This is the first in a two-part series on health literacy.

Most of us probably consider ourselves literate. More than that, we know how to read critically, ask questions about the content, apply what we learn to new situations, and maybe even teach it to others. So when you read the question in the title, what comes to mind? 

Here’s an example of how a common dosage instruction can be misunderstood. Do you know how to read it?


Source: Legacy Health Oregon and SW Washington Health Literacy Conference.

Being “health literate” is not simply about being able to read the words a prescription label. It requires fundamental knowledge, numeracy, critical thinking, and communication skills that enable you to understand what you read or are told and use that information to actively manage your own health. It even includes skills like navigating your health insurance plan features or searching a document for information. 

Health literacy is not a new concern. In fact, the AMA has been working on raising awareness of our collective health literacy deficits since 1998. With the changes in health care delivery and who shoulders the costs, the roles of the obedient, trusting, deferential patient and paternalistic, all-knowing doctor have radically changed. With the burden of care shifting to patients and their families at home, low health literacy can be downright life-threatening. The New York Times stated “Patients with limited health literacy tend to be in poorer health, partake less frequently of preventive health measures and screening, and become hospitalized more frequently, resulting in an estimated annual cost of $50 billion to $73 billion.... [and] elderly patients with limited health literacy are almost twice as likely to die.”

Different Types of Health Literacy

According to the Healthy People initiative, heath literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Simple enough—until you put it into context. Imagine a busy father with his toddler at the pediatrician’s. The child is screaming in pain, the dad is sleep-deprived and missing a meeting, and the doctor is hurrying to see her next patient. Will the dad remember to ask if the antibiotic being prescribed can be mixed with the baby’s juice, since he won’t take it any other way? Will it occur to him to ask the pharmacist? What about dosing every four hours, does that mean the child must be awakened during the night? Can he just use what is left of the old prescription that is sitting in the refrigerator at home so he can avoid the high cost of the new bottle? If the pain isn’t resolved in the next two or three days, what should the parents do next? When is surgery recommended? Will their insurance cover it? What if the doctor’s heavily accented English is difficult to understand? What is an in-network provider?

This dad is not someone you would expect to be health “illiterate.” However, any number of factors might contribute to his inability to ask the right questions, gather the right information, and speak up if he does not understand something. Like many parents, he may simply be embarrassed to ask, he may not trust the doctor, or he may assume that if something is important, the doctor will tell him. He may have poor numeracy skills or not understand the difference between brand-name and generic drugs. He could be dyslexic or have attention-deficit disorder. All or any of these reasons can prevent this dad from accessing the best care for his child and for himself.

According to a survey commissioned by consumer healthcare company iTriage, this dad is not alone. The survey found that nearly 42% of adults “never or only sometimes ask questions of their care provider, even when they don’t understand what they are being told.” Men are even less likely than women to ask such questions. Only a little more than half of the group surveyed knew when it is appropriate to seek care at an urgent care center. Of young adults, ages 18–24, only 38% could correctly identify when going to urgent care was appropriate (if their doctor’s office was closed). The report goes on to reveal similar problems in people’s understanding of insurance terms and policies such as deductibles, copayments, and coinsurance.

There are direct consequences of such confusion: higher costs to individuals and families, inappropriate utilization of health care resources, inefficiency, and waste. Of course, the costs can quickly escalate, if a patient is experiencing a life-threatening event but does not seek appropriate care.

Let’s look at reading those prescription labels again, with an example from the iTriage report.

iTriage_rx-label-bigWhile more than 75% of the young adults surveyed could interpret the prescription instructions correctly, nearly a quarter of them were at risk of non-compliance at best, and overdosing at worst. That is far from optimal.

What Does Health Literacy Involve?

The National Assessment of Health Literacy is conducted every ten years in the US. It evaluates performance of tasks like the following to assess health literacy levels. (Source: The Best Medical Care: What Is Health Literacy?)

