Section of Hygiene, Epidemiology and Public Health – University of Brescia (Italy)

1. 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” GraziaOrizio Lugano, 9 March 2010

2. Trust and SourcesofHealth Information The impact of internet and itsimplicationsforhealth care providers • ArchInternMed, 2005 • AuthorsAffiliations: UnitedStates • CDC • GerogeMasonUniversity (VA) • Universtyof North Carolina • Harvard University (MASS) • 6369 interviews

3. AIMS “Toprovidenationallyrepresentative estimate for: • health-relateduseof the internet, • levelof trust in health information sources, • and preferencesforcancer information.”

6. RESULTS • Internet: • 63.0% internet users • e-health • 63.7% searchedforhealth information

8. TRUST IN INFIRMATION SOURCES Regressione logistica per valutare l’associazione con le variabili sociodemografiche

10. CANCER:intentiontovs effectivebehavior

13. Internet Users in the European Union

14. AIMSThe internhe@lth Project to investigate the public healthimplications of the spread internet

15. BACKGROUND INFORMATION DEMAND CITIZENS / PATIENTS HEALTH SERVICES DEMAND PROFESSIONAL UPDATING DOCTORS ADVERTISMENT HEALTH ORGANIZATION MARKETING

16. DOCTORS WEB Drugs Diagnostic Test Medical consultations Clinical Management Social Networking Health Education Internet usage and perception Portals for Doctors Health Marketing CITIZENS HEALTH ORGANIZATIONS

17. The Internhe@lth: Study Design 2009 Drugsanalysis Pilotstudy Online pharmacies (OPs) monitoragefor 2 years 1° step 2° step 2007 33 OPs 2007 118 OPs 2008 Economicalanalisys (100 OPs) 2008-2009 2008 Questionnariesanalysis 57 OPs 2008 31 sites Diagnostictestswebsitesanalysis (2008-2009) Hospitalswebsitesanalysis (2008-2009) LocalHealthAuthoritieswebsitesanalysis (2009)

18. ONLINE PHARMACIES • Pilotstudy: 33 OPs • First Survey: 118 OPs • AnalisisofOPs • Economicanalysis • Online questionnairesanalysis • Secondsurvey: 175 FO • Analysisof the persuasionstrategies

20. BACKGROUND • e-health • Information / knowledge • Access to: • medicaldevices • diagnostictests (i.e., genetictests) • treatment -> drugs • WHO: context of counterfeit medicines, defined as “a global public health crisis” • FDA: “seriouspublic health risk” • Directto Consumer Advertising • YES: Patientempowerment • NO: Itgeneratesdemandofmedicalservices

23. AIMS To investigate offering and advertising ofPrescriptionOnlyDrugs on the internet • Trasversalstudytoobtainanimageof online pharmaciescharacteristics • Sellingstrategiesanalysis • Howis consumer’s trust built in the ”protected market” ofdrugs ? • Whichkindofguaranties are presenttoprevent the risksofself-medication?

24. INTERNET SITES CODING • Contentanalysis • Formal categories • Address declaration • Domain registration • Delivery declared location • Language • Communication channels • Content categories • Selling Aspects • Selling Arguments • Medicines available • Disclaimers METHODS WEBSITES SELECTION • www.google.it • Inclusion criteria: • Direct selling sites • By 3 clicks from google • Almost English language • Each site considered only once

25. PRESCRIPTION REQUIREMENTS

26. P=0.000 PHYSICAL ADDRESS 66 OP (38%) displayed their physiscal address

27. PHYSICAL ADDRESS / DOMAIN 56 %Address=Domain Canada UnitedStates Central America Europe Address Domain Address=Domain Oceania Asia IndianOcean Australia

28. 96 % India DECLARED DELIVERY LOCATION NO 58% (69) YES 42% (49)

29. AVAILABLE DRUGS

30. Sildenafil Fluoxetina Tramadolo Amitriptilina SIDE EFFECTS DECLARED (Sildenafil, fluoxetine, tramadol and amitryptiline) NO SIDE EFFECTS DECLARED

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

32. P=0.000 QUALITY MARKERS

33. SELLING ARGUMENTS * * * * * *

34. SELLING ARGUMENTS • 1. Better from us: • Economical reasons • Privacy issues • No prescription • 2. Don’t worry: • Service quality • Drug quality • It is legal

36. Want to give a try?

37. Examples(www.mycanadapharmacy.info)

38. Sales and induced demand

39. Free offer of not required drugs

40. Confiscation policy

41. Examplestestimonials42 OPs (36%)(www.rx-giant.com)

42. Questionnariesanalysis(57 websites) – ANAMNESIS ISSUES

43. Pre-filled in70% (40)

44. Questionnariesanalysis(57 websites) – DOCTOR INVOLVMENT 53% 19% 63% 21% 57 Numero dei siti web

45. Access tohealthservices Drugslike the othercommodities Advertisement in anargumentative fashion Sellingarguments play on aspects far awayfrom the intrinsiccharacteristicsof the drug Empoweredofempoored? Gap between the information got and the information shouldbereceivedtomakeinformedhealthdecisions Effects on patient-doctorcommunication? Legalimplications Whichrulesshouldapply? Drugsqualityissues CONCLUSIONS

46. 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 CONCLUSIONS

49. CONCLUSIONS • The prescription has a value on the market. A consumer who wants to buy a drug without prescription has to pay a higher price. • The unit cost of the active principle decreases with quantity; this may be due to decreasing marginal cost, but it may also suggest a strong demand inducement effect • Active principles that do not originate from the US/Europe/Canada, because the drug is shipped from elsewhere, cost less. The shipping origin may be related to the quality of the drug sold.