Storylines of family medicine II: foundational building blocks-context, community and health.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Long-term fear of recurrence in young breast cancer survivors and partners.

BACKGROUND: Fear of a breast cancer recurrence is the most prevalent and disruptive source of distress for long-term survivors and their partners. However, few studies have focused on predictors of fear of recurrence. The aim of this study is to test the efficacy of the Social Cognitive Processing Theory (SCPT) in predicting fear of recurrence in long-term breast cancer survivors diagnosed at age 45 years or younger and their partners. METHODS: In a large cross-sectional study, breast cancer survivors (n = 222) 3-8 years from diagnosis and their partners completed a survey assessing demographic characteristics, fear of recurrence, social constraints, and cognitive processing (intrusive thoughts and cognitive avoidance). Mediation analyses were conducted for survivors and partners separately to determine if cognitive processing would mediate the relationship between social constraints and fear of recurrence. RESULTS: Cognitive processing mediated the relationship between social constraints and fear of recurrence both for survivors [F(3,213) = 47.541, R2 = 0.401, p < 0.001] and partners [F(3,215) = 27.917, R2 = 0.280, p < 0.001). Demographic variables were not significant predictors of fear of recurrence. CONCLUSIONS: As predicted, cognitive processing mediated the relationship between social constraints and fear of recurrence. Results expand the utility of the SCPT in long-term survivors and their partners by supporting its use in intervention design. Copyright © 2015 John Wiley & Sons, Ltd.

Relationship Between Depressive Symptoms and Social Cognitive Processing in Partners of Long-Term Breast Cancer Survivors.

PURPOSE/OBJECTIVES: To determine (a) if depressive symptoms in partners of long-term breast cancer survivors (BCSs) could be predicted by social cognitive processing theory and (b) if partners of younger and older BCSs were differentially affected by the cancer experience.
. DESIGN: A cross-sectional, descriptive study using self-report questionnaires.
. SETTING: Indiana University in Bloomington and 97 ECOG-ACRIN Cancer Research Group sites in the United States.
. SAMPLE: 508 partners of BCSs diagnosed three to eight years prior to the study. 
. METHODS: Secondary data mediation analyses were conducted to determine if cognitive processing mediated the relationship between social constraints and depressive symptoms. Age-related differences on all scales were tested.
. MAIN RESEARCH VARIABLES: Depressive symptoms; secondary variables included social constraints, cognitive processing (avoidance and intrusive thoughts), and potentially confounding variables.
. FINDINGS: Cognitive processing mediated the relationship between social constraints and depressive symptoms for partners. Partners of younger BCSs reported worse outcomes on all measures than partners of older BCSs.
. CONCLUSIONS: As predicted by the social cognitive processing theory, cognitive processing mediated the relationship between social constraints and depressive symptoms. In addition, partners of younger BCSs fared worse on social constraints, intrusive thoughts, and depressive symptoms than partners of older BCSs. 
. IMPLICATIONS FOR NURSING: Results provide support for using the social cognitive processing theory in an intervention design with partners of long-term BCSs to decrease depressive symptoms.

Factors associated with depressive symptoms in young long-term breast cancer survivors.

PURPOSE: Long-term breast cancer survivors frequently report distress (i.e., depressive symptoms) that impacts their quality of life. Previous studies have found that negative social interactions ("social constraints") from partners contribute to long-term, unresolved cycling of intrusive thoughts and cognitive avoidance, resulting in psychological distress. However, these relationships have not been tested in long-term breast cancer survivors. Furthermore, the effect of partners' depressive symptoms on the survivors' depressive symptoms has not been tested within the context of these relationships. Therefore, the purpose of this study was to test relationships between breast cancer survivors' depressive symptoms and (1) social constraints, cognitive avoidance, and intrusive thoughts, and (2) partners' depressive symptoms. METHODS: Data were from a cross-sectional descriptive study of breast cancer survivors (N = 222) 3-8 years post-diagnosis and their partners, who completed surveys assessing demographic characteristics, social constraints, intrusive thoughts, cognitive avoidance, and depressive symptoms. Structural equation modeling confirmatory path analyses were conducted to determine significant relationships between survivors' depressive symptoms and all other variables. RESULTS: Our model fits the data well. Breast cancer survivors' depressive symptoms were predicted by social constraints and intrusive thoughts. The relationship between survivors' depressive symptoms and partners' depressive symptoms was close but not significant. CONCLUSIONS: As hypothesized, depressive symptoms were predicted by social constraints and intrusive thoughts. Further research is needed to understand the possible relationship between survivors' long-term depressive symptoms and cognitive avoidance and partners' depressive symptoms. Our findings highlight the negative impact of social constraints from partners on psychological outcomes in long-term breast cancer survivors.

The cost effectiveness of 5 interventions to increase mammography adherence in a managed care population.

OBJECTIVE: To determine the cost effectiveness of 5 combinations of strategies for increasing adherence to mammography recommendations in a population of women between the ages of 50 and 85 years enrolled in a large midwestern health maintenance organization. STUDY DESIGN: A randomized control trial comparing interventions believed to increase mammography adherence. PATIENTS AND METHODS: Intervention strategies included 5 combinations of physician recommendation, telephone, and in-person counseling. A total of 652 participants were randomly assigned to 1 of 6 intervention groups and 628 (95.9%) were available at 6-month follow-up. A logistic regression model with adherence as the dependent variable and group as the independent variable was used to test for significant differences between groups. A ratio of cost to improvement in mammogram adherence evaluated the cost effectiveness at 6 months. RESULTS: All 5 interventions resulted in significantly higher rates of adherence compared to no intervention. However, when considering costs, only 1 emerged as the superior strategy for the overall study population. In-person counseling was the most cost-effective strategy overall, followed closely by in-person counseling and physician's letter intervention. For women contemplating mammography, the telephone contact and physician's letter combination was the most cost-effective intervention. For women not contemplating mammography, the physician's letter was superior. The physician's letter worked best with women who had previous mammograms. For women with no mammogram history, the in-person counseling and physician's letter combination was clearly superior. CONCLUSIONS: The cost effectiveness of mammography screening interventions varies based on women's prior history of mammograms and their future intent. Further, managed care organization member characteristics can be used to determine the most cost-effective mammography screening intervention based on individual readiness.