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Combinations of professional and commercial communication are typically very controversial, particularly in health care communication on the Internet. Websites of licensed community pharmacies on the other hand tend to raise remarkably little controversy, although they typically contain controversial combinations of clinical and commercial services previously unprecedented in professional health care communication.
The aim of this study was to fill the void of knowledge about the combination of clinical and commercial services presented on the websites of licensed community pharmacies.
A content analysis of clinical and commercial services presented in a random sample of 200 licensed community pharmacy websites from Great Britain, the Netherlands, the Canadian provinces British Columbia and Manitoba, and the Australian states New South Wales and Western Australia was conducted.
The top five specific services mentioned on the community pharmacy websites were cosmetic products (126/200, 63.0%), medication refill request options (124/200, 62.0%), over-the-counter medicine (115/200, 57.5%), complementary and alternative medicine (107/200, 53.5%), and home medical aids (98/200, 49.0%). On average, 72.5% (145/200) of the community pharmacy websites across the 4 countries included a combination of clinical and commercial services. A combination of clinical and commercial services was more often present on chain pharmacy websites (120/147, 82.8%) than single pharmacy websites (25/53, 47%;
A considerable share of websites of licensed community pharmacies in Great Britain, the Netherlands, Canada, and Australia combine clinical services with commercial services. Previous research into the presence of a combination of commercial and professional services suggests that such a combination may lead to increased interest in commercial services that may be unnecessary or inappropriate to patients’ health.
Combinations of professional and commercial communication are typically very controversial, particularly in health care, where vulnerable patient groups may become interested in goods or services that may be unnecessary, inappropriate, or even dangerous to their health [
This study aimed to fill the currently large void in knowledge about the contents of licensed community pharmacy websites, guided by the following research question:
The ideal clinical professional stays away from involvement in commercial communication, or so it seems. Professional clinical associations often promote straight bans or use highly restrictive codes of conduct for members’ commercial communication, sometimes against pressure from government administrations to loosen their regulations. The American Federal Trade Commission (FTC), for instance, has fought a lengthy statutory battle against the American Medical Association for restricting free competition through its persistent ban on physician advertising. This was later followed up by comparable cases of the FTC against other professional associations for restricting advertising, such as dentists, optometrists, accountants, and lawyers [
The principal argument against clinical professionals’ involvement with commercial communication revolves around a perceived conflict between commercial communication on the one hand and the clinical profession’s “fiduciary responsibility” on the other, that is, the duty to prioritize and protect patients’ interests at all times [
This study focused on the combination of clinical and commercial communication on community pharmacy websites. On the basis of the existing strong norms against combining clinical and commercial communication in the clinical professions, most people would be at least surprised, and possibly dismayed, if their family physician’s website would promote a branded pain reliever or line of mascaras. However, it is not uncommon to see this on a community pharmacy website. For example, the website of Service Apotheek, one of the largest community pharmacy chains in the Netherlands, mentions clinical consultation services for patients with chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD). At the same time, the website presents promotion for a branded facial cream that is claimed to “fill the skin with youth” and a slimming belt that will allegedly “redefine the body contours instantly.” Such a combination of clinical and commercial communication can be found in community pharmacies across the world today, from Australia [
Given today’s proliferation of commercial communication in community pharmacies, it may be assumed that a community pharmacy is largely evolving into a commercial retail business, with little in the way of an enduring role in the provision of clinical health care. Nonetheless, this is only one side of the coin. Community pharmacies’ clinical care activities largely waned during the course of the 20thcentury, when the “golden age of doctoring” was in its heydays and pharmacists’ role largely hinged on those of physicians [
All in all, developments in community pharmacies over the last few years have led to the presence of a combination of clinical and commercial services that were previously unprecedented in the domain of professional clinical care. To what extent this is mirrored on community pharmacy websites however is unknown. Extant research on community pharmacy websites is scant, with very few exceptions [
A systematic content analysis was conducted to allow for an unobtrusive observation of representative samples of licensed community pharmacies’ websites and their contents. To strengthen the generalizability of the findings beyond the specific context of one particular country, community pharmacy websites from 4 different countries and different continents were included in the study, namely from Great Britain, the Netherlands, Canada, and Australia. The choice for these 4 countries was in part based on practical reasons of the researchers’ command of the languages. Furthermore, low and middle-income countries were not included because pharmacy legislation may often be fragmented with limited enforcement of regulations in these countries [
The sample consisted of 200 licensed community pharmacy websites: 50 from Great Britain, 50 from The Netherlands, 50 from the Canadian provinces British Columbia and Manitoba, and 50 from the Australian states New South Wales and Western Australia.
