'Where and how do you buy medicines?' A pilot survey of consumption strategies among the public in Sweden.

BACKGROUND: Substandard and falsified (SF) medical products are a major danger to public health. They affect every region of the world, and have been identified in all major therapeutic categories. Studies from medicine, pharmacology, law and public health dominate this research area with a focus on the supply side. However, the spread of SF medical products cannot be fully understood without information about the demand side or a sociocultural perspective on market formation. The aim of this short report is to present findings from a pilot study that examines the attitudes of the Swedish public regarding consumption of medicines.
METHODS: We conducted a pilot survey in 2016 'Where and how do you buy medicines?' using LimeSurvey, an open-source online survey software. In total 155 respondents completed the survey.
RESULTS: The majority of respondents turn to doctors within healthcare for prescription-only medicines (POM). Simultaneously, some respondents would consider buying POMs without prior contact with experts even if medicines may come from unsafe sources.
CONCLUSIONS: There is a tendency that people move away from formal healthcare towards an unregulated market. In parallel, people's approach to doctors becomes more personalized and pragmatic than in former patriarchal relationships. Risk becomes a negotiable concept.

Introduction

Substandard and falsified (SF) medical products are a major danger to public health.

They affect every region of the world, and have been identified in all major therapeutic categories.[1] The World Health Organization (WHO) estimates that the increasing spread of SF medical products not only leads to adverse drug reactions, increased morbidity or even death and economic losses, but also to diminished public confidence in health systems.[2] Researchers from medicine, pharmacology, law and public health dominate this research area, focusing on the supply side, emphasizing innovative tracking technologies and advocating international legal frameworks.[3-7] Such interventions are essential to tackle the spread of SF medical products. The mechanism of the trade, however, cannot be fully understood without knowledge about the demand side or without a sociocultural perspective on market formation.[8-10] In this short report we draw on findings from a pilot study, ‘Where and how do you buy medicines?’, with the aim of examining the attitudes of the Swedish public towards increasingly diversified medicine purchasing channels, especially the purchase of prescription-only medicines (POM).

Methods

The pilot study was conducted between April and May 2016 among Swedish residents. It forms an initial attempt to understand the mechanism of SF medical products from a sociocultural perspective and lays the foundation for a larger interdisciplinary project ‘Spurious and falsified medicines—a danger to public and personal health’.

The study takes the form of a qualitative survey. The design and distribution of the survey were accomplished through collaboration between the authors and the Folklife Archives at Lund University, Sweden. The list of questions was edited on LimeSurvey, an open-source online survey software. After two rounds of pilot tests, 14 questions were eventually finalized, with a mixture of single-choice, multiple-choice and open-ended questions. The survey was then spread out through Lund University’s Folklife Archive’s official website and their social media platforms, Swedish patient organizations and researchers’ personal contacts. In total 155 respondents participated in the survey. Empirical data was coded as themes emerging and then categorized accordingly. It is worth mentioning that, although we work primarily with qualitative data and themes derived from open-ended questions, in the following section we also present numbers and percentages on the side in order to map out a general context where those themes emerge.

Results and analysis

Here we present an overview of our findings with a focus on two themes: self-care practices and instrumentalization of health care professionals (I), and conception of risk (II).

The majority (81%) of respondents turn to doctors within healthcare for POMs. Simultaneously, some respondents (11%) would consider buying POMs without prior contact with experts, for example on various Internet sites or in countries abroad. A respondent says: ‘If I suffered from a disease that caused me major problems but for some reason, I could not get drugs for it in Sweden, I would buy it in any country, as long as it’s a country I can trust.’ This respondent, like others in the survey, is positive about practicing self-care. In addition, some of them approach doctors in an instrumental way to find out what medicines they are in need of, as this person declares: ‘Getting prescription requires a consultation, but I always read on my own in advance, and ask for the stuff I need.’ Or as another respondent reflects: ‘I want to know what the doctor recommends but then I am not sure I will do exactly as he/she advises. But I weigh it before I make my decision.’