Below Basic Skills

  • Circle the date of a medical appointment on a clinic appointment slip.
  • Identify what they can drink before a medical test, based on a short set of instructions.
  • Identify how often they should have a certain medical test, based on information in a simple pamphlet.

Basic Skills

  • Give two reasons a person with no symptoms should be tested for a specific disease, after reading a simple pamphlet.
  • Explain why it is difficult for people to know they have a certain chronic illness, based on a two-page article about the illness.

Intermediate Skills

  • Determine a healthy weight range for a person of a certain height, based on a graph illustrating height, weight, and body mass index.
  • Find the age range during which children should have a certain vaccine, using a chart that shows all the childhood vaccines and the ages children should receive them.
  • Identify three substances that may interact with an over-the-counter medicine, based on information provided on the package.

Proficient Skills

  • Look up the definition of a medical term by sifting through a complex document.
  • Evaluate given information to determine what legal document could be of use in a specific health care situation.
  • Calculate an employee’s share of health insurance costs for a year, using a table that shows how the employee’s monthly contribution varies.

Health literacy is a huge and complex topic, well beyond the scope of this article. However, it is important to be aware and informed about it, not only for our own health or that of our loved ones. As designers in the health care space, this is a fundamental problem that we must address in every medium. Next week, we’ll look at how we can contribute to improving health communication by addressing the appropriate design considerations and providing the right tools.

We are finally able to think about something besides snow here in Arlington. Here are a few things we’ve been learning about.

Reinventing Health Care The Coevolution of Biology, Technology, and Culture


sparks&honey The Ad world’s Open Agency with a strong focus on cultural trends, talks about healthcare. We are living in a sci-fi world full of bionic limbs, wonder drugs, 3D-printed organs, lab-grown muscles, and brain-computer interfaces.

Battling Infectious Diseases in the 20th Century: The Impact of Vaccines


Have you seen our new Health Axiom design, “Vaccinate Your Child”? The Wall Street Journal recently posted a series of interactive infographics that show the remarkable efficacy of vaccination over the past 80 years.

5 tips for protecting PHI in Web apps


It can be as simple as excluding PHI from a URL. HIMSS Media executive editor Tom Sullivan for HealthcareIT News.

From this week:

In this week’s podcast, The Digital Life: The Frontiers of Digital Health Diagnostics  Jon and Dirk discuss the latest achievements in digital health diagnostics from 23andMe, Columbia University, and Scanadu, and explore the future of mHealth.

On Wednesday, Dirk Knemeyer took ESPN to task for a small but important information design issue in A Little Info Design Lesson.

On Monday we showed you the realities of Invo designers, the studio, and impassable snow. Around the Studio: (except when we’re not): Working Remotely


Have you pre-ordered your iPhone 6, or would you rather not think about screen sizes just now?


Engineering intern Clement Prod’homme found this interesting PaintCode infographic that explains the resolution of the two new iPhones. For example, the 6 Plus uses a 3x scale but then “downsamples” the image to fit the screen.


We love technology that enables you to know your numbers, especially when it comes to diabetes management. Juhan came across this open source and cloud-based CGM project on hackaday. Scroll down and read about how people are adapting the code to improve its features. It's inspiring.


Another cool data-catcher in the works is the DynoSense, a "personal thermometer on steroids"; a scanner that can track 33 body metrics in 60 seconds, such as temperature and heart rate.


While you're keeping your body fit, you can also do a little on-the-move brain training with the Peak mobile app. (I wonder if their logo designer deliberately replaced the "E" in Peak with the nonsensical hamburger menu icon. Is it a test?)


A much more straightforward set of visuals appears in this informative (and mostly reassuring) infographic from the Cleveland Clinic. I think I'll go get another glass of water now.

This week's highlights:

In Episode 68 of The Digital Life, Jon and Dirk talk about the right way to hire a digital studio, from skipping the RFP to starting with a test project to making sure company culture matches up between designer and client, based on Dirk's series of blog posts. We're more than three decades into the digital age, and yet companies still have difficulty finding the right fit when it comes to design providers. Why should that be the case? Join us as we share our experience in the trenches of software design, and reflect on the right way to establish the best client / consultant relationship possible. If you haven't yet, read the most recent article in the series, "Culture is Key."

