**4.2 A new understanding of older men's construction of prostate cancer literacy**

Through a discourse analysis technique called "abduction in communication" (Boudon, 1998, 1999, 2000), reasons why men with disparate levels of education (from three years of home schooling to doctorate) used similar information strategies were identified. Three analytical assumptions guided the analysis that revealed the similarity of these cognitive processes: (a) men's attempts to connect general health information with prostate cancer information would disclose the *modus operandi* of becoming prostate cancer literate, (b) men's key motivations for learning would determine the strategies they used to construct information strategies, and (c) external factors initially considered negative, noncollaborative, and obstructive would motivate men to construct more information strategies. The results of the analysis are (presented in the rest of Section 4.2 and in Figure 3 to 6) portray how older men's use of prostate cancer information and their discourse about prostate cancer was framed by ideas of space, distance, and possibility. Men's use of information responded to their need to deal with notions of truth, lies, and the possibility of errors; plausible and non-plausible uses of information; possible and impossible decisions; fact and illusion, and so on. In addition, men dealt with how long they might live; whether they would remain in their own homes as they grew older or move to retirement homes or seniors' apartments; and where they might ultimately die.

#### **4.2.1 Core information strategies men use to become prostate-cancer literate**

Despite differences in men's self-reported levels of schooling and self-rated health literacy, with survival as an ultimate goal for learning, men looked for new informational support among peers, other individuals, relatives, media, and health professionals. Men mainly used hypothetical reasoning to decode the prostate cancer information they acquired from health professionals and informal sources (newspapers, television, internet, books, pamphlets, etc.). Men's struggles to become prostate cancer literate included reflecting on life and death as well as using the cognitive processes of hypothesizing, deducting, and comparing. To do that, they combined prostate cancer information they gathered from medical journals and their physicians with information from their own illness experiences. Figure 3 presents the general analytical categories and shows how the interpretative poles oscillate between the positive and negative impacts of decoded information related to the dimensions of health, diagnosis of prostate cancer and illness, men's socio-cultural identity, the external world, and the imprints of life and prostate cancer-related information. One of the key strategies men used to decode information was to compare information from different sources about the accuracy of medical prognoses, changes in lifestyle due to cancer, recovery expectations, and expected difficulties in end-of-life situations. As men felt more certain about the predictability of medical prognoses, some men's attitudes changed. Although some remained socially isolated, others enrolled in prostate cancer support groups, became more committed to their own health, or to men's collective health. Certainty also brought to older men a greater will to live and a peaceful acceptance of possible death from prostate cancer.

Renewing Perspectives on Men's Prostate Cancer

Literacy and Engagement Along the Disease Continuum 53

Fig. 4. Strategies for dealing with prostate cancer-related information

**4.2.3 Strategies men use to make sense of prostate cancer information** 

information support that they received from significant others were important.

Men's constant hypothesizing seemed to be an attempt to understand and compare information from multiple sources, information that created doubts in their minds. With these doubts, men constantly struggled to reduce abstraction and uncertainty in the information they gathered. The difficulty with abstraction related most often to descriptions of cellular processes and cell-level responses to treatment, as expressed by levels of PSA, prostate cancer recurrence, and metastasis. Without being able to understand this complex information, men could not evaluate its pertinence and quality.

Men's use of hypothesizing and of deductive and inductive reasoning varied in intensity and frequency, depending on older men's self-rated level of health literacy and the uncertainty they faced about their medical conditions. Men's use of these analytical techniques was congruent with their tendency to assess information logically by seeking to understand events and facts and by decoding large amounts of (sometimes contradictory) prostate cancer information. The intensity and frequency of men's hypothesizing, deduction, and induction seemed to be associated with the importance they attributed to the process of decision making, regardless of its domain. The cognitive processes of hypothesizing and deducting also influenced men's acceptance or refusal of prostate cancer information, because men selected information based on their values. Selecting, valuing, and incorporating prostate cancer information, and other information indirectly related to prostate cancer, can be explained by men's increasing interest in information seeking. Men's main focus was learning what to do to ensure their survival and how to do it. This focus led men to value what could help them understand clinical facts. Men sought to find, in each piece of prostate cancer information, anything that could contribute to a pragmatic plan for surviving cancer. Men valued information that was personally relevant to them and could contribute to decision-making. In this information-selection process, men's participation in information networks and the

In the figures 3 to 6, the arrow going from bottom left to top right of each figure means the paradigm of understanding from a negative to a positive pole.

#### **4.2.2 Strategies for dealing with prostate cancer-related information within the paradigm of health literacy**

Older men also used their new prostate-cancer health literacy to create multiple possibilities for living with prostate cancer. They used their accumulated knowledge to transform previous representations about life after prostate cancer and the disease itself. From their contacts with other individuals in their social networks, men learned how to survive better and longer with prostate cancer. Particularly relevant in this transformation were information exchanges with other prostate cancer survivors, sharing information with undiagnosed men, and new information provided by significant others.

Analysis of men's accounts of exchanges of information also revealed controversies about whether information gathered through the process mentioned above actually contributed to men's prostate cancer literacy. First, older men seemed to be more interested in communicating information and personal experiences with prostate cancer than in the process of learning itself. Second, partial, imprecise, or superficial information about prostate cancer could either stagnate or propel older men's learning about prostate cancer. Third, the hypotheses (deductive and inductive) those men generated after contact with prostate cancer information impelled them to either confirm or refute the hypotheses. In doing so, older men built the core of their interpretative logic and thereby created meaning out of their experiences with prostate cancer. The information strategies thus fueled men's determination to transform all future contact they had with prostate cancer information. Figure 4 presents how men compared their situations with those of other individuals living with cancer and, whether they had low or high levels of health literacy, formed hypotheses, made comparisons, and decisions.

Fig. 3. General analytical categories related to core information strategies

In the figures 3 to 6, the arrow going from bottom left to top right of each figure means the

paradigm of understanding from a negative to a positive pole.

Fig. 3. General analytical categories related to core information strategies

undiagnosed men, and new information provided by significant others.

**paradigm of health literacy** 

made comparisons, and decisions.

**4.2.2 Strategies for dealing with prostate cancer-related information within the** 

Older men also used their new prostate-cancer health literacy to create multiple possibilities for living with prostate cancer. They used their accumulated knowledge to transform previous representations about life after prostate cancer and the disease itself. From their contacts with other individuals in their social networks, men learned how to survive better and longer with prostate cancer. Particularly relevant in this transformation were information exchanges with other prostate cancer survivors, sharing information with

Analysis of men's accounts of exchanges of information also revealed controversies about whether information gathered through the process mentioned above actually contributed to men's prostate cancer literacy. First, older men seemed to be more interested in communicating information and personal experiences with prostate cancer than in the process of learning itself. Second, partial, imprecise, or superficial information about prostate cancer could either stagnate or propel older men's learning about prostate cancer. Third, the hypotheses (deductive and inductive) those men generated after contact with prostate cancer information impelled them to either confirm or refute the hypotheses. In doing so, older men built the core of their interpretative logic and thereby created meaning out of their experiences with prostate cancer. The information strategies thus fueled men's determination to transform all future contact they had with prostate cancer information. Figure 4 presents how men compared their situations with those of other individuals living with cancer and, whether they had low or high levels of health literacy, formed hypotheses,

Fig. 4. Strategies for dealing with prostate cancer-related information
