Graph literacy is an important factor in the design of visual timelines of patient-reported outcomes (PROs) data intended to help prostate cancer survivors understand survivorship trajectories. However, traditional reporting formats are often poorly understood by many patients, which can inhibit their capability for informed decision making. These findings were published in the Journal of the American Medical Informatics Association.

Limited health and graph literacy can be impediments to understanding; therefore, the researchers recruited 18 prostate cancer survivors between the ages of 61 and 77 to assess the utility of 4 different prototype PRO visualizations to determine which might be more effective in helping patients plan for their future. The majority had inadequate health literacy (78%) and low graph literacy (86%). Half were African American.

The 4 prototypes that were assessed could be used as alternatives to traditional pie charts and bar graphs:

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  • Meter Evokes a car speedometer
  • Words Textual information about symptoms that contribute to Expanded Prostate Cancer Index Composite (EPIC) urinary function scores
  • Comic Pictorial representations of conversations between patients and their providers, with the expressions of the people pictured corresponding to the urinary function scores
  • Emoji Simplest representations of facial expressions

The most preferred option was Meter, with the best gist comprehension. The participants also preferred Emoji, which the researchers noted had the highest verbatim comprehension, as well as the highest rated utility including confidence, helpfulness, and satisfaction.

“Our findings provide insights into co-designed longitudinal PRO visualization that were best comprehended, found useful, and preferred by prostate cancer survivors with limited education,” they reported, adding that simplicity and ease of understanding were valued, but participants also wanted complete and informative depictions.

The study was limited by a small number of participants, especially in the interactive usability section. “Although participants provided rich qualitative data regarding their prostate cancer experience, the qualitative data we collected regarding the prototypes was sparse and limited our qualitative findings,” the researchers reported. But they noted that the inclusion of racially diverse patients was a strength of the study, since medical research often lacks diversity.

Future research should focus on comparing perceptions and performance from a larger group of people from a variety of backgrounds and literacy levels.


Snyder LE, Phan DF, Williams KC, et al. Comprehension, utility, and preferences of prostate cancer survivors for visual timelines of patient-reported outcomes co-designed for limited graph literacy: meters and emojis over comics. J Am Med Inform Assoc. Published online August 30, 2022. doi:10.1093/jamia/ocac148

This article originally appeared on Oncology Nurse Advisor