"Now I get what's important" - Shifting philosophies of hospice society staff and trained volunteers involved in peer-facilitated Advance Care Planning workshops for the public.

OBJECTIVE: Community-led approaches can increase public engagement in Advance Care Planning (ACP). Better understanding of the experiences and perspectives of community staff and volunteers who host and facilitate community-led, peer-facilitated ACP workshops is valuable when considering the spread of these approaches. METHODS: Content analysis of qualitative data from community-based hospice societies delivering ACP workshops to the public in British Columbia: one-on-one interviews with 5 organizational representatives and focus groups with 13 peer facilitators. RESULTS: Three main categories emerged: 1) ACP is about 'Living well'; 2) Transitioning focus from legal forms to conversations; 3) Benefits to all involved. CONCLUSIONS: Community staff and volunteers acknowledge the role they could play in promoting ACP in their communities. They recognize the benefits to the facilitators and public participants from following a community-led approach that emphasizes the importance of ACP conversations over the completion of relevant legal forms. Additional potential benefits of this approach, as reported by the organizational representatives, are increased volunteer engagement, more community partnerships, and an enhanced organizational profile. PRACTICE IMPLICATIONS: This community-led model can be a meaningful and approachable way to engage the public in ACP. Hospice societies are well positioned in the community to incorporate ACP workshops into their programming.

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings.

PURPOSE: Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS: We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS: In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS: Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

Holistic Experiences and Strategies for Conducting Research With Couples.

In this article, we outline methodological considerations for conducting research interviews with couples. We draw from two qualitative men's health studies, both developed to explore social interactions between men and their partners of either sex in relation to their health practices. We utilized a combination of separate interviews and joint couple interviews. From these studies, we offer insight into our experiences of using both types of interview styles, addressing four key areas which span elements across the research project journey: (a) choosing a mode of interview, (b) ethical concerns in couple research,

Gender relations and couple negotiations of British men's food practice changes after prostate cancer.

Nutrition plays an important role in the health of men diagnosed with prostate cancer and dietary interventions can therefore be a significant part of prostate cancer survivorship supportive care. Family food provision, however, involves complex social interactions, which shape how men engage with their diets and dietary interventions. The role that gender plays in shaping prostate cancer couples' food practices and men's diets after a prostate cancer diagnosis is thought to be important but is little understood. This study explored couples' accounts of nutrition information seeking and diet change to gain a better understanding of how gender relations shaped men's food practices after prostate cancer diagnosis. Qualitative health interviews with men and their partners were conducted and analysed using interpretive descriptive methods. Findings demonstrated how couples navigated food change journeys that involved seeking information, deciding what changes were warranted and implementing and regulating diet changes. Two overarching themes that illustrated couples' food negotiations were called 'Seeking information and deciding on food changes' and 'Monitoring food changes'. Additional sub-themes described who led food changes, women's filtering of information, and moderation or 'treats'. Throughout these food change journeys, interactions between men and women were at play, demonstrating how gender relations and dynamics acted to shape couples' food negotiations and men's food practices. Findings reveal that attention to gender relations and the men's family food dynamics should inform diet interventions for men with prostate cancer in order to improve uptake.

Heterosexual couples and prostate cancer support groups: a gender relations analysis.

INTRODUCTION: Men diagnosed with prostate cancer (PCa) can receive supportive care from an array of sources including female partners and prostate cancer support groups (PCSGs). However, little is known about how heterosexual gender relations and supportive care play out among couples who attend PCSGs. Distilling such gender relation patterns is a key to understanding and advancing supportive care for men who experience PCa and their families. PURPOSE: This study describes connections between heterosexual gender relations and PCa supportive care among couples who attend PCSGs. METHOD: In-depth, individual interviews with 30 participants (15 men treated for PCa and their female partners) were analyzed using interpretive descriptive methods. Couples were asked about their relationships, supportive care needs, and attendance at PCSGs. A heterosexual gender relations framework was used to theorize the findings. RESULTS: Findings showed that traditional heterosexual gender relations guided most couples' PCa-related support both in and out of PCSGs. Three themes were inductively derived: "Not pushing too hard"-balancing women's support with men's autonomy, "Confreres"-men supporting men at PCSGs, and "Women are better at reassuring"-support from and for women. CONCLUSIONS: Couples both aligned to and resisted traditional gender roles to accommodate, explain, and rationalize how, as a couple, they approached PCa supportive care needs.