On Monday in Around the Studio, Interns Amy Loomis and Sara Berndt joined forces to tell the story of an ambitious electrified installation project they designed and built during their summer internships.


We've been in a healthcare design state of mind all week, but we still want to have fun. It's Friday.


As we mentioned in an earlier post, Involution Creative Director Juhan Sonin is speaking at Stanford MedicineX this weekend. His session, Design for Life, suggests some innovative ways that emerging technologies can help people to stay healthy without even thinking about it.


Wearable healthcare devices are a frequent topic of conversation around the studio, so we were intrigued to learn that Abbott Laboratories has received the CE Mark (Conformite Europeenne) for its FreeStyle® Libre Flash Glucose Monitoring System, a new glucose sensing technology for people with diabetes. The system reads glucose levels through a sensor that can be worn on the back of the upper arm and eliminates the need for routine finger pricks.


Designer Jen Patel came across the Nymi, a wristband that uses your heart rhythm to securely authenticate and wirelessly control your smart devices.


And just so you know that we don't only dole out design criticism, designer Eric Benoit shared a recent post on Medium that talks about how actually pretty **** good their CSS is. Bonus: it's really well written—even a CSS noob like me can make sense of it!



Finally, those of you who are familiar with that pure burst of gooey goodness that is Marshmallow Fluff may not know that it was invented just a stone's throw from the doors of Involution Studios, in Somerville, MA. Plan your travel now because on the 27th of this month, you are sure to run into a few of us at the annual Union Square Fluff Festival, What the Fluff?.

This week’s highlights:

Be sure to catch Episode 67 of The Digital Life, Why UX is a Hot Commodity and Automating Knowledge Work. Dirk and Jon delve into the reasons that user experience has become the "it" field of the moment. Is it the desire for great design, created by companies like Apple? Is it pressure to create universal software experiences that honor and support the BYOD movement in the enterprise? Is it the app-ification of software? And, for the creative class who thought their jobs were safe, they explore the (possibly) frightening topic of the automation of knowledge work. Are no industries safe from the eventual reach of the machine?

Read part 2 of our four-part series on how to hire a design team with The Right Way to Hire a Design Studio: Start With a Test Project. You might be surprised at how valuable it can be to take a design team on a test drive—of your project—to evaluate their work.

Monday’s Around the Studio: Natural Light offers a look at the studio’s beautifully lit spaces and how important they are to our work life. (See the desk at which these articles are written, too!)


Stanford MedicineX logo
Stanford Medicine X 2014
Stanford University
September 5-7, 2014

Remember doctor's visits when you were growing up? The wooden tongue depressor. The well-worn stethoscope. That weird thing they jammed in your ears. And now, my young children are getting about that same treatment. But that is going to change.

Involution Creative Director Juhan Sonin has been invited to present "Design For Life" at Stanford Medicine X in September. Along with other innovators in patient-centered design, Sonin will talk about design-for-health possibilities and responsibilities.

As design harnesses digital, materials and networking technologies, a very new health experience is just over the horizon. Proactive, lifestyle design. Tracking real-time health data. Non-invasive tools. Custom "just for you" treatments based on your actual genome. These are all real technologies, being used by ordinary people. Together they are leading us to "stage zero" detection and treatment which has the potential to double or better the lifespan of every first-world citizen. It's not science fiction—the children of the 2020s will only know this reality. Tongue depressors will be limited to school craft projects and popsicles. And it is all the product of technology and design.

"Design For Life" will introduces the macro factors shaping these realities, along with an in-depth exploration of the various impacts of and opportunities for design.

About Medicine X
Medicine X is a catalyst for new ideas about the future of medicine and health care. The Medicine X initiative is designed to explore the potential of social media and information technology to advance the practice of medicine, improve health, and empower patients to be active participants in their own care. The “X” is meant to evoke a move beyond numbers and trends—it represents the infinite possibilities for current and future information technologies to improve health. Under the direction of Dr. Larry Chu, Associate Professor of Anesthesia, Medicine X is a project of the Stanford AIM Lab.

