Background
Hematopoietic stem cell transplantation (HSCT) is a treatment used to restore bone marrow function by injecting hematopoietic stem cells into patients with bone marrow failure, blood cancer, or those who have received myelotoxic therapy [ 1 ]. It has become an essential therapeutic option worldwide for patients with hematologic malignancies and bone marrow failure. In 2018, over 93,000 HSCT procedures were performed globally, underscoring its critical role in modern hematology [ 2 ]. In South Korea, the number of HSCT procedures has steadily increased since the first transplant was performed in 1983, reaching a cumulative total of 48,917 cases by 2023 [ 3 ]. HSCT is primarily performed to achieve a cure and prolong survival; however, this procedure is physically and psychologically demanding for patients, with many perceiving it as a highly stressful event. Studies report that 5–19% of HSCT recipients develop post-traumatic stress disorder, which may manifest symptoms such as avoidance, hypervigilance, emotional numbing, or intrusive re-experiencing of traumatic events [ 4 ]. Most studies have focused on the negative aspects of cancer diagnosis and treatment, emphasizing the management of physical and psychological symptoms, including pain, fatigue, nausea, depression, and anxiety, primarily through medical interventions and supportive nursing care. Nevertheless, certain researchers have attempted to broaden our understanding by exploring the potential for positive psychological outcomes, such as post-traumatic growth (PTG), in individuals undergoing cancer treatment [ 5 ]. Changes resulting from cancer are not solely negative and can foster personal growth in many cases. Patients may develop a greater appreciation for positive aspects of life amid distress, find meaning in their post-cancer journey, and establish new goals [ 6 ]. Additionally, they may experience inner growth, adopt a more positive perspective, and cultivate stronger interpersonal relationships [ 7 ]. This concept has been expressed using terms such as stress-related growth, benefit finding, perceived benefit, thriving, adversarial growth, changes in outlook, and positive product [ 8 ]. Particularly, the concept of PTG, introduced by Tedeschi and Calhoun, describes changes following a traumatic experience that extend beyond the ability to cope with the situation and result in improvements surpassing pre-trauma levels [ 9 ]. Therefore, viewing cancer solely as a source of negative outcomes may lead to a distorted understanding of patients’ experiences, and the potential for positive change through experiencing the hardships of cancer should be considered [ 10 ]. PTG has been observed in multiple patients with cancer; therefore, we hypothesized that patients may experience shifts in life values and positive changes in self-image, even when faced with the extreme stress of cancer diagnosis, anticancer therapy, and HSCT.
In cancer-related literature, PTG has been reported to be more strongly associated with psychosocial variables than with demographic or medical variables, with important factors including coping, optimism, resilience, self-esteem, rumination, social support, and quality of life (QoL) [ 11 – 13 ]. Several studies examining psychological characteristics that promote PTG have emphasized the significance of enhancing emotional regulation ability and transforming intrusive rumination into deliberate reflection [ 14 – 16 ]. Additionally, social support has been consistently reported to correlate with higher levels of PTG [ 17 – 19 ]. Studies on HSCT survivors have reported a strong correlation between PTG and the level of distress experienced before transplantation and during the acute phase [ 20 ]. Notably, higher post-transplant distress has been associated with lower QoL, demonstrating the association between psychological support, stress management, and PTG among HSCT recipients [ 21 , 22 ].
Thus, although the importance of PTG for HSCT survivors has been increasingly recognized, previous studies have largely focused on long-term patients, particularly those who received allogeneic HSCT and had survived for 5 years or more [ 20 , 23 ]. While a few recent longitudinal studies have begun to explore PTG in HSCT recipients [ 23 , 24 ], studies specifically examining the early post-transplantation period-particularly within the first year after HSCT-remain limited. This period is marked by heightened physical vulnerability and psychological adjustment demands. Timely psychosocial support during this early phase may be critical for fostering long-term PTG, especially in underrepresented populations such as Asian HSCT recipients.
Purpose
While previous studies have primarily examined long-term outcomes among allogeneic HSCT recipients, patients undergoing autologous transplantation may also experience significant psychological challenges and opportunities for growth. Given the differing trajectories and treatment burdens associated with autologous and allogeneic HSCT, including both groups, allows for a more comprehensive understanding of the factors influencing PTG during the acute post-transplant phase. Therefore, this study aimed to examine PTG as a central psychological outcome following HSCT and to assess the effects of psychosocial variables on PTG in patients who had received autologous or allogeneic HSCT within the first year. The specific objectives were as follows:
To ascertain the general and disease-related characteristics of patients.
To determine the patients’ levels of social support, rumination, distress, QoL, and PTG.
To investigate differences in social support, rumination, distress, QoL, and PTG depending on the patients’ general and disease characteristics.
To explore the correlations among social support, rumination, distress, QoL, and PTG, thereby identifying candidate predictors for regression analysis.
To identify factors contributing to the patients’ PTG.
