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” Grazia Orizio Lugano, 9 March 2010

2. 2 Trust and Sources of Health Information The impact of internet and its implications for health care providers Arch Intern Med, 2005 Arch Intern Med, 2005 Authors Affiliations: United States Authors Affiliations: United States CDC CDC Geroge Mason University (VA) Geroge Mason University (VA) Universty of North Carolina Universty of North Carolina Harvard University (MASS) Harvard University (MASS) 6369 interviews 6369 interviews

3. 3 AIMS “To provide nationally representative 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.”

4. 4

6. 6 RESULTS Internet: Internet: 63.0% internet users 63.0% internet users e-health e-health 63.7% searched for health information 63.7% searched for health information

7. 7

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

9. 9

10. CANCER: intention to vs effective behavior 10

11. 11

13. Internet Users in the European Union

14. 14 AIMS The internhe@lth Project to investigate the public health implications of the spread internet

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

16. 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

17. Online pharmacies (OPs) monitorage for 2 years 1° step 2° step Pilot study 2007 33 OPs 2007 118 OPs 2008 Economical analisys (100 OPs) 2008- 2009 Diagnostic tests websites analysis (2008-2009) 2008 Questionnaries analysis 57 OPs 2009 Drugs analysis Hospitals websites analysis (2008-2009) Local Health Authorities websites analysis (2009) 2008 31 sites The Internhe@lth: Study Design

18. 18 ONLINE PHARMACIES 1. Pilot study: 33 OPs 2. First Survey: 118 OPs 1. Analisis of OPs 2. Economic analysis 3. Online questionnaires analysis 3. Second survey: 175 FO 1. Analysis of the persuasion strategies

19. 19

20.  e-health › Information / knowledge › Access to: › medical devices › diagnostic tests (i.e., genetic tests) › treatment -> drugs › WHO: context of counterfeit medicines, defined as “a global public health crisis” › FDA: “serious public health risk”  Direct to Consumer Advertising › YES: Patient empowerment › NO: It generates demand of medical services BACKGROUND

23. AIMS To investigate offering and advertising of Prescription Only Drugs on the internet Trasversal study to obtain an image of online pharmacies characteristics Trasversal study to obtain an image of online pharmacies characteristics Selling strategies analysis Selling strategies analysis How is consumer’s trust built in the ”protected market” of drugs ? How is consumer’s trust built in the ”protected market” of drugs ? Which kind of guaranties are present to prevent the risks of self-medication? Which kind of guaranties are present to prevent the risks of self-medication?

24. 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  DisclaimersMETHODS

25. PRESCRIPTION REQUIREMENTS

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

27. 56 %Address=Domain Address Domain Address=Domain Canada Canada United States United States Central America Central America Asia Asia Indian Ocean Indian Ocean Europe Oceania Oceania Australia Australia PHYSICAL ADDRESS / DOMAIN

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

29. AVAILABLE DRUGS

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

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

32. QUALITY MARKERS P=0.000

33. SELLING ARGUMENTS * * * * * *

34. 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. Examples testimonials 42 OPs (36%) (www.rx-giant.com)

42. Questionnaries analysis (57 websites) – ANAMNESIS ISSUES

43. Pre-filled in 70% (40)

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

45. 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 issuesCONCLUSIONS

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

47. 47

48. 48

49. 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 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 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. 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.