While the majority emphasize the importance of obtaining medical information from formal healthcare, others find it less important, as illustrated by a respondent: ‘I don’t care about that, I just buy it online.’ Another respondent states: ‘If I shopped for medicines online and needed it cheap and fast, I would probably buy from the first website that offers it.’ Such consumption strategies express that the buyers may search for the best deal without thinking about where the medicine comes from. Thus, these respondents do not seem to associate purchasing medicines outside formal healthcare with potential risks, while some other respondents consider exactly such risks. In our survey we informed that since 2015 all pharmacies that operate legally within the European Union need to have an official logo displayed on their website.[11] However, 63% of respondents do not recognize this logo, which confirms findings from the Swedish Medical Products Agency (MPA).[12] Many perceive it as necessary, from a safety aspect, to have some types of certifier of authorized pharmacies, as expressed by a respondent: ‘It is important to know one is shopping in a real pharmacy.’ On the other hand, some respondents express scepticism against the logo, as one of them reflects: ‘It feels too easy to plagiarize and misuse logos on the Internet.’ The different views communicated by our respondents indicate that risk is a fluid concept that ties into individual perceptions and understandings.

Discussion

Main finding of this study

Globalization opens up for the purchase of medicines in countries abroad, while digitization provides access to various purchasing channels. This is reflected in our data. Purchasing medicines outside formal healthcare may be due to an increasing lack of accessibility to healthcare, a practical situation that does exist in Sweden. However, as our results show, sociocultural factors matter as well. In today’s neoliberal societies, including Sweden, there appears to be a shift in responsibility from the state to the individuals, which has significant social consequences,[13] including decreased trust in the health care system. Meanwhile, self-care practices increase followed by a pragmatic instrumentalization of health care professionals. Changing social structures and a growing individualism not only result in new relationships with the healthcare system. Such processes also mean that seemingly solid concepts such as ‘risk’ become negotiable and hinge on individuals’ personal views and needs.

A majority of the respondents feel hesitant about buying POMs online or at what are perceived as unsafe places abroad. Nevertheless, the purchase of medicines in such channels appears to be an option. In parallel to the search for alternative medical markets, people’s approach to doctors becomes more personalized and pragmatic than in former patriarchal relationships.

What is already known of this topic

Researchers from medicine, law and public health study SF medical products with a focus on the supply side.[9] Accessibility and unaffordability are often highlighted in the existing literature. Besides, self-care is identified as an increasingly common practice among the public that may lead to individual harm, especially due to the emergence of a growing number of rogue Internet phamracies.[14,15] However, a limited number of sociocultural analyses of this topic have shown that people tend to move away from formal healthcare and bypass medical professionals even in welfare states where formal healthcare service is highly accessible and affordable.[16] Further, it is also known that since the state-owned pharmacy monopoly ended in 2009, a thriving pharmaceutical market has opened up for the purchase in various settings.[12] The Swedish MPA reports that among the Swedish public there is a tendency that more and more people purchase medicines, especially POMs, from unauthorized Internet pharmacies.[12] However, knowledge about the demand side is scarce and insufficient to delineate what leads people away from the formal healthcare system.

What this study adds

This study adds knowledge about the demand side. More specifically, we demonstrate ambivalent attitudes people hold towards increasingly diversified medicine purchasing channels. Moreover, we also examine the interplay between self-care, the liberal market and new consumption strategies when it comes to medicines and healthcare service. This study thus shows the importance of understanding this interplay through sociocultural analysis in order to counter the increase of SF medical products. Qualitative research is therefore necessary to provide useful insight for policy makers and, not least, to provide the public with information about buying medicines in safe environments.

Limitation of this study

As this is a pilot study, the number of respondents is not representative of the entire Swedish population. Besides, as we did not intend to profile consumers who buy medicines outside the formal healthcare system, we did not collect specific background information regarding respondents’ income or previous online shopping experiences. This information is important and may have an impact on people’s attitudes towards purchasing medicines online or self-care practice.

Conclusion

There is a tendency that people move away from formal healthcare towards an unregulated market. In parallel, people’s approach to doctors becomes more personalized and pragmatic than in former patriarchal relationships. Furthermore, risk becomes a negotiable concept.