Masculinities and patient perspectives of communication about active surveillance for prostate cancer.

OBJECTIVE: The purpose of this study is to describe connections between masculinities and patient perspectives of active surveillance (AS) related communication with male physicians. METHOD: An interpretive descriptive qualitative design was used to explore patient-physician communication from the perspectives of 25 men on AS. In-depth, semistructured interviews were recorded, transcribed verbatim, and coded. Key concepts were described and a masculinities gender framework guided analyses of patients' perspectives. RESULTS: Patient-physician communication of diagnosis, treatment options, and specificities of AS featured prominently within participants' interviews. Most participants reported brevity in patient-physician communication amid accepting the physician's communication style and recommendations. Participants' accounts suggested "therapeutic" communications as contingent on positioning physicians as authoritative and assigning them control, while patients were stoic in accepting AS. However, some participants reported being confused about their diagnosis details and specific AS protocols, and resisted traditional physician-patient hierarchies, desiring more collaborative decision-making processes. In this regard communications emerged as "threat," in that participants lacked and/or lost confidence in their physician and were uncertain and anxious about the legitimacy of AS. These findings were interpreted within a gender framework, showing how patients drew on an array of masculine ideals, including stoicism, denying illness, and respecting expertise in different ways. CONCLUSIONS: Our novel findings illuminate complexities of men's perspectives about patient-physician communication in AS, and offer insights about how masculinities influence what can be understood as potentially helpful and unhelpful communication among this emergent patient population.

Gender relations, prostate cancer and diet: re-inscribing hetero-normative food practices.

Although diet might be a valuable adjunct to prostate cancer care, men typically have poorer diets than women and are less likely to change the way they eat after a cancer diagnosis. Gender theory suggests that dominant ideals of masculinity shape men's health and food practices; however, the role of female partners in men's diets is poorly understood. Through qualitative analysis of in-depth interviews, this article explores accounts of 14 Canadian couples' food practices guided by a gender relations framework to expose how tacit performances of masculinity and femininity interact to shape the diets of men with prostate cancer. Findings show that many men became more interested and involved in their diets after a prostate cancer diagnosis, practices that might be theorized as a counter hegemonic project or 'feminization', adding to other prostate cancer induced emasculations (i.e., treatment induced incontinence and impotence). At the same time, however, couples mutually limited men's engagement with diet while concurrently reinforcing women's traditional femininities in nurturing the men in their lives through food provision. Also embedded here were women's attempts to mitigate subordinate productions of masculinity by catering to their partner's tastes as well as monitoring their diets. Most couples mutually maintained traditional gender food 'roles' by positioning women as proficient leaders in domestic food provision and men as unskilled 'try-hard' and sometimes uninterested assistants. Findings also revealed complex gender power dynamics that predominated as complicit in sustaining hegemonic masculinity through women's deference to men's preferences and careful negotiation of instrumental support for men's diet changes. Overall men and women jointly worked to re-inscribe hetero-normative family food practices that shaped men's diets and nutritional health.

Men, food, and prostate cancer: gender influences on men's diets.