Methods
Study design
This was a descriptive survey study to ascertain factors affecting PTG in patients who had received autologous or allogeneic HSCT. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional observational studies to ensure methodological transparency and completeness of reporting.
Study participants
Participants were selected using a convenience sampling method from adult patients who had undergone HSCT within the past year at the HSCT unit of C University Hospital in Seoul, South Korea. Eligible patients were identified through hospital medical records and were approached consecutively during their scheduled outpatient follow-up visits. The inclusion criteria were patients aged ≥ 19 years who received autologous or allogeneic HSCT once and who consented to participate in the study after a thorough discussion of its objectives and rationale. The exclusion criteria were patients who were unable to respond to the questionnaire, those with major organ failure or psychiatric disease, and those receiving a retransplant due to relapse. We conducted a priori power analysis using G*Power 3.1.9 to calculate the required sample size for multiple regression analysis examining the influence of psychosocial variables on PTG, which is the primary outcome of this study. A moderate effect size (f² = 0.15) was selected in accordance with Cohen’s convention for behavioral and social science research, which defines f² = 0.02 as small, f² = 0.15 as moderate, and f² = 0.35 as large [ 25 ]. Based on a significance level of 0.05, a statistical power of 0.80, and five predictors, the minimum required sample size was estimated to be 92 participants. The selection of these five predictors—four psychosocial factors (social support, rumination, distress, and QoL) and one general characteristic (sex)—was informed by previous studies identifying key factors influencing PTG in patients with HSCT [ 20 , 23 , 24 ]. To account for a potential 20% dropout rate, 110 patients were initially recruited. After excluding incomplete or inadequate responses, a total of 106 participants were included in the final analysis. A post hoc power analysis indicated a power of 0.87, confirming that the final sample size was sufficient to detect the observed effects.
Study tools
We obtained approval for all research tools from the original developers through email.
Post-traumatic growth inventory (PTGI)
The PTGI, developed by Tedeschi and Calhoun [ 26 ] to measure PTG, consists of 21 items grouped into the following five subdomains: improved relationships, new possibilities, personal strength, spiritual/religious growth, and appreciation for life. In this study, we used the Korean version of the PTGI [ 27 ], which was translated and culturally adapted through a standardized forward-backward translation process by bilingual experts, followed by pilot testing with Korean patients with cancer to ensure conceptual equivalence and cultural appropriateness. Each item was scored on a 6-point Likert scale from 0 (‘not experienced’) to 5 (‘experience to a very great degree’), with higher scores indicating a greater degree of PTG. A total score of 45 and below represented low PTG levels, whereas scores of 46 and above represented medium to very high PTG levels. Cronbach’s α was 0.80 for the original tool and 0.94 in our study.
Multidimensional scale of perceived social support (MSPSS)
We used the MSPSS to measure social support [ 28 ]. For this study, we used the Korean version of the MSPSS [ 29 ], which was translated and validated in previous Korean studies with oncology and general medical populations. The translation followed a forward-backward method, and the scale demonstrated high internal consistency and construct validity in Korean samples. The MSPSS is a self-report tool that measures the degree to which adults perceive that they are receiving appropriate support from others. It comprises 12 items in total, with four items in each of the following three subdomains: family, friends, and significant others. Each item was scored on a Likert scale from 1 (‘very strongly disagree’) to 7 (‘very strongly agree’), with higher scores indicating a higher level of perceived social support. The MSPSS yielded a total score ranging from 12 to 84. Scores from 12 to 35 indicated low perceived social support, 36 to 60 indicated medium support, and 61 to 84 reflected high perceived support. Cronbach’s α was 0.96 for the original tool and 0.92 in our study.
Korean-event related rumination inventory (ERRI)
The ERRI, developed by Cann et al. [ 30 ], is a 20-item self-report questionnaire. In this study, we used the Korean-ERRI version [ 31 ], which was linguistically adapted through a forward-backward translation process and pilot-tested among Korean patients. This tool was used to measure the cognitive processes of intrusive rumination and deliberate rumination after experiencing a major stressful life event. Intrusive and deliberate rumination contained 10 items each, measured on 4-point Likert scales from 0 (‘not at all’) to 3 (‘often’), with higher scores indicating greater use of the corresponding rumination type. The use of this tool, in combination with a scale for measuring PTG, can improve our understanding of the role of intrusive and deliberate rumination in posttraumatic recovery and growth. In certain items, the term “event” was replaced with “at the time of cancer diagnosis and treatment” by an investigator to aid patients’ understanding of the questionnaire. Cronbach’s α was 0.94 in the study by Cann et al. and 0.93 in our study.
