Social support as a moderator of healthcare adherence and distress in long-term hematopoietic cell transplantation survivors

A Correction to this article was published on 07 April 2021

This article has been updated



Treatment with hematopoietic cell transplantation (HCT) has potentially severe effects on physical and psychosocial functioning. Poor social support has been linked with physical morbidity and mortality as well as psychological distress in HCT survivors. This study tested a theory-driven hypothesis that social support buffers adverse effects of health stressors of comorbidities and graft-versus-host disease (cGVHD) on distress and adherence to recommended healthcare among long-term HCT survivors.


This cross-sectional study analyzed baseline data from a randomized controlled trial in adult survivors 3–18 years post-HCT. Data included medical records and patient-reported outcomes including cancer and treatment distress (CTXD), healthcare adherence (HCA), comorbidity index, cGVHD, ENRICHD Social Support Instrument (ESSI), Social Activity Log, and Health Self-Efficacy. We tested hypothesized models for HCA and CTXD using blocked hierarchical linear regressions.


Among the 781 HCT survivors completing baseline assessment, 38% had > 3 comorbidities, 8% had moderate–severe cGVHD, 30% reported low social support, 30% reported elevated distress, and 49% reported low healthcare adherence. Social support and self-efficacy were directly related to both adherence and distress. Regression models supported the hypothesized moderated relationships for distress but not for healthcare adherence.


The two tested models confirm that the health stressors of comorbidities and cGVHD are moderated by better social support and self-efficacy in their associations with lower distress but without moderating effects for healthcare adherence.

Implications for Cancer Survivors

Social support and self-efficacy confer protective benefits on healthcare adherence and psychological distress. Interventions are needed that focus on maintaining social networks or finding new networks if necessary.

Clinical trial registration number


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The authors thank all of the HCT survivors who participated in this study.

Author contributions—CRediT taxonomy

Kristina Holmegaard Nørskov: Visualization, methodology, formal analysis, writing original draft, and review and editing.

Jean Yi: Project administration, software, data curation, visualization, formal analysis, validation, writing—review and editing.

Marie-Laure Crouch: Data curation, visualization, writing—review and editing.

Allison Stover Fiscalini: Investigation, data curation, writing—review and editing.

Mary E.D. Flowers: Investigation, writing—review and editing.

Karen Syrjala: Funding acquisition, conceptualization, methodology, investigation, data curation, formal analysis, resources, software, supervision, validation, visualization, conceptualization, methodology, formal analysis, writing—original draft and review and editing.


Supported by grants from the National Cancer Institute/National Institutes of Health R01 CA112631 and R01 CA215134 to Dr. Syrjala.

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Correspondence to Kristina Holmegaard Nørskov.

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All procedures were approved by the Institutional Review Board of the Fred Hutchinson Cancer Research Center (Fred Hutch).

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Informed consent was obtained from all individual participants included in the study.

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The participants provided informed consent regarding publishing their data in this article.

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Nørskov, K.H., Yi, J.C., Crouch, ML. et al. Social support as a moderator of healthcare adherence and distress in long-term hematopoietic cell transplantation survivors. J Cancer Surviv (2021).

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  • Hematopoietic stem cell transplantation
  • Social support
  • Adherence
  • Distress
  • Cancer survivor
  • Self-efficacy