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Ambiguity and confusion about health promotion terminology are widely recognised in the health promotion literature and have been identified amongst GPs, health visitors, health education officers and school-teachers (Collins, 1983; Downie et al, 1990). The semi-structured interviews revealed confusion in health promotion terminology amongst

the 50 pharmacists. When asked what activities were encompassed by the term health promotion, one pharmacist replied:-

'7 really couldn't say. How do you mean? Well I don't know whether you are talking about promoting the role o f the pharmacist...are you talking about promoting healthcare products? Are you talking about giving people advice on healthcare, how they can lead a healthier life? I fin d it difficult to understand what you mean by health promotion..J'm finding difficulties with the term health promotion. I mean its a very obscure phrase."

Despite the confusion in terminology, classification of pharmacists' health promotion activities using Tannahill's model of health promotion (see Section 1.1 and Table 3.6) enabled clarification of the pharmacists' concepts of health promotion. The model illustrates the relationships between the 3 major components of health promotion: preventive health services, health education and health protection. Collectively, the pharmacists placed greatest en^hasis on health education: education for positive health and education for the prevention of ill-health. Preventive health services such as diagnostic testing and medication supplied in response to symptoms, received moderate attention. Only one pharmacist alluded to health protection measures, when talking about health promotion activities. None of the interviewees referred to activities which could be categorised as preventive health protection services or education about health protection.

The vast majority of health promotion activities identified by interviewees were relevant to individuals rather than the wider community. This may have been because the interviewees were thinking about health promotion in the context of community pharmacy, or may be because they have a limited concept of health promotion which fails to recognise health protection measures and community action for health.

The pharmacists' concepts of health promotion seemed to reflect interpretation of "promotion" and were associated with commercial advertising. There was a minority view of health promotion as the provision of biased information, which was provided to customers with the aim of commercial gain. The manufacturers of nicotine patches were cited as an example of those who exploited the public under the barmer of "health promotion", in an attempt to increase company profits.

Commercial promotions aim to increase the demand for certain products. The association between commercial promotions and health promotion may explain why health promotion was viewed by some as product- or service-related. Alternatively those pharmacists who described health promotion as the promotion of vitamins, or the

provision of diagnostic testing services, may arise from their bio-medical model of health, which views health itself as a commodity.

The interviewees identified as health promotion, specific activities which had been classified as "health education" over 10 years ago (Pilkington, 1979; Harris, 1982). These activities included responding to customers’ symptoms/requests, and provision of verbal advice about medication or vitamins. Thus the majority of pharmacists appeared to think of health promotion in terms of health education, and most of pharmacy-based health promotion in practice is more probably more correctly termed "health education." 3.4.3 Concepts of Health Education.

During the 1980s pharmacy-based health education was considered to comprise the advisory role about prescribed and non-prescribed medication, patients’ symptoms and other requests (Pilkington, 1979; Harris, 1982). Comparison of the major components of health education which the interviewees identified, with those of Pilkington and Harris, suggest that during the last decade pharmacy-based health education has expanded to include provision of advice about lifestyles and behaviour change, whilst maintaining emphasis on the medication- and symptom-related advice.

Several pharmacists’ concepts of health education were closely linked with the interpretation of the word "education". These interviewees perceived continuing education for pharmacists, pharmacy staff and other health professionals, as a health education activity. Since pharmacists are familiar with continuing education as a process of learning detailed knowledge about specific health topics, this may explain why so many of the interviewees perceived health education as the delivery of specific, detailed information to the public. In contrast, health promotion was frequently referred as the delivery of superficial information to the public.

A major component of the pharmacist's health education role was reported to be symptom- and medication-related, thus focusing on a reactive approach to negative health. A dominant theme in the interviewees’ responses was that "health education" comprised the provision of information and the promotion of an awareness among pharmacy customers about health issues. On the whole, the pharmacists believed it was their job to provide the information, but any responsibility for acting upon that information was seen to lie with the customer. Their overall aim was to induce "healthy" behaviour in their customers, although none of the pharmacists referred to changes in attitude, or decision-making as intermediary steps between receipt of information and change in behaviour. Nevertheless, all pharmacists, at some time during the interview, made statements congruent with the behaviour change model of health education.

The behaviour change model of health education incites victim-blaming, and this was evident in the majority of transcripts. Victim-blaming must be avoided in health education because it is contrary to helping people to develop health-related lifeskills and health behaviours e.g. drinking and smoking, to decision-making, and to taking responsibility for their own health.

Some interviewees reported operating within the educational model because they considered it unethical to tell someone else how to live their life, they were reluctant to prescribe behaviour for the customers, preferring to give them "factual information" and leave the decision about whether to act on this information up to the customer. These pharmacists appeared to view this form of education as a precursor towards behavioural change.

According to health education theory, education should involve two-way interaction between the health educator and the "client". In all 50 interviews the pharmacists referred to health education or health promotion as a process in which they the "expert" delivered information or advice in one direction to the customer.

Although the interviewees talked about self-care:- the importance of knowing how to look after your own health, and actually putting this knowledge into practice ty "healthy" living, none of them referred to a deeper motivation for such behaviour, such as might arise ûom raised self-esteem or increased internal locus of control. Realistically, it is unlikely that pharmacists have the skills or periods of uninterrupted time available to enable them to truly empower customers in health promotion.

All 50 pharmacists interviewed indicated the expert-dominated "traditional" approach to health education and none of them uttered any statements which were compatible with the transitional approach. A minority of pharmacists made statements which implied certain aspects of the "modem" approach, such as appreciation of positive health and the effect of the socio-economic environment on health.

Unlike many health education programmes which are planned in advance, the bulk of pharmacy-based health education seems to occur in practice in a spontaneous manner, as pharmacists respond to the requests of their patients or undertake proactive opportunistic health promotion. Some aspects of the pharmacy health education effort are planned in advance and co-ordinated with multidisciplinary health education campaigns, e.g the "Pharmacy healthcare" leaflet scheme. Many of the health education leaflets displayed in pharmacies focus on negative health and are capable, in educational terms, of no more than information-dissémination. Considering the community

factor oriented. Such methods dominate health promotion policy and the practice of health education elsewhere within the NHS (Department of Health, 1992). If pharmacists and other health professionals were to adopt a more positive approach to health education in accordance with the health-oriented approach, by emphasising the short­ term positive benefits of "healthy" lifestyle rather than the long-term preventive benefits, their health education efforts may prove more effective in future.

Collectively the qualitative data about health, health education and health promotion emphasises the importance of personal behaviour change in preventing ill-health, and neglects socio-economic and environmental issues. This reflects the Government health policy of the 1970s and 1980s and the model of the pharmaceutical professional bodies (DHSS, 1976; DHSS, 1987; RPSGB, 1992).