Impact of event Scale-Revised-Korean version (IES-R-K)
The IES-R-K scale was developed by Weiss and Marmer [ 32 ] to measure distress experienced after a traumatic event and contains 22 items in total, measuring intrusive, avoidance, and hypervigilance symptoms. We used the Korean version (IES-R-K) [ 33 ], which has been culturally adapted and psychometrically validated in Korean clinical populations, including patients with cancer and trauma survivors. Individuals were asked to rate subjective symptoms experienced in the last month concerning a specific traumatic event. Items were rated on a 5-point Likert scale from 0 (‘not at all’) to 4 (‘extremely often’), with higher scores indicating more severe symptoms. In certain items, the term ‘event’ was replaced with ‘at the time of cancer diagnosis and treatment’ by an investigator to aid patients’ understanding of the questionnaire. A cutoff point of 25 or higher is considered to indicate elevated psychological distress. Cronbach’s α was 0.79 in the study by Weiss and Marmer and 0.94 in our study.
QoL (Functional assessment of cancer therapy - bone marrow transplantation [FACT-BMT])
We obtained approval to use the Korean version of the FACT-BMT (Version 4) tool from the FACIT team to measure QoL [ 34 ]. The FACT-BMT is a self-report tool containing 50 items in total, classified into the five subdomains of physical well-being (7 items), social/family well-being (7 items), emotional well-being (6 items), functional well-being (7 items), and other (13 items). The items were scored on a 5-point scale of 0 = ”not at all,” 1 = ’’a little bit,” 2 = ”somewhat,” 3 = ”quite a bit,” and 4 = ”very much,” with higher scores indicating better QoL. Experts validated the scale, and Cronbach’s α was 0.89 at the time of development and 0.81 in our study.
General and disease-related characteristics
We collected data on the following general and clinical characteristics: sex, age, educational level, marital status, occupation, religion, average monthly family income, medical expense guarantor, primary caregiver, diagnosis, type of HSCT, type of treatment received prior to HSCT, and time since transplantation. Perceived positive change refers to the patient’s subjective recognition of having experienced meaningful or beneficial changes in their thoughts, emotions, or behaviors following HSCT. It reflects the patient’s internal perception of positive transformation that occurred after the transplantation experience. It was assessed using a single self-reported item with three response options: yes, no, or not sure.
Data collection and ethical considerations
This study was reviewed and approved by an institutional review board (IRB No. KC16QISI0447). As an observational study, it was not registered in a clinical trial registry because it did not meet the criteria for interventional trial registration. After receiving approval, we collected data from patients undergoing post-HSCT outpatient follow-up at C University Hospital, a tertiary healthcare organization in Seoul, between March 2018 and March 2022. This was a questionnaire survey study, and data collected through participation in the study will be destroyed after study completion and managed appropriately in accordance with the Personal Information Protection Act. Collected personal information was not provided to anyone other than the researchers. The collected data was processed using unique identification numbers to ensure the protection of patients’ personal information and treatment data, thereby preventing any infringement of human rights or ethics violations. The questionnaires required approximately 15 min to complete. Upon completing the questionnaire, patients were provided with a small gift (a prepaid gift card equivalent to approximately $5) as a token of appreciation, and an investigator directly collected the completed forms.
Statistical analysis
All data were coded and analyzed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were used to summarize participants’ sociodemographic and clinical characteristics. To examine differences in PTG scores according to categorical patient characteristics independent t-tests and one-way analysis of variance (ANOVA) were conducted, with Scheffé’s post hoc tests applied where appropriate. To explore bivariate associations between PTG and continuous psychosocial variables Pearson’s correlation coefficients were calculated. These correlation results informed the selection of variables for inclusion in the multiple regression model. Prior to regression analysis, multicollinearity was assessed using variance inflation factors (VIF) and tolerance values. Finally, stepwise multiple linear regression analysis was performed to identify significant predictors of PTG. This study followed the STROBE guidelines to ensure transparency, reproducibility, and completeness in reporting cross-sectional observational data [ 35 ].
Results
General and disease-related characteristics
Overall, 106 patients were analyzed. The mean age was 43.27 years (SD = 12.98), with more male patients (52.8%) than female patients (47.2%). Most participants were married (68.9%) and had no religious affiliation (51.9%). A majority had at least a college education (66.0%) and were employed (65.1%). Nearly half (45.5%) reported a monthly family income of 5 million KRW or more. The most common source of medical expense payment was self-funded (49.1%), and the primary caregiver was most often the spouse (50.0%). Regarding disease-related factors, acute myeloid leukemia was the most common diagnosis (37.7%), and sibling donor transplantation was the most frequent HSCT type (52.8%). Pre-transplant treatments included total body irradiation (TBI) and immunosuppressants in 42.4% and 71.7% of patients, respectively. The majority (83.0%) underwent HSCT within 6 months of diagnosis. Additionally, 45.8% reported experiencing a positive change in their thinking following transplantation (Table 1 ).