Although healthy eating might enhance long-term survival, few men with prostate cancer make diet changes to advance their well-being. Men's typically poor diets and uninterest in self-health may impede nutrition interventions and diet change. Food choice behavior is complex involving many determinants, including gender, which can shape men's health practices, diets, and prostate cancer experiences. Developing men-centered prostate cancer nutrition interventions to engage men (and where appropriate their partners) in promoting healthy diets can afford health benefits. This article presents an overview and synthesis of current knowledge about men's food practices and provides an analysis of diet and diet change behaviors for men with prostate cancer. Masculinity and gender relations theory are discussed in the context of men's food practices, and suggestions for future applications to nutrition and prostate cancer research and diet interventions are made.

Prostate cancer, masculinity and food. Rationales for perceived diet change.

Research indicating that certain diets can lower prostate-specific antigen levels suggests that diet change might be a beneficial treatment adjunct for low-grade prostate cancer. However, few men with prostate cancer adopt significant diet change, indicating a need to better understand how and why they make food choices. This qualitative study explored men's perceptions of their diets following a prostate cancer diagnosis, and the rationales underpinning diet changes (or lack thereof). Individual semi-structured interviews were conducted with 14 men ages 48-78 years who had been diagnosed with prostate cancer within the previous 5 years. Findings show that participants exhibited varied dietary patterns, which we labeled 'eating as usual', 'intensifying efforts', 'adding-on', and 'overhauling diets'. Four main domains informed rationales for diet changes or lack thereof: perception of pre-prostate cancer diet, diet and health understandings, orientation towards prostate cancer, and the need for "doing something." Dietary ideals framed as masculine, important, action-oriented and autonomous endeavors contributed to participants' food choice behaviors, suggesting that their alignment to masculine dietary ideals influenced if and how they engaged in diet change. A better understanding of how masculine food ideals shape food choice might be useful in expanding food choice models and in developing effective nutrition education interventions for this group.

The self-management of uncertainty among men undertaking active surveillance for low-risk prostate cancer.

Asymptomatic men with low-risk, early-stage prostate cancer are eligible for active surveillance (AS), which offers a means to monitor the cancer while delaying treatment. However, AS operates within a unique set of circumstances that advocate monitoring, rather than immediate treatment, and men's health practices are central to coping with the inherent uncertainty of living with an untreated cancer. A qualitative study was completed to describe the range of men's self-management strategies used to overcome AS-related uncertainty. The study findings reveal two strategies. First, positioning prostate cancer as benign through stoicism and solitary discourses were common to men intent on "living a normal life." Second, men committed to "doing something extra" complemented AS protocols, and often collaborated with their wives to focus on diet as an adjunct therapy. Although most participants exhibited typical men's health practices, it is clear that tailored AS psychosocial interventions will benefit men and their families.

Factors influencing men undertaking active surveillance for the management of low-risk prostate cancer.

PURPOSE/OBJECTIVES: To identify and describe decision-making influences on men who decide to manage their low-risk prostate cancer with active surveillance. RESEARCH APPROACH: Qualitative, semistructured interview. SETTING: The Prostate Centre at Vancouver General Hospital in Canada. PARTICIPANTS: 25 patients diagnosed with low-risk prostate cancer and on active surveillance. METHODOLOGIC APPROACH: An interpretative, descriptive, qualitative design. MAIN RESEARCH VARIABLES: Factors that influenced men's decisions to take up active surveillance. FINDINGS: The specialists' description of the prostate cancer was the most influential factor on men choosing active surveillance. Patients did not consider their prostate cancer to be life threatening and, in general, were relieved that no treatment was required. Avoiding treatment-related suffering and physical dysfunction and side effects such as impotence and incontinence was cited as the major reason to delay treatment. Few men actively sought treatment or health-promotion information following their treatment decision. Female partners played a supportive role in the decision. The need for active treatment if the cancer progressed was acknowledged. Patients were hopeful that new treatments would be available when and if they needed them. Being older and having comorbidities did not preclude the desire for future active treatment. Patients carried on with their lives as usual and did not report having any major distress related to being on active surveillance. CONCLUSIONS: The study findings indicate that men are strongly influenced by the treating specialist in taking up active surveillance and planning future active treatments. As such, most men relied on their specialists' recommendation and did not perceive the need for any adjunct therapy or support until the cancer required active treatment. INTERPRETATION: Oncology nurses should work collaborative-ly with specialists to ensure that men receive the information they need to make informed treatment decisions.

