reading level of all materials was appropriate for the audience. According to Gould, social marketers already consider health literacy in their efforts, though they define it as effective public engagement.

Gould’s concerns with the paper’s focus were in regard to behavior change and using social marketing to improve equity and promote health. Behavior, he said, is not determined solely by knowledge. Therefore, it is important to focus on what other methods, in addition to fostering knowledge, can be used to create the desired behavior. Many people understand the messages and have the knowledge, but do not act on it due to other barriers or beliefs. For example, a small subsample of teens known as high sensation seekers understand the risks of smoking, and still engage in the behavior despite this knowledge—some even enjoy taking the risk. The Truth campaign ( targeted this population by presenting tobacco corporations as manipulative and terrible, and leaving the decision of smoking up to the consumer.

Gould expressed his support for the policy recommendations made in the paper. Health literacy from Gould’s perspective is an umbrella term that means effectively engaging the public. Such engagement is required for prevention efforts to be successful, he said, and primary and clinical prevention are key investments in the public’s health.

Charles J. Homer, M.D.
President and Chief Executive Officer
National Initiative for Children’s Healthcare Quality

Homer focused his comments on quality, which he defined generally as delivering the right care to the right person at the right time. In Crossing the Quality Chasm (IOM, 2001), quality health care is defined as having six characteristics: safe, timely, effective, efficient, equitable, and patient-centered. Patient-centered or family-centered care means that the care meets the needs of patients and families and is communicated in a way that can be understood. This is particularly important in the areas of chronic care and of prevention because in order to make care effective, one must influence behaviors, and the only way to influence behaviors, Homer said, is through patient- and family-centered care.

Quality is related to the construct of health literacy because meeting the needs of patients and families requires clear communication. Clinicians focus on reliable and effective delivery of care, and they are increasingly turning to public health methods of quality measurement and improvement to enhance performance.

The National Initiative for Children’s Healthcare Quality places a major focus on childhood obesity and on applying the principles of quality improvement in both clinical and community settings, Homer said.

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