Table 1
Descriptive statistics of demographical and clinical characteristics ( N = 106)
| Variable | Category | n | % | |
| Demographical | Sex | Male | 56 | 52.8 |
| Female | 50 | 47.2 | ||
| Age (yr) | 19–29 | 22 | 20.8 | |
| 43.27 ± 12.98 | 30–39 | 15 | 14.2 | |
| 40–49 | 28 | 26.4 | ||
| 50–59 | 30 | 28.3 | ||
| ≥ 60 | 11 | 10.4 | ||
| Education | ≤High school | 27 | 26.4 | |
| University student | 8 | 7.5 | ||
| ≥University | 70 | 66.0 | ||
| Marital Status | Married | 32 | 30.2 | |
| Unmarried | 74 | 69.8 | ||
| Occupation | Employed | 69 | 65.1 | |
| Unemployed | 37 | 34.9 | ||
| Religion | Yes | 51 | 48.1 | |
| No | 55 | 51.9 | ||
| Average Family Income (10,000won) | < 300 | 28 | 26.4 | |
| ≥300~ ≤500 | 33 | 31.1 | ||
| > 500 | 45 | 45.5 | ||
| Medical Expense Guarantor | Parents | 22 | 20.8 | |
| Spouse | 30 | 28.3 | ||
| Child | 1 | 0.9 | ||
| Self | 52 | 49.1 | ||
| Others | 1 | 0.9 | ||
| Primary Caregiver | Parents | 39 | 36.8 | |
| Spouse | 56 | 50.0 | ||
| Child | 6 | 5.7 | ||
| Sibling | 5 | 4.7 | ||
| Self | 3 | 2.8 | ||
| Clinical | Diagnosis | Acute Myeloid Leukemia | 40 | 37.7 |
| Acute Lymphocytic Leukemia | 23 | 21.7 | ||
| Severe Aplastic Anemia | 8 | 7.2 | ||
| Myelodysplastic Syndrome | 18 | 17.0 | ||
| Multiple Myeloma | 8 | 7.5 | ||
| Lymphoma | 8 | 7.5 | ||
| Primary Myelofibrosis | 1 | 0.9 | ||
| Type of HSCT | Sibling | 56 | 52.8 | |
| Unrelated | 34 | 32.1 | ||
| Autologous | 13 | 12.3 | ||
| Cord | 3 | 2.8 | ||
| Total body irradiation | Yes | 45 | 42.5 | |
| No | 61 | 57.5 | ||
| Immunosuppressant | Yes | 76 | 71.7 | |
| No | 30 | 28.3 | ||
| Time since transplantation | < 6 months | 88 | 83.0 | |
| > 6 months | 18 | 17.0 | ||
| Perceived Positive Change(self-reported) | Positive Change | Yes | 65 | 61.3 |
| No | 7 | 6.6 | ||
| Not sure | 34 | 32.1 |
PTG, social support, rumination, distress, and QoL
Based on the interpretation that PTG scores of 46 or higher indicate a moderate to high level of PTG, participants in this study showed moderate to high PTG, with a mean score of 73.75 ± 19.07 (range: 0–105). Social support was a medium level, with a mean score of 53.05 ± 6.86 (range: 12–84). The mean intrusive rumination score was 11.91 ± 7.45, and the mean deliberate rumination score was 18.14 ± 6.12, both on a 0–30 point scale. The total rumination score was relatively low, with a combined mean of 30.05 ± 6.12 (range: 0–60), suggesting limited cognitive engagement with the traumatic experience. Psychological distress was measured on a 0–88 scale, with scores of 25 or higher indication elevated distress. The mean distress score was 35.06 ± 18.59, suggesting a relatively high level of distress. The mean QoL score was 88.99 ± 19.87 on a 0–156 scale, indicating reduced overall life satisfaction and well-being (Table 2 ).