The sample of British community pharmacies was randomly drawn from a directory of all 14,437 licensed community pharmacies from the British General Pharmaceutical Council, and the sample of Dutch pharmacies from a directory of all 1981 licensed pharmacies in the Netherlands from the Dutch Healthcare Inspectorate. Community pharmacy licensing and directories in Australia and Canada are organized by the given state or province, which is why the sampling of community pharmacies proceeded with the use of the directories of two states or provinces per country. For Canada, 25 community pharmacy websites were drawn from the directory of the 1256 licensed community pharmacies of the College of Pharmacists of British Columbia and 25 from the 415 registered pharmacies by the College of Pharmacists of Manitoba. For Australia, 25 community pharmacy websites were drawn from the directory of the 2514 licensed community pharmacies by the Pharmacy Council of New South Wales and 25 from the 637 licensed pharmacies by the Pharmacy Registration Board of Western Australia.
Since this study endeavored to study community pharmacy websites, community pharmacies in the directories without a (working) website were excluded from the sample; this concerned 33.3% (67/200) community pharmacies of the original selection (26 Australian, 13 British, 28 Canadian, and 0 Dutch original selections). Also, the pharmacy departments of mass merchants and health centers had to be excluded. This is because the websites of these merchants and centers do not allow a valid separation between services offered through the pharmacy department and services offered through other departments, such as those of family physicians or a nurse on a health care center’s website or banking or petrol services on a retail centers’ website. Inclusion of these websites thus would have led to a significant overestimation of combinations of clinical and commercial services on community pharmacy websites. This concerned 8.5% (17/200 community pharmacies of the original selection (4 Australian, 4 British, 7 Canadian, and 2 Dutch original selections). When a pharmacy in the random selection had to be excluded from the sample, the next one in the directory was always chosen.
Share of single and chain community pharmacies in the sample.
Pharmacy business type | Community pharmacies | ||||
Australia, |
Great Britain, |
Canada, |
Netherlands, |
All, |
|
Single pharmacy, n (%) | 15 (30) | 10 (20) | 12 (24) | 16 (32) | 53 (27.0) |
Chain pharmacya, n (%) | 35 (70) | 40 (80) | 38 (76) | 34 (68) | 147 (73.0) |
aChain pharmacies are community pharmacies belonging to a group of four or more community pharmacies that operate under a joint brand name and often participate in one or more centralized programs [
Considering the present study’s aims, it is of relevance to note that community pharmacies operating under a chain pharmacy retailer name often participate in one or more centralized programs, such as supply chains, pharmacist training schemes, or store brands. This could impact the variation in the services mentioned on the websites. However, the extent to which individual pharmacies partake in the pharmacy chain’s centralized programs varies between, as well as within, pharmacy chains, while individual pharmacies may also include their own local services on the website. For instance, the Boots community pharmacy from the town of St Austell in the United Kingdom in our sample listed 10 services on its website, whereas the Boots pharmacy from the British town of Peebles in our sample listed only 2 services. That is why each community pharmacy website in the sample was coded separately and often contributed to variation in the data.
Screenshot of website Hollywood Pharmacy, Nedlands (Australia), taken on March 29, 2017.
Screenshot of website Roadnight Pharmacy, Sidcup (Great Britain), taken on March 29, 2017.
Screenshot of website Medsen pharmacy, Hilversum (Netherlands), taken on March 29, 2017.
Screenshot of website Rexall pharmacy (Canada), taken on March 29, 2017.
Clinical services were defined as clinical and pharmaceutical goods and services that are typically restricted to qualified pharmacists and other health care professionals. Three categories of clinical goods and services were distinguished in the coding, based on how current community pharmacy commonly defines its own roles [
In the coding procedure, each