reads “The increasing feminization of old age has meant that widowhood is a mostly female experience.” What does this mean? Are the authors trying to say that women are more likely to experience widowhood because they tend to live longer than men?

6. The sentence on lines 241-243 the authors say that their heterogeneous sample “is representative of the general multimorbid and polymedicated population, increasing its external validity.” But it seems to me that the external validity depends more on the sampling methodology (i.e., random sampling drawn from a representative sampling frame) rather than the sample demographics. It is difficult to tell if participants were randomly selected or if a convenience sampling method was used instead. Perhaps more importantly, however, the participants appear to have first been contacted in health centers, which—if true—would not make it a representative sample of the general population since only those who went to the health centers were eligible for being selected into the study. These distinctions should be noted in the manuscript.

Reviewer #2: I have just read the manuscript entitled "Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Project", an interesting work exploring determinants of social support perceived by sex. The study is focused on polymedicated older adults with multimorbidity. After reading the manuscript, I have the following comments:

- The article is focused in older adults, although only in those aged 65-74 years. Why people older than 75 were not considered in the sample?

- All the instruments used in this study have been previously validated in other samples. I wonder whether the authors could provide data on internal consistency (e.g., Cronbach’s alpha for unidimensional scales) according to the sample considered in this study.

- In Table 4, the 95% CI associated to “Number of drugs” in men cannot provide a significant p-value. This would be checked and also revised in the Results section in the main text.

- The authors have found an association between lower perception of social support and multimorbidity in men. This result is not observed in women and should be discussed.

- Potential limitations of this study should be highlighted in the Discussion section.

Minor comments:

- Line 101: "Random sampling". Which type of random sampling was used?

- Lines 141-142: “Explanatory linear regression models”. Why explanatory?

- Lines 190-192: “In contrast, a higher number of diseases was associated with a lower social support score; it fell by 0.4 points (95% CI -0.87–0.30) for each disease”. Please revise the use of hyphen in confidence intervals when negative values are reported. On the other hand, it is not a significant result.

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Reviewer #1: No

Reviewer #2: No

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31 Mar 2022

We are very grateful for your evaluation of our manuscript entitled "Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Study"

We appreciate the comments of the reviewers and editors and have made the suggested changes. We have attached the reviewers' response.

We hope that these changes will contribute to improve the quality of the manuscript and the interest of potential readers.

On behalf of the research team,

Best regards,

Cristina María Lozano Hernández

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

26 Apr 2022

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Study.

PONE-D-21-30179R1

Dear Dr. Lozano Hernández,

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.

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Thomas Penzel

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

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 #1: Yes

Reviewer #2: 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 #1: (No Response)

Reviewer #2: I have read the last version of the manuscript entitled "Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Study" and the authors have adequately addressed all my previous comments.

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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.

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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

28 Apr 2022

PONE-D-21-30179R1

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP Study.

Dear Dr. Lozano-Hernández:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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