Table 2
Descriptive statistics of post-traumatic growth, social support, rumination, distress, and quality of life ( N = 106)
PWB Physical well-being, SWB Social/Family Well-Being, EWB Emotional Well-Being, FWB Functional Well-Being, FACT-G Functional Assessment of Cancer Therapy - General, BMTS Bone Marrow Transplant Subscale, SD Standard deviation
| Variables | Minimum | Maximum | Mean ± SD | |
| Post-traumatic Growth | Total | 0 | 105 | 73.75 ± 19.07 |
| Relating to others | 0 | 35 | 17.44 ± 5.08 | |
| New possibility | 0 | 25 | 17.46 ± 5.31 | |
| Personal strength | 0 | 20 | 14.45 ± 4.14 | |
| Spiritual changes | 0 | 10 | 6.01 ± 2.57 | |
| Appreciation of life | 0 | 15 | 12.26 ± 2.77 | |
| Social Support | Total | 12 | 84 | 53.05 ± 6.86 |
| Rumination | Total | 0 | 59 | 30.05 ± 11.53 |
| Intrusive rumination | 0 | 30 | 11.91 ± 7.45 | |
| Deliberate rumination | 0 | 30 | 18.14 ± 6.12 | |
| Distress | Total | 0 | 88 | 35.06 ± 18.59 |
| Quality of Life | Total | 0 | 156 | 88.99 ± 19.87 |
| PWB | 0 | 28 | 15.84 ± 6.31 | |
| SWB | 0 | 28 | 18.75 ± 5.03 | |
| EWB | 0 | 24 | 16.64 ± 4.49 | |
| FWB | 0 | 28 | 16.35 ± 5.98 | |
| FACTG | 0 | 108 | 67.60 ± 14.84 | |
| BMTS | 0 | 48 | 21.38 ± 6.49 |
PTG differences depending on patients’ characteristics
Significant differences in PTG were observed based on sex, religion, age, marital status, HSCT type, and TBI. Female patients scored higher than male patients (t= −2.379, p =.019). Non-religious patients reported higher PTG than religious participants (t = 2.314, p =.023). Age was also associated with PTG, with older patients scoring higher than younger patients (F = 3.378, p =.012). Post-hoc analysis revealed no significant differences between the age groups. Additionally, married patients scored lower than unmarried patients (t= −4.960, p =.000). Autologous HSCT recipients reported significantly higher PTG than allogeneic recipients (F = 4.667, p =.004). Patients who did not receive TBI had higher PTG than those who did (t = 2.114, p =.037). Moreover, those who experienced positive change after transplantation showed the highest PTG compared to those who did not (F = 18.606, p <.001) (Table 3 ).
Table 3
Differences in post-traumatic growth according to demographical and clinical characteristics ( N = 106)
SD Standard deviation
| Variable | Category | Mean ± SD | t or F ( p ) (Scheffe) | |
| Demographical | Sex | Male | 69.67 ± 19.68 | −2.379 (0.019) * |
| Female | 78.32 ± 17.46 | |||
| Age (yr) | 19–29 | 67.00 ± 16.67 | 3.378(0.012) * | |
| 43.27 ± 12.98 | 30–39 | 68.60 ± 17.13 | ||
| 40–49 | 70.61 ± 17.52 | |||
| 50–59 | 79.47 ± 19.21 | |||
| ≥ 60 | 86.72 ± 21.87 | |||
| Education | ≤High school | 76.92 ± 16.70 | 1.525(0.212) | |
| University student | 63.75 ± 15.97 | |||
| ≥University | 73.24 ± 20.05 | |||
| Marital Status | Married | 61.12 ± 16.22 | −4.960(0.000) * | |
| Unmarried | 79.21 ± 17.65 | |||
| Occupation | Employed | 74.51 ± 18.91 | −0.553(0.582) | |
| Unemployed | 72.35 ± 19.57 | |||
| Religion | Yes | 81.09 ± 25.80 | 2.314(0.023) * | |
| No | 86.59 ± 25.80 | |||
| Average Family Income (10,000 won) | < 300 | 75.08 ± 22.56 | 0.585(0.626) | |
| 300–500 | 71.36 ± 19.39 | |||
| > 500 | 75.53 ± 16.86 | |||
| Medical Expense Guarantor | Parents | 66.18 ± 16.67 | 3.718 (0.007) * | |
| Spouse | 82.27 ± 14.04 | |||
| Child | 101.00 ± 0.00 | |||
| Self | 71.98 ± 20.65 | |||
| Others | 50.00 ± 0.00 | |||
| Primary Caregiver | Parents a | 66.54 ± 17.54 | 5.377(0.001) * | |
| Spouse b | 78.68 ± 17.08 | |||
| Child c | 92.67 ± 11.06 | |||
| Sibling d | 58.60 ± 19.93 | |||
| Self e | 68.00 ± 35.00 | |||
| Clinical | Diagnosis | Acute myeloid Leukemia | 74.05 ± 18.92 | 0.715(0.638) |
| Acute Lymphocytic Leukemia | 71.04 ± 19.43 | |||
| Severe Aplastic Anemia | 70.13 ± 18.29 | |||
| Myelodysplastic Syndrome | 73.39 ± 20.34 | |||
| Multiple Myeloma | 86.37 ± 23.32 | |||
| Lymphoma | 71.75 ± 20.41 | |||
| Primary Myelofibrosis | 75.00 ± 0.00 | |||
| Type of HSCT | Sibling | 73.26 ± 15.20 | 4.677(0.004) * | |
| Unrelated | 71.65 ± 24.30 | |||
| Autologous | 87.43 ± 10.79 | |||
| Cord | 47.67 ± 1.53 | |||
| Total body irradiation | Yes | 69.27 ± 17.93 | 2.144(0.037) * | |
| No | 77.07 ± 19.36 | |||
| Immunosuppressant | Yes | 73.46 ± 18.45 | 0.252(0.802) | |
| No | 74.50 ± 20.89 | |||
| Time since transplantation | < 6 months | 73.79 ± 19.26 | 0.048(0.962) | |
| > 6 months | 73.56 ± 18.68 | |||
| Perceived Positive Change | Positive Change | Yes a | 79.86 ± 14.81 | 18.606(.<001) * b < c < a |
| No b | 42.57 ± 17.59 | |||
| Not sure c | 68.53 ± 19.21 |
Relationships between PTG and social support, rumination, distress, and QoL
We investigated the relationships between PTG and social support, rumination, distress, and QoL. PTG was positively correlated with social support, rumination, and distress. Specifically, higher levels of social support ( r =.254, p =.009), rumination ( r =.392, p <.001), and distress ( r =.337, p <.001) were associated with higher PTG (Table 4 ).