Women and prostate cancer support groups: the gender connect?

There are more than 100 prostate cancer support groups (PCSGs) in Canada, most of which meet on a monthly basis-yet little attention has been paid to the role of women at these groups. As part of an ongoing ethnographic study of PCSGs, we examined women's motivations for attending the groups, their ways of functioning in PCSGs and the benefits they accrued. Participant observations conducted at 13 British Columbian-based PCSGs and individual interview data from 20 women who regularly attended PCSG meetings were analyzed. Although the groups did not overtly limit women's attendance, the women's decisions to attend and their participation at group meetings were subject to much self-reflection, uncertainty and tension. Motivations to access a PCSG included a desire to support their partners, develop understandings about the illness and disease, and to manage their own experience of prostate cancer. Our analyses revealed that women assume three roles in PCSGs: social facilitator, background supporter and cancer co-survivor. The women reported many interrelated benefits as a result of attending, including information, hope and reassurance, and connecting with other women in similar circumstances. The results from this study reveal how traditional feminine ideals, such as nurturing and caring for the men in their lives, facilitating social connections and the desire to share emotional experiences guided the behaviors. Based on the study findings, we suggest that efforts to support women's involvement in PCSGs are critical to enhancing the effectiveness of the groups for both men and women.

How prostate cancer support groups do and do not survive: British Columbian perspectives.

Many prostate cancer support groups (PCSGs) have formed in North America during the past decade, yet their operation or factors influencing sustainability are poorly understood. This article reports micro (intragroup), meso (intergroup), and macro (group/structure) analyses drawn from the fieldwork and participant observations conducted for an ethnographic study of PCSGs based in British Columbia, Canada. The findings indicate that effective group leadership is integral to group sustainability and the recruitment and retention of attendees. At the meso level, intergroup connections and communication were often informal; however, the primary purpose of all the PCSGs was to provide information and support to men and their families. Many PCSGs were uncertain how formal associations with cancer fund-raising societies would influence group effectiveness. Macro issues such as prostate cancer activism resided with individual group "champions" through activities coordinated by provincial and national PCSG organizations. However, activism did not guarantee group sustainability. The study findings reveal why some groups flourish while others appear untenable, and form the basis for discussion about how PCSG sustainability might be best achieved.

Men's constructions of smoking in the context of women's tobacco reduction during pregnancy and postpartum.

Men's smoking is largely under-examined despite research that has consistently linked partner smoking to pregnant women's smoking and smoking relapse in the postpartum. An on-going qualitative study involving 31 couples in Canada exploring the influence of couple interactions on women's tobacco reduction provided the opportunity to examine men's smoking in the context of women's tobacco reduction or cessation during pregnancy and postpartum. Individual open-ended interviews with 20 men who smoked were conducted at 0-6 weeks following the birth of their infants and again at 16-24 weeks postpartum. Constant comparative methods were used along with social constructivist perspectives of fatherhood and gender to guide data analysis and enhance theoretical sensitivity. Four themes emerged in men's accounts of their tobacco use: (1) expressing masculinity through smoking, (2) reconciling smoking as a family man, (3) losing the freedom to smoke, and (4) resisting a smoke-less life. Men's reliance on and commitment to dominant ideals of masculinity seemed to preclude them from viewing their partner's tobacco reduction or cessation for pregnancy as an opportunity for cessation. Expectant and new fathers who smoke, however, may be optimally targeted for cessation interventions because it is a time when men experience discomfort with their smoking and when discontinuities in everyday life associated with the transition to fatherhood and presence of a new baby provide opportunities for establishing new routines. Implications for gender-sensitive smoking cessation interventions are discussed.