Section of Hygiene, Epidemiology and Public Health – University of Brescia (Italy)Institute of Communication and Care – University of Lugano (Switzerland) Research Centre on “Quality and Technology Assessment, Governance and Communication Strategies in Health Systems” – University of Brescia (Italy)

“The Internhe@lth Project: the Public Health implications

of the spread of Internet”

Grazia Orizio

Lugano, 9 March 2010Lugano, 9 March 2010

22

Trust and Sources of Health InformationTrust and Sources of Health InformationThe impact of internet and its implications for health The impact of internet and its implications for health

care providerscare providers

Arch Intern Med, 2005 Arch Intern Med, 2005 Authors Affiliations: United StatesAuthors Affiliations: United States

CDCCDC Geroge Mason University (VA)Geroge Mason University (VA) Universty of North CarolinaUniversty of North Carolina Harvard University (MASS)Harvard University (MASS)

6369 interviews6369 interviews

33

AIMSAIMS

““To provide nationally representative To provide nationally representative estimate for: estimate for: health-related use of the internet,health-related use of the internet, level of trust in health information sources,level of trust in health information sources,and preferences for cancer information.”and preferences for cancer information.”

44

66

RESULTSRESULTS

Internet: Internet: 63.0% internet users63.0% internet users

e-healthe-health63.7% searched for health 63.7% searched for health

informationinformation

77

TRUST IN INFIRMATION TRUST IN INFIRMATION SOURCESSOURCES

88

Regressione logistica per valutare l’associazione con le variabili sociodemografiche

99

CANCER:CANCER:

intention to intention to vs vs

effective behavioreffective behavior

1010

1111

Internet Users in the European Union

1414

AIMSAIMSThe internThe internhe@lthhe@lth Project Project

to investigate to investigate

the public health implications the public health implications

of the spread internetof the spread internet

CITIZENS / PATIENTS

DOCTORS

HEALTH ORGANIZATION

INFORMATION DEMAND

PROFESSIONALUPDATING

MARKETING

ADVERTISMENT

HEALTH SERVICESDEMAND

BACKGBACKGROUNROUNDD

WEB

Drugs

Diagnostic Test

Medical consultations

Clinical Management

Social Networking

Health Education

Internet usage and perception

Portals for Doctors

Health Marketing

CITIZENS

HEALTH ORGANIZATIONS

DOCTORS

Online pharmacies (OPs) monitorage for 2 years1° step 2° step

Pilot study

200733 OPs

2007118

OPs

2008 Economical analisys (100 OPs)

2008-2009

Diagnostic tests websites analysis (2008-2009)

2008Questionnaries analysis 57 OPs

2009Drugs analysis

Hospitals websites analysis (2008-2009)

Local Health Authorities websites analysis (2009)

200831 sites

The Internhe@lth:Study Design

1818

ONLINE PHARMACIESONLINE PHARMACIES

1.1. Pilot study: 33 OPsPilot study: 33 OPs

2.2. First Survey: 118 OPsFirst Survey: 118 OPs1.1. Analisis of OPsAnalisis of OPs

2.2. Economic analysisEconomic analysis

3.3. Online questionnaires analysisOnline questionnaires analysis

3.3. Second survey: 175 FOSecond survey: 175 FO1.1. Analysis of the persuasion strategiesAnalysis of the persuasion strategies

1919

e-healthe-health› Information / knowledgeInformation / knowledge› Access to:Access to:

› medical devicesmedical devices› diagnostic tests (i.e., genetic tests)diagnostic tests (i.e., genetic tests)› treatment -> drugstreatment -> drugs

› WHO: WHO: context of counterfeit medicines, defined context of counterfeit medicines, defined as as “a global public health crisis”“a global public health crisis”

› FDA: FDA: “serious “serious public health riskpublic health risk””

Direct to Consumer AdvertisingDirect to Consumer Advertising› YES: Patient empowermentYES: Patient empowerment› NO: It generates demand of medical services NO: It generates demand of medical services

BACKGROUNDBACKGROUND

AIMSAIMSTo investigate offering and advertising of To investigate offering and advertising of Prescription Only Drugs on the internetPrescription Only Drugs on the internet

Trasversal study to obtain an image of online Trasversal study to obtain an image of online pharmacies characteristicspharmacies characteristics

Selling strategies analysisSelling strategies analysis How is consumer’s trust built in the ”protected How is consumer’s trust built in the ”protected

market” of drugs ?market” of drugs ? Which kind of Which kind of guarantiesguaranties are present to are present to

prevent the risks of self-medication?prevent the risks of self-medication?