Table 4
Correlation between Post-traumatic growth and major variables ( N = 106)
** p <.001
| Post-traumatic Growth | Social Support | Rumination | Distress | Quality of Life | |
| r( p ) | r( p ) | r( p ) | r( p ) | r( p ) | |
| Social Support | 0.254 (0.009) ** | 1 | |||
| Rumination | 0.392 (.<001) ** | − 0.011 (0.912) | 1 | ||
| Distress | 0.337 (,<001) ** | − 0.156 (0.110) | 0.657 (.<001) ** | 1 | |
| Quality of Life | 0.049 (0.619) | 0.309 (0.001) ** | − 0.383 (.<001) ** | −534 (.<001) ** | 1 |
Factors affecting PTG
We performed a regression analysis to identify factors influencing patients’ PTG. Categorical variables that showed significant differences (sex, marital status, healthcare expense guarantor, primary caregiver, religion, HSCT type, and perceived positive change) were included after dummy-coding. Additionally, variables that demonstrated significant correlations with PTG (social support, rumination, and distress) were also included in the model. We examined tolerance and VIFs to assess multicollinearity before performing stepwise multiple regression analysis. The tolerance values for the main variables all exceeded 0.1 (0.119–0.831), and the VIFs were all ≤ 2.249, which was lower than the threshold of < 10, indicating no multicollinearity between the independent variables. In stepwise regression, the regression model including all variables was significant (F = 20.773, p <.001), with an explanatory power of 53.0%. Variables affecting PTG included being married (β=−0.291, p =.000), having no positive change in thinking after transplantation (β=−0.196, p =.000), rumination (β = 0.298, p =.000), positive change in thinking after transplantation (β = 0.265, p =.000), autologous HSCT (β = 0.268, p =.000), and social support (β = 0.191, p =.006) (Table 5 ).
Table 5
Influencing factors on Post-traumatic growth among HSCT recipients ( N = 106)
B Unstandardized beta, SE Standard error, HSCT Hematopoietic stem cell transplantation Ref) Positive change (Not sure), Marital Status (Unmarried), Type of HSCT (Sibling)
| Variables | B | SE | β | t | p |
| (Constants) | 37.116 | 11.020 | 2.461 | 0.016 | |
| Marital Status(Married) | −12.051 | 2.861 | − 0.291 | −4.212 | 0.000 |
| Type of HSCT(Auto) | 15.528 | 3.955 | 3268 | 3.927 | 0.000 |
| Positive change (No) | −14.991 | 5.608 | − 0.196 | −2.673 | 0.009 |
| Positive change (Yes) | 10.313 | 2.854 | 0.265 | 3.614 | 0.000 |
| Rumination | 0.494 | 0.113 | 0.298 | 4.363 | 0.000 |
| Social Support | 0.513 | 0.189 | 0.191 | 2.805 | 0.006 |
| F = 20.773 ( p <.001), R 2 = 0.557, R adj =0.530 |
Discussion
This study aimed to investigate the level of PTG in autologous and allogeneic HSCT survivors and analyze the factors affecting PTG. Its significance lies in focusing on HSCT recipients within the first year post-transplantation, a critical period for psychological adjustment. The findings are expected to contribute to the development of effective supportive strategies to enhance psychological adaptation and QoL in HSCT recipients.
The mean PTG score of the HSCT survivors in our study was 73.75 points, which is higher than the scores of 48.48 points reported in a previous study measuring PTG in allogeneic HSCT survivors [ 36 ] and 68.60 points reported in a study measuring PTG in general cancer survivors [ 37 ]. These discrepancies can be attributed to differences in participant characteristics, such as years of survival after transplantation, physical or psychological factors, and social support, or differences in the study design. Specifically, this study focused solely on survivors within 1 year of undergoing HSCT, in contrast to a previous study [ 36 ] that included survivors up to 10 years post-transplantation, indicating differing ranges of survival durations. Differences in PTG based on survival duration suggest that the psychological and emotional changes experienced by survivors after treatment may evolve. The participants in our study had undergone transplantation relatively recently and showed high PTG scores, suggesting that traumatic experiences may not only result in negative outcomes but also provide an opportunity for psychological growth and shifts in life perspective. This finding aligns with Cordova et al. [ 37 ], who reported that cancer survivors may experience growth beyond their level of adaptation and psychological function before diagnosis. Future studies should analyze PTG changes in HSCT survivors based on survival duration. Developing tailored intervention strategies depending on survival duration may facilitate the systematic support of both short- and long-term psychological adaptation in HSCT survivors.
