A preliminary study to evaluate the behavior of Indian population toward E-pharmacy.

The use of the Internet has increased exponentially for buying as well as selling of goods. Even the purchase of medications online is no exception. Owing to its benefits, there are certain risk factors in purchase of online medicines. Currently, the data on the use of Internet pharmacies are limited. Thus, the main objective of our study is to assess the knowledge, attitude, and practices (KAP) of Indian population toward E-pharmacy in India carried out in the Department of Pharmacology, PGIMER, Chandigarh. A KAP questionnaire was prepared which was distributed to the participants through Google Forms and a URL sent to them. This questionnaire was divided into four sections including demographics, occupation, income, and use of the Internet to measure the alertness toward the online purchase of medicines. A total of 322 responses were collected, out of which only 268 (83.2%) participants were aware of online pharmacy. The awareness was more in males and that too in urban population. Among the respondents, majority of the users prefer to buy medicines offline (81%, n = 217) which can be due to poor quality of medicines and lack of trustworthy websites. The utmost reason for buying the medicine online was deficiency of availability in the market and differences in the prices. The most preferred drugs respondents were willing to buy online were prescription drugs followed by cosmetics and dietary supplements. In conclusion, of our results, most of the people use the Internet to search for the medications online who prefer to consult the physicians before buying. Therefore, the future of online pharmacy can be improved if there will be some set guidelines, awareness, and knowledge among the users.

Introduction

E-commerce is defined as the online selling and buying of goods or products, and this concept was developed during the early 1970s. It is done through an online shop, e-shop, e-store, Internet shop, or online store. The description of all the online products is described through text, with photos and with multimedia files.[1]

Application of E-commerce in medicine led to the beginning of online pharmacies which was first initiated in the United States during the year 1999. This included the selling of both nonprescription and prescription-only medicines. However, the official approval for online drug transaction services started on December 1, 2005, after China's Food and Drug Administration issued the provisional rules of the Internet for examination.[2]

The benefit by making use of online shopping is the use of technology for better marketing performance, where retailers generally use different strategies to meet the demand of online purchasers. They also try to understand the consumer in the field of online shopping and specifically study those factors which influence the consumers to shop online. The other advantages of buying online are lower transaction and search cost in comparison to other types of shopping. It also makes faster shopping, providing more alternatives and with reasonable prices.[3]

Although purchasing from E-pharmacies holds many advantages, data from the World Health Organization (WHO) have marked a question upon its safety. The complexity and seriousness of this problem increased when the WHO estimated that about 50% of the medications marketed on the Internet are from counterfeited websites. Internet pharmacies without any regulation sell counterfeit drugs, hence posing a great threat to public health with tragic consequences to consumers.[3] A Western European study conducted on 14,000 people has reported that out of five, one people is acquiring medication from the Internet without prescription. This demonstrated that purchasing Western Europe spent around 10.5 million Euros per year on nonprescription medicines from illegal resources.[4] A survey was also done in Romania to assess the attitude of patients and customers on online purchasing of drugs. It was reported that maximum of the people were not aware about the differences between medications purchased from Internet and conventional pharmacies. Such studies indicate that attention should be paid toward online purchasing of drugs during routine patient care.[5]

Hence, the above literature made us to aim our study to evaluate the knowledge, attitude, and practices (KAP) of Indian population toward E-pharmacy. KAP studies are the most frequently used tool in health-seeking behavior research where it represents a precise population collecting evidence on what is known, believed, and done in relation to a particular topic.[6] Thus, the major objective of this study is to evaluate the current situation concerning purchasing of drugs from online sources and how it influences the use of medical products and drug safety. This was achieved by surveying patients/consumers/caregivers and clients of community practices. The advantage of this kind of survey is that it also assesses the customer attitude toward purchase of other medicinal products such as dietary supplements and herbal remedies.

Materials and Methods

Study design

This was a questionnaire-based study, carried out in the Department of Pharmacology, PGIMER, Chandigarh. A KAP questionnaire was planned to measure the awareness toward online purchase of medicines. It was divided into four sections, in which the first section was focused on demographic information, i.e., age, gender, education level, occupation, income, and use of the Internet. In addition to this, it also focused on their knowledge of E-pharmacy, their attitude, and practices toward purchase of medicines from E-pharmacy. There were 24 questions in all (8 each related about KAP). The primary version of the survey was developed via wide literature review in English language.[789]

Validation of questionnaire

The questionnaire content was screened out for appropriateness. Validity and pretesting of the questionnaire were randomly done on 20 selected participants of the institute and were performed by experts at the Department of Pharmacology, PGIMER, Chandigarh. The questionnaire was finalized after modification of indefinite and incompatible questions on the basis of the result of the Pretest.

