The chain mediation model of psychological resilience and social participation among stroke survivors with disability: the role of exercise adherence and physical disability

This study aimed to examine the chain mediating roles of exercise adherence and physical disability in the relationship between psychological resilience and social participation among stroke survivors with disability. A cross-sectional study was conducted with 271 stroke survivors recruited from five rehabilitation departments in Shanghai between March and June 2025. Participants were assessed with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P), 10-item Connor-Davidson Resilience Scale (CD-RISC-10), Exercise Adherence Questionnaire (EAQ), and modified Rankin Scale (mRS). Structural equation model (SEM) with bootstrap resampling was employed to test the hypothesized pathways, adjusting for potential confounders. Psychological resilience significantly predicted all three dimensions of social participation. After adjusting for confounders, exercise adherence and physical disability jointly mediated the relationship for participation frequency (indirect effect = 0.050, 95% CI [0.018, 0.096], accounting for 13.7% of the total effect) and participation restrictions (indirect effect = 0.104, 95% CI [0.038, 0.197], explaining 9.97% of the total effect). For participation satisfaction, exercise adherence alone was a stronger mediator (indirect effect = 0.388, 95% CI [0.124, 0.685], representing 36.78% of the total effect) than the chain pathway including physical disability. Exercise adherence and physical disability mediate the association between psychological resilience and social participation in stroke survivors with disability, with adherence playing a particularly central role in enhancing participation satisfaction. Rehabilitation programs should incorporate resilience-building interventions and strategies to enhance exercise adherence to facilitate social participation.