In this study, we observed differences in the PTG of HSCT survivors depending on general characteristics, including sex, age, religion, and marital status. Considering sex differences, female patients showed higher PTG than male patients, a trend consistent with findings reported in previous studies [ 20 ]. Females have been reported to show a stronger tendency to interpret traumatic events as opportunities to reframe life’s meaning and pursue internal growth [ 38 ]. In the South Korean cultural context, females are often socialized to take on caregiving and emotionally expressive roles within families and communities, which may foster greater engagement in reflective processes such as deliberate rumination and the active seeking of social support. These culturally reinforced behaviors can facilitate psychological adaptation and may contribute to higher levels of PTG. Future studies should thoroughly investigate sex differences in the PTG process to inform the development of psychosocial interventions that are sensitive to sex-specific experiences and coping styles rather than assuming uniform needs across all male or female patients. While our study showed a significant difference in PTG according to age group, post-hoc analysis did not reveal statistically significant differences between specific age groups. Interestingly, participants aged 60 and older demonstrated the highest PTG scores. This may be attributed to greater life experience, which may enhance emotional resilience and meaning-making capacity. Older adults may also approach illness-related challenges in qualitatively different ways, shaped by their social roles, life context, and prior adversity experiences. Additionally, older survivors may have a deeper appreciation of life’s finiteness, which likely reinforces their motivation to find new meaning in life after transplantation [ 39 ]. These findings highlight the importance of developing and implementing tailored intervention programs that foster psychological adaptation and strengthen life meaning, particularly among older HSCT recipients. Notably, we found that patients without formal religious affiliation reported higher PTG compared to those with a religious background. This finding contrasts with previous studies suggesting that religious belief and activity can facilitate PTG by providing frameworks for meaning-making and coping [ 22 , 40 ]. However, it is important to distinguish religious affiliation from spirituality. Some individuals may derive existential meaning through personal reflection, nature, relationships, or philosophical beliefs independent of organized religion. In this context, the higher PTG observed among non-religious patients in our study may reflect individualized meaning-making processes—such as deliberate rumination or self-exploration—rather than reliance on traditional religious frameworks. These findings underscore the need to tailor psychosocial support to accommodate both religious and non-religious pathways to growth. Future research should further examine the relationship between PTG and personal meaning-making, including the specific role of religious beliefs among HSCT survivors. Additionally, in contrast to prior research, our study found higher PTG among unmarried patients compared to those who were married. Previous studies have reported that HSCT recipients may experience guilt over the psychological and financial burden placed on their families during treatment [ 41 , 42 ], potentially hindering PTG in married individuals. In contrast, unmarried patients may have greater opportunities for self-reflection, personal transformation, and access to diverse social support networks. These findings suggest that married and unmarried patients may have differing psychological needs, underscoring the importance of tailoring psychosocial support strategies accordingly.
Regarding the PTG of HSCT survivors based on disease characteristics, significant differences were observed depending on HSCT type and the administration of TBI. Patients who received autologous HSCT reported higher PTG levels than those who underwent allogeneic HSCT, and those who did not receive TBI exhibited higher PTG than those who did. These differences may be attributed to the varying intensity of conditioning regimens associated with each treatment type. HSCT pretreatment typically involves high-dose chemotherapy and/or TBI to eradicate malignant cells and reset the hematopoietic system. Allogeneic HSCT, in particular, often requires more intensive conditioning, which may result in more severe physical and psychological adverse effects compared to autologous HSCT [ 43 ]. Similarly, patients who underwent TBI may have experienced greater physical and emotional strain, potentially hindering their ability to achieve PTG. These findings highlight the importance of targeted psychosocial interventions, especially for allogeneic HSCT recipients and those who have received TBI. Developing supportive programs that help patients reconstruct meaning and promote psychological growth after treatment is essential.
We found significant positive correlations between PTG and social support, rumination, and distress, whereas QoL was not significantly correlated with PTG. Notably, a higher level of distress was associated with increased PTG, suggesting that PTG may arise not only from positive experiences but also from internal growth and cognitive changes that occur in response to traumatic stress [ 44 ]. Previous studies have similarly reported that psychological stress can facilitate PTG by prompting individuals to develop adaptive strategies for survival in extreme situations [ 45 ]. HSCT recipients often endure substantial physical and emotional distress during treatment, which may prompt a reassessment of life’s meaning and values, ultimately contributing to psychological recovery and growth. However, excessive distress may instead result in negative psychological outcomes. Therefore, it is important to closely monitor patients’ distress levels and implement interventions to alleviate psychological burden. In contrast, QoL was not significantly associated with PTG in our study, suggesting that PTG reflects a distinct aspect of psychological and emotional adaptation that may not be directly linked to QoL. While QoL generally encompasses physical health, emotional well-being, functional capacity, and social relationships [ 46 ], PTG refers more specifically to psychological changes following trauma, such as the re-evaluation of life priorities, personal strength, and new meaning in life [ 9 ]. Thus, high QoL does not necessarily indicate the presence of PTG, and experiencing PTG may not always result in immediate improvements in QoL. These findings suggest that PTG and QoL may involve independent psychological processes. Moreover, because our study targeted HSCT survivors within the first year post-transplantation, the relationship between PTG and QoL may not have been fully established. Future research should explore the long-term effects of PTG on QoL and investigate how their relationship may evolve over time. Specifically, longitudinal studies involving long-term survivors are needed to assess the dynamic changes in PTG and QoL across the survivorship trajectory.