About Juhan Sonin
Juhan is the Creative Director of Involution Studios, and has been the creative leader of four different organizations, producing work recognized by the BBC, the New York Times, Ars Electronica, National Public Radio, and Billboard Magazine. Prior to joining Involution, Juhan spent time at Apple, the National Center for Supercomputing Applications (NCSA), a few startups, and MITRE. He is also a lecturer on design and rapid prototyping at MIT.

NPR Health Axioms Story

Involution's Health Axioms are grabbing the attention of the health innovation community.

NPR Health Blogger Nancy Shute posted her impressions of the Health Axioms recently in If A Picture's Worth 1,000 Words, Could It Help You Floss?

After getting her own Health Axioms in the mail — with a personal note — Shute called Involution's Juhan Sonin, one of the creative minds behind the deck. She had spread the cards on her desk at work and watched her co-workers' reactions, which ranged from "Health tarot cards!" to "But who are they for?" Not surprisingly, Sonin was frank in saying that the decks reflect a first-release "primordial ooze stage" and that he hopes to get feedback and ideas from a broad audience. Given the number of responses already posted to this one article it's clear that people want to talk about health and want to be heard.

Shute lets the cards speak for themselves by including several images from the deck, summing them up as not Crazy Eights but having their own "geeky charm," even with Manga-style illustrations reminiscent of "Soviet propaganda posters (but in a nice way)"(!) She let colleagues bring them home, reporting both delight (from a 10-year-old) and shrugs of indifference (from teens). She was puzzled by two of the axioms ("Know Your Numbers," "Who Is Your Wingman?") and demonstrates how quickly these two became worth the small effort of reading the card backs.

Read Shute's blog post. Check out the Health Axioms. Let us know your thoughts.

Learn more about/order Health Axioms.

About Involution’s Health Design Practice
For almost 10 years, Involution has been building software for health companies of every shape and size, from household names like AstraZeneca and Walgreens, to research leaders like the Personal Genome Project and Partners HealthCare. We also work with the most exciting and progressive health startups. We’ve made digital healthcare our top focus. logo

March 1, 2014

From protein to pixel to policy, design-for-health possibilities and responsibilities are immense.

Involution’s Creative Director Juhan Sonin talks about design-for-health possibilities in an upcoming interview with host Rob Woodbridge.

What we call “health” is made up of episodic issues and interventions … we are most conscious of our health during the moments when we’re face-to-face with a clinician.

In “Design for Life,” Juhan posits that continuous but noninvasive collection of individual health data may hold the key to those “teachable moments” in data that signal potential outcomes and prompt micro behavior shifts that, in turn, offer feedback and affirm new behaviors. If health is beautifully integrated into our daily life, so that we're getting continuous assessments, we’ll be able to adjust in near-real time.

This design space needs to chew on the massive volume of data and massive volume of human factors and their interrelationships — from what we're eating, how we're moving, how we work, and what makes up our genome, and expand that to an entire system picture of a human living on Planet Earth. All of that interconnecting and interlocked information tissue needs to be condensed into a single decision space that's not a data dump but a highly personalized, insightful crystal ball.

About Juhan Sonin
Juhan is the Creative Director of Involution Studios, and has been the creative leader of four different organizations, producing work recognized by the BBC, the New York Times, Ars Electronica, National Public Radio, and Billboard Magazine. Prior to joining Involution, Juhan spent time at Apple, the National Center for Supercomputing Applications (NCSA), a few startups, and MITRE. He is also a lecturer on design and rapid prototyping at MIT.

Mass Innovation Nights Logo

Involution Studios Presents Health Axioms at Mass Innovation Nights
January 8, 2014
6:00-8:30 p.m.