WEBSITES SELECTION www.google.it Inclusion criteria:

Direct selling sites By 3 clicks from google Almost English language Each site considered only once

INTERNET SITES CODING

Content analysis› Formal categories

› Address declaration› Domain registration› Delivery declared location› Language› Communication channels

› Content categories Selling Aspects Selling Arguments Medicines available Disclaimers

METHODSMETHODS

136; 78%

39; 22%

No-prescription

With prescritption

57; 42%

79; 58%

Not asking for anyinformationOnline questionnaire

PRESCRIPTION REQUIREMENTSPRESCRIPTION REQUIREMENTS

34

320%

20%

40%

60%

80%

100%

With prescription No-prescription

Physical address Virtual interface

P=0.000

66 OP (38%) displayed their physiscal address

PHYSICAL ADDRESSPHYSICAL ADDRESS

56 %Address=Domain

Address Domain Address=Domain

CanadaCanada United StatesUnited States

Central AmericaCentral America

AsiaAsia

Indian Ocean Indian Ocean

EuropeEurope OceaniaOceania

Australia Australia

PHYSICAL ADDRESS / DOMAINPHYSICAL ADDRESS / DOMAIN

YES42%(49)

NO58%(69)

111; 63%

64; 37%

Declared Not declared

42%

22%

14%

13%

6%3%

Asia Variable Canada

USA Europe Other

96 % India

DECLARED DELIVERY LOCATIONDECLARED DELIVERY LOCATION

020406080

100120140160

No-Prescription OPs Prescription OPs

020406080

100120140160

No-Prescription OPs Prescription OPs

AVAILABLE DRUGSAVAILABLE DRUGS

SIDE EFFECTS DECLARED(Sildenafil, fluoxetine, tramadol and amitryptiline)

34%

66%

Sildenafil

36%

64%

Fluoxetina

34%

66%

Amitriptilina

30%

70%

Tramadolo

NO SIDE EFFECTS DECLARED

0

20

40

60

80

Nu

mb

er

of

de

clar

ed

sid

e e

ffe

cts

Fluoxetine* Amitriptyline* Tramadol Sildenafil*

No prescription OPs Prescription OPs *p<0.05

0

20

40

60

80

Nu

mb

er

of

de

clar

ed

sid

e e

ffe

cts

Fluoxetine* Amitriptyline* Tramadol Sildenafil*

No prescription OPs Prescription OPs *p<0.05

SIDE EFFECTS DECLARED(Sildenafil, fluoxetine, tramadol and amitryptiline)

QUALITY MARKERS

22

10%

20%

40%

60%

80%

100%

With prescription No-prescription

Quality marker No quality marker

P=0.000

SELLING ARGUMENTSSELLING ARGUMENTS

**

**

**

SELLING ARGUMENTSSELLING ARGUMENTS

1. Better from us:•Economical reasons•Privacy issues•No prescription

2. Don’t worry:•Service quality•Drug quality•It is legal

Want to give a try?

ExamplesExamples (www.mycanadapharmacy.info)(www.mycanadapharmacy.info)

Sales and induced demand

Free offer of not required drugs

Confiscation policy

ExamplesExamplestestimonials testimonials 42 OPs (36%)42 OPs (36%)

(www.rx-giant.com)(www.rx-giant.com)

Questionnaries analysis Questionnaries analysis (57 websites) – ANAMNESIS ISSUES(57 websites) – ANAMNESIS ISSUES

Pre-filled inPre-filled in70% (40)70% (40)

Questionnaries analysis Questionnaries analysis (57 websites) – DOCTOR INVOLVMENT(57 websites) – DOCTOR INVOLVMENT

Numero dei siti web

53%

19%

63%

57

21%

• Access to health services• Drugs like the other commodities

• Advertisement in an argumentative fashion• Selling arguments play on aspects far away from

the intrinsic characteristics of the drug• Empowered of empoored?

• Gap between the information got and the information should be received to make informed health decisions

• Effects on patient-doctor communication?

Legal implications• Which rules should apply?

• Drugs quality issues

CONCLUSIONSCONCLUSIONS

• Which strategies to face the issue?• There is no shared international regulation so far• A law enforcement appproach is costly and few

effective• Health education seems to be the winning plan

CONCLUSIONSCONCLUSIONS

4747

4848

4949

CONCLUSIONSCONCLUSIONS The The prescriptionprescription has a value on the market. A has a value on the market. A

consumer who wants to buy a drug without consumer who wants to buy a drug without prescription has to pay a higher price.prescription has to pay a higher price.

The The unit cost unit cost of the active principle decreases with of the active principle decreases with quantity; this may be due to decreasing marginal quantity; this may be due to decreasing marginal cost, but it may also suggest a strong demand cost, but it may also suggest a strong demand inducement effectinducement effect

Active principles that do not Active principles that do not originate from originate from the the US/Europe/Canada, because the drug is shipped US/Europe/Canada, because the drug is shipped from elsewhere, cost less. The shipping origin from elsewhere, cost less. The shipping origin may be related to the quality of the drug sold.may be related to the quality of the drug sold.