Data collection

The pretested questionnaire was distributed among all the participants. Google Forms was used to manage the survey questionnaire as it was user-friendly. A message relating to the survey was sent to friends, with a URL link to the survey. One-day time was allotted to them for the collection of the filled forms. The participants were requested to answer in as multiple-choice formats.

Statistical analysis

Data were analyzed statistically using SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc. To illustrate demographic characteristics of participants, descriptive statistics were used. Continuous variables were expressed as mean ± standard deviation (SD) while categorical variables were measured as percentages.

Data analysis

Data were retrieved in Excel format from online forms, whereas from offline forms, data were entered into Excel manually. The data were further analyzed by using SPSS statistical software. Qualitative variables were represented as percentage. In the case of normally distributed quantitative data (age), mean ± SD was used for further representation.

Results

Baseline characteristics of the participants

We approached a total of 550 potential participants for participation in the survey (350 online and 200 offline), out of which 322 volunteered to participate in the survey (online: 195 and offline: 127). The response rate was 64.4%. Out of 322 total participants, 268 participants (83.2%) were aware of online pharmacy. In the next phase, data regarding online pharmacy were collected from these 268 participants [Figure 1].

Figure 1

Participant flowchart

Awareness about online pharmacy

Aware about online pharmacy (n = 268)

The awareness regarding online availability of medicines is comparable across both genders (males: 51.49% and females: 48.50%). The educational status of the aware population ranged from graduate (n = 153, 57.08%) to postgraduate (n = 83, 30.97%). Awareness was more in urban population (n = 200, 74.62%) as compared to rural (n = 60, 22.38%). Among them, 27.61% used the Internet daily (n = 74), 26.49% used 3–4 times a week (n = 71), 24.62% used the Internet less than once a week (n = 66), and interestingly, 11.19% (n = 30) never used the Internet [Table 1a].

Table 1a

Baseline characteristics of the population (aware versus unaware about online pharmacy)

Parameters	Aware about online pharmacy (n=268), n (%)	Unaware about online pharmacy (n=54), n (%)
Age	28.67±7.197	27.87±6.942
Sex
Male	138 (51.49)	27 (50)
Female	130 (48.50)	27 (50)
Education
Below 5th student	0	0
5th-10th student	0	1 (1.85)
10th-12th student	31 (11.56)	9 (16.66)
Graduate	153 (57.08)	31 (57.4)
Postgraduate	83 (30.97)	13 (24.07)
None	1 (0.37)	0
Occupation
Business	1 (0.37)	0
Doctor	14 (5.22)	2 (3.7)
Engineer	2 (0.74)	0
Government job	8 (2.98)	1 (1.85)
Homemaker	0	2 (3.7)
Student	48 (17.91)	6 (11.11)
Nursing	82 (30.59)	20 (37.03)
Pharmacist	3 (1.11)	1 (1.85)
Private job	24 (8.95)	8 (14.81)
Location
Rural	60 (22.38)	18 (33.33)
Semi-urban	1 (0.37)	1 (1.85)
Urban	200 (74.62)	35 (64.81)
Income
<5000	32 (11.94)	9 (16.66)
5000-10,000	5 (1.86)	3 (5.55)
11,000-20,000	30 (11.19)	13 (24.07)
21,000-50,000	54 (20.14)	9 (16.66)
51,000-1 lakh	111 (41.41)	17 (31.48)
>1 lakh	24 (8.95)	1 (1.85)
Internet use
Never	30 (11.19)	21 (38.88)
Less than once a week	66 (24.62)	11 (20.37)
Once a week	26 (9.7)	4 (7.40)
Several times a week	71 (26.49)	10 (18.51)
Daily	74 (27.61)	8 (14.81)

Not aware about online pharmacy (n = 54)

Among the respondents who were unaware about the online pharmacy, most of them were graduates (n = 31, 57.4%) followed by postgraduates (13, 24.07%). SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc. Among participants who were unaware of online pharmacy, 38.88% (n = 21) never used the Internet while interestingly it included 8 participants who used the Internet daily (14.81%) [Table 1a].

Online versus offline users: Baseline characteristics

Although a total of 268 respondents were aware about online pharmacy, majority of them preferred to purchase medicine offline (n = 185, 69%).