Progress Software
Bedford, MA
RSVP to Attend

Monthly Innovation Nights are designed to help local innovators increase the buzz around new products and companies. Start-ups and entrepreneurs present their latest works and the social media community turns out to blog, tweet, post pictures and video, add product mentions on LinkedIn and Facebook, and otherwise help spread the word.

Join Involution Studio's Creative Director Juhan Sonin and Principal Jonathan Follett, and see Involution's new Health Axioms.

Health Axioms

About the Health Axioms
We believe living the Health Axioms is better for our pocketbooks, smarter for our lives, and allows us to directly impact our health. Health Axioms put you in touch with habits to improve your health, life, and well-being. Thirty-two beautifully illustrated cards in a pocket-sized deck remind you of simple, profound, and sometimes surprising principles of better health. On the back of each card, you'll find essential insights, tips, and help in manifesting that axiom in your life.

You can learn more about how we created the Health Axioms here.

The team at Involution Studios — made up of Sarah Kaiser, Jane Kokernak, Kelly Mansfield, Harry Sleeper, and Juhan Sonin — created the Health Axioms card deck over an eight-month period. Starting with a dozen core, personal health habits, they turned these initial ideas into short catch phrases. Sarah and Kelly drew hundreds of sketches, which often drove the name and card story.

Health Axioms Sketches

The creative process started with sketches of different concepts for each Health Axiom.

Next, Jane honed the narrative, based on research, and edited each axiom story arc. Throughout this iterative process of conceptualization and refinement, the team continued to brainstorm more ways — big and small — to influence health and life, incorporating those insights into the deck.

Health Axioms Sketches

From the initial concepts, the team selected ideas to further refine.

Health Axioms Vector

The selected illustration for each Health Axiom was next converted to vector art.

Health Axioms Post Processing

As the last step in the process, color and texture were added.

You can view a higher resolution PDF showing further detail in the process.

Thirty-two cards made it into the final deck. On the front of each card is a beautiful illustration reminding you of a specific axiom that can move you in the direction of better health. On the back of each card, we give you essential insights, tips, and help in manifesting that axiom in your life.

We want to print and distribute 3,000 copies of our Health Axioms. And you can make a small pledge for a big impact on our Indiegogo campaign. It's just $15 for one set of cards. Give them to your work team, your social group, your family, your friends, your doctor, and your nurse. More than the gorgeous art and valuable life insights, you are helping us to amplify the clarion call to show the world a better vision for health. Doing good and getting something lovely for a modest price: What’s not to like?

What People Are Saying
"People are thirsty for health advice. They read, search online, and wonder: Am I doing OK? Am I doing the right things for my health? What if, when someone asks the universe (read: the internet), for health advice, they got back a quick tip, backed by evidence?"
- Susannah Fox, Digital Health Strategist

Involution Studios' hGraph — the only open source visualization for your complete health metrics — is being featured this month in "Digital Diagnosis: A New Generation of Healthcare Technology" in EContent Magazine.

The column, written by Eileen Mullan, explores how apps and visualization services like hGraph can help cut through the hassle of going to the doctor. Mullan writes, "hGraph is [...] designed to increase awareness of the individual factors that can affect overall health. Basically, it gives you (and your doctor) a holistic view of your health. You can have your entire medical history in one place, just like that. Imagine what something like hGraph will do for the future of healthcare industry (and for the time you waste in the waiting room)?"

hGraph, your health in one picture

hGraph, the only open source visualization for your complete health, developed by Involution

"Digital Diagnosis" is the latest in a string of articles on hGraph. Earlier this year hGraph was featured in as a part of their series "How Restyling the Mundane Medical Record Could Improve Health Care." The Wired article highlights hGraph’s strong social component. By tracking the data for entire families hGraph illustrates how some conditions, like obesity and heart disease, can be affected by collective health choices. hGraph was also mentioned in Health IT Buzz, the U.S. Department of Health and Human Services innovation blog. hGraph was a notable entry in the Patient Health Record Graphic Design Contest. The article notes that Involution designers “weren’t afraid to think outside the box, and both inspired the judges and challenged the status quo.

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