Section of Hygiene, Epidemiology and Public Health – University of Brescia (Italy)
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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 2010 Lugano, 9 March 2010
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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
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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
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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.”
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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
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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
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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
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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
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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.