Among the offline and online pharmacy users, the mean age across both the groups was almost similar (online: 28.34 ± 7.369 and offline: 28.82 ± 7.134).

Regarding educational status, most respondents across both the groups were graduates and postgraduates.

Regarding those who purchase medicine online, 78.31% (n = 65) belonged to urban area and 20.48% (n = 17) to rural area as compared to offline users where 72.97% (n = 135) belonged to urban area and 23.24% (n = 43) to rural area [Table 1b].

Table 1b

Characteristics of online and offline pharmacy users (among those who are aware of online pharmacy)

	Online users (n=83), n (%)	Offline users (n=185), n (%)
Age, mean±SD	28.34±7.369	28.82±7.134
Sex
Male	49 (59.03)	89 (48.1)
Female	34 (40.96)	96 (51.89)
Education
Below 5th student	0	0
5th–10th student	0	0
10th–12th student	10 (12.04)	21 (11.35)
Graduate	51 (61.44)	102 (55.13)
Postgraduate	21 (25.3)	62 (33.51)
None	1 (1.20)	0
Occupation
Business	0	1 (0.54)
Doctor	2 (2.40)	12 (6.48)
Engineer	1 (1.20)	1 (0.54)
Government job	2 (2.40)	6 (3.24)
Homemaker	0	0
Student	12 (14.45)	36 (19.45)
Nursing	26 (31.32)	56 (30.27)
Pharmacist	2 (2.40)	1 (0.54)
Private job	8 (9.63)	16 (8.64)
Location
Rural	17 (20.48)	43 (23.24)
Semi-urban	1 (1.20)	7 (3.78)
Urban	65 (78.31)	135 (72.97)
Income
<5000	10 (12.04)	22 (11.89)
5000-10,000	2 (2.40)	3 (1.62)
11,000-20,000	9 (10.84)	21 (11.35)
21,000-50,000	18 (21.68)	36 (19.45)
51,000-1 lakh	31 (37.34)	80 (43.24)
>1 lakh	9 (10.84)	15 (8.1)
Internet use
Never	3 (3.61)	27 (14.59)
Less than once a week	22 (26.50)	44 (23.78)
Once a week	11 (13.25)	15 (8.1)
Several times a week	23 (27.71)	48 (25.94)
Daily	24 (28.91)	50 (27.02)

SD=Standard deviation

Knowledge, attitude, and practice domains (evaluated in participants who are aware about online pharmacy)

Knowledge domain

Among the respondents who were aware about the online purchase of medicines, only 37.7% (n = 101) were aware about the trustworthy websites for purchasing medicines online. 19.4% (n = 52) of respondents knew about the availability of the pharmacist for responding to queries on online pharmacies. 36.9% (n = 99) of participants considered the name of country to be mandatory aspect for purchasing via online pharmacy. Despite knowledge, only 10.8% (n = 29) of people responded to naming the different sites being used by them for making an online purchase [Table 1c].

Table 1c

Knowledge domain questions

Knowledge domain questions	Outcome/result, n (%)
Do you know about trustworthy websites of online pharmacy?
Yes	101/268 (37.7)
Do you require prescription for online purchase of medicine?
Yes (required for all products)	107/268 (39.9)
Yes (required for some restricted access products only)	23/268 (8.58)
Do not require prescription	0
Do not know	138/268 (51.49)
Is there any pharmacist available for answering the questions on online pharmacies?
Yes	52/268 (19.4)
Is it mandatory to question the name of the country from which the online purchase of medicine has been done?
Yes	99/268 (36.9)
Can you mention some of the websites from which you are ordering medicines online?
Netmeds	5/268 (1.9)
1 mg	5/268 (1.9)
PharmEasy	2/268 (0.7)
Practo	1/268 (0.4)
Medlife	1/268 (0.4)
MedPlusMart	1/268 (0.4)
No idea	14/268 (5.2)
Not answered	239/268 (89.2)

Attitude domain

Despite being aware regarding the online availability of medicines, majority of the users (81%, n = 217) prefer to buy medicine offline. The reason for which can be attributed partly to the perceived threats (38.1%, n = 102) by the users. The chief threats perceived by them included possibility of poor quality of medicine (60.86%, n = 56) and lack of trustworthy website/fear of fake website (18.47%, n = 17). However, 19% (n = 51) of users opine that the medicines available online are authentic as compared to 15.3% (n = 41) who believe the medicines to be of substandard quality while 3% (n = 8) believe them to be fake. The most commonly cited reasons for online purchase were the nonavailability of medicines in the market (20.1%, n = 54), difference in price (20.8%, n = 56), and 24-h availability (17.1%, n = 46) among others. Whereas availability of medicine in the market (26.8%, n = 72) and no idea about the quality of medicine (27.2%, n = 73) have been quoted majorly as a reason behind not buying medicine online. Availability of pharmacists (45.52%, n = 56), ease of access for illiterate (31.7%, n = 39), ease in returning medicines if needed (26%, n = 32), buying as per requirement (34.4%, n = 42), and immediate availability (36.58%, n = 45) have been cited as major reasons behind offline purchase of medicines. Lack of privacy (51.21%, n = 63) and less available brands to choose from (23.57%, n = 29) have been found to be the disadvantages when preferring offline purchase. As far as the experience of both pharmacies is concerned only 16.7% (n = 45) found the online pharmacy to be good in comparison to offline pharmacy where 85.4% (n = 229) of users had good experience [Table 2].

Table 2

Attitude domain questions

Attitude domain	Output/result, n (%)
Which pharmacy you prefer for routine nonemergency day-to-day medication buy?
Online	51/268 (19)
Offline	217/268 (81)
Do you feel any extortions for purchasing medicines online?
Yes	102/268 (38.1)
What are the perceived threats?
Possibility of poor quality of medicine	56/92 (60.86)
Lack of trustworthy website/fear of fake website	17/92 (18.47)
Do not know	19/92 (20.65)
How was your last experience of online pharmacy?
Good	45/268 (16.7)
How was your last experience of offline pharmacy?
Good	229/268 (85.4)
What is your belief about difference between the qualities of drugs purchased online or purchased from available in pharmacies?
Authentic	51/268 (19)
Fake	8/268 (3)
Nonstandard	41/268 (15.3)
What do you think what the future of online pharmacy is?
Do not know	11/30 (36.66)
Doubtful	5/30 (16.66)
Good	14/30 (46.66)
What is the reason of buying medicine online? Or advantage?
Drug to be purchased online is unavailable in market	54/236 (22.88)
Due to difference in price	56/236 (23.72)
It is more convenient	29/236 (12.28)
Extra good service is provided by online suppliers	11/236 (4.66)
It is available for 24 h	46/236 (19.49)
Online suppliers are providing a health information and consultation	4/236 (1.69)
More privacy	17/236 (7.2)
There is waiting in community pharmacy	18/236 (7.62)
Medicines always in stock	1/236 (0.42)
If no, what is reason for not buying online medicine? Or disadvantage of online pharmacy?
No idea about quality of medicine	73/208 (35.09)
No privacy	2/208 (0.96)
Supplier without license	0
No reason	22/208 (10.57 )
No Interest	33/208 (15.86 )
Medicine available in market	72/208 (34.61)
Bad service	6/208 (2.88)
Any advantage of offline medicine buying?
Can buy any time you require	45/123 (36.58)
Can return immediately if needed	32/123 (26)
Pharmacists are available for guidance	21/123 (17.07)
Can ask pharmacists for medicine	56/123 (45.52)
Accessible even for illiterate	39/123 (31.7)
Medicines are stored under controlled condition	15/123 (12.19)
Can buy as per requirement as like two-three tablets as per requirement	42/123 (34.4)
Any disadvantage of offline medicine buying?
No privacy	63/123 (51.21)
Less medicines brands to choose especially in the case of remote areas	29/123 (23.57)

Practice domain

46.66% (n = 21) of the users have been purchasing medicines for about 6–12 months as compared to 37.77% (n = 17) who were buying for more than 1 year. Awareness is least helpful for determining the online purchase as 69% (n = 185) of users never purchased any medicine online as compared to occasional purchasers (24.3%, n = 65). Internet use and the quest for gaining knowledge regarding medical information have increased with the advent of technological advancement. The users who indulge in Internet surfing and search for medical information daily were 27.6% (n = 74) in contrast to 25.4% (n = 68) and 23.9% (n = 64) who used the Internet for sometimes a week and less than once a week, respectively. 51.9% (n = 139) of the users who were aware prefer to consult their physician before purchasing medicines online. 52.2% (n = 140) check whether the package insert is in their familial language or not. As far as preference regarding category of drugs for purchasing online is concerned, 27.2% (n = 73) of users were willing to purchase prescription drugs followed by cosmetics (22.3%, n = 60), dietary supplements (17.9%, n = 48), lifestyle medications (3.7%, n = 10), and narcotics (1.8%, n = 2). However, 25% (n = 67) of users preferred to buy as per their requirement irrespective of the category of drugs. Among the respondents, 59.3% (n = 98) preferred both branded and generic while purchasing online as compared to 26.5% (n = 44) who preferred to buy branded drugs and 14.45% (n = 24) who preferred generic drugs [Table 3].