In this study, marital status, perceived positive change in thinking after transplantation, rumination, HSCT type, and social support were identified as significant predictors of PTG in HSCT survivors, collectively explaining 53.0% of the variance in PTG. Marital status emerged as an important factor, aligning with previous evidence that social support plays a critical role in promoting PTG. A meta-analysis reported that social support is a key predictor of PTG [ 47 ]. Emotional and practical support from a spouse or family members may facilitate psychological adjustment and growth, especially in South Korea’s family-oriented cultural context. Thus, interventions for patients with spouses should actively involve their partners, while patients without spouses may benefit from support systems involving other family members or close acquaintances. Additionally, perceived positive cognitive changes after transplantation and levels of rumination significantly influenced PTG. This supports previous findings that the shift from intrusive to deliberate rumination plays a central role in PTG [ 48 ]. Although intrusive rumination may initially cause psychological distress, it can serve as a catalyst for cognitive restructuring and meaning-making, leading to deliberate rumination and eventual growth. Therefore, interventions should aim not simply to suppress intrusive thoughts, but to guide patients in transforming them into purposeful, reflective rumination. Psychological education, rumination control training, and positive meaning-making programs may facilitate this process and promote psychological recovery and QoL in HSCT survivors.
A key strength of this study is the empirical investigation of the psychological adaptation process and PTG factors in patients after HSCT, emphasizing the need for multidimensional support strategies. However, this study has some limitations that should be considered when interpreting the findings. First, the cross-sectional design of this study limits the ability to draw causal inference regarding relationships among PTG, social support, rumination, and other psychological variables. Longitudinal research is necessary to elucidate the temporal dynamics and causal pathways of PTG following HSCT. Second, participants were recruited from a single tertiary hospital in one metropolitan region of South Korea using convenience sampling, which may limit the generalizability of the findings to other geographic regions or healthcare settings. Third, all psychological variables were measured via self-report, which may introduce social desirability bias or response bias. Additionally, although both autologous and allogeneic transplant recipients were included, the subgroup sample sizes were insufficient for robust comparative analyses. Future studies should employ multicenter, longitudinal designs with more diverse and representative samples and incorporate both qualitative and quantitative methods to better understand the mechanisms underlying PTG and its potential moderators. Future studies should consider individual variability in spiritual beliefs, social resources, and psychological coping processes.
Conclusions
This study examined factors influencing PTG in HSCT recipients and explored practical support strategies based on the findings. Marital status, positive changes in thinking after transplantation, rumination, HSCT type, and social support were identified as significant factors influencing PTG, with these factors explaining 53.0% of PTG variance. These findings highlight the importance of early identification of psychosocial risk and resilience factors during the acute post-transplant phase. From a clinical nursing perspective, the results underscore the need for tailored nursing interventions that address emotional processing, strengthen social support systems, and facilitate meaning-making in patients undergoing HSCT. Nurses play a critical role in assessing psychological adaptation, guiding patients through reflective rumination, and fostering supportive relationships throughout the recovery trajectory. Additionally, interdisciplinary collaboration that incorporates psychosocial care, rehabilitation, and social support services is essential for developing sustainable strategies that enhance long-term adjustment and improve patients’ overall QoL. Future longitudinal studies are needed to further validate these findings and inform evidence-based nursing practices for this population.
Acknowledgements
Not applicable.
Abbreviations
Hematopoietic Stem Cell Transplantation
Posttraumatic Growth
Quality of Life
Total Body Irradiation
Analysis of Variance
Functional Assessment of Cancer Therapy - Bone Marrow Transplantation
Impact of Event Scale-Revised - Korean version
Korean-Event Related Rumination Inventory
Multidimensional Scale of Perceived Social Support
Posttraumatic Growth Inventory
Variance Inflation Factors
Authors’ contributions
KB and EJ contributed to the conception and design of this study. EJ collected the data and performed the statistical analysis and interpretation. KB drafted and critically revised the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Our study was approved by St. Mary’s Hospital, The Catholic University of Korea Human Research Ethics Committee(approval no. KC16QISI0447). All participants gave written informed consent to participate. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
Data Availability Statement
No datasets were generated or analysed during the current study.