Table 3

Practice domain questions

Practice domain questions	Output/results, n (%)
For how long have you been purchased online medicines?
<1 month	7/45 (15.55)
6-12 months	21/45 (46.66)
>1 year	17/45 (37.77)
How many times you have purchased online medicine?
Always	8/268 (3)
Never	185/268 (69)
Occasionally	65/268 (24.3)
Sometimes	10/268 (3.7)
How much is your consistency to search on the Internet about use and information about medicines?
Less than once a week	64/268 (23.9)
Once a week	26/268 (9.7)
Several times a week	68/268 (25.4)
Once a month	1/268 (0.4)
If needed	1/268 (0.4)
Daily	74/268 (27.6)
Sometimes	2 (0.7)
Not responded	2/268 (0.7)
Do you consult your doctor before purchasing drugs online?
Yes	139/268 (51.9)
Do you check whether package leaflet is in familial language?
No	62/268 (23.1)
Yes	140/268 (52.2)
Sometimes	58/268 (21.6)
What type of drugs you prefer to purchase online?
Branded	44/166 (26.5)
Generic	24/166 (14.45)
Both branded and generic	98/166 (59.03)
What category of drugs you are willing to purchase online?
Nonprescription medicine	18/268 (6.7)
Prescription drugs	73/268 (27.2)
Cosmetics	60/268 (22.3)
Lifestyle medicines such as birth control	10/268 (3.7)
Narcotics	5/268 (1.8)
Dietary supplements	48/268 (17.9)
Herbal medicines	26/268 (9.7)
As per requirement	67/268 (25)
None	75/268 (27.9)

Discussion

Our study represents one of the few attempts in the literature to determine the current situation of acquiring medicines online and its impact on drug safety and medical product use. The survey was conducted on patients/consumers/caregivers and clients of community pharmacies. To our knowledge, this is the first study in India where we have evaluated the KAP not only toward online purchase of medicines but also other supplementary medicinal products.

It was observed that more than half of the participants were aware of the online purchase of medicines. Age, gender, and educational qualification do not have any significant effect on the purchasing behavior of individuals toward online pharmacy as also demonstrated by Fittler.[8] A survey by Abanmy et al. showed less extensive online purchase of medicines, as 268 participants were aware of the E-pharmacy, but only 83 of them actually purchased the medicines online. There are other population surveys as well on the perceptions and attitude of the consumer but could not find any consistent information on the number of consumers and their characteristics.[2] In our study, most online customers were found to be graduates (61.44%) and belonged to the urban areas (78.31%).

The patient's attitude toward online pharmacies for purchasing of medicines and health products is very important to maintain the integrity of the medication supply chain and for the protection of the patients from illegitimate websites.[10] Even in our survey, it was demonstrated that only 37.7% of the participants were aware of the trustworthy sites and 89.2% did not even answer from which websites they order the medicine. This showed that they had no knowledge of the websites for purchasing of health-care products.

The findings in our survey had some main features which would attract the use of online pharmacy such as differences in the prices and nonavailability of medications in market. These results were consistent with other studies where the most frequent reasons quoted by the interviewees were convenience-related factors such as easy availability (59%) and reduced trips to the pharmacy (41%).[511]

Study results also indicates that people used the internet to search medical information however, and half of them consulted the physician before purchasing the medicine online. Our study also demonstrated the preference of the participants in which maximum number of individuals bought both branded and generic medications.

Limitations of study

The study is exploratory and sample size is small, thus more deep investigation is required.

Conclusion

In our study, 268 participants were aware of E-pharmacy, but only 83 of them actually purchased the medicines online. While majority of the participants did not respond (88.8%), only 5.2% of people perceive the future of online pharmacy to be good as compared to 1.9% who perceive it to be doubtful. E-pharmacy is the need of an hour today, so it should be allowed to the consumers of India, however sufficient safeguard and rigid regulatory conditions should be maintained to ensure the safety and quality of medicines purchased from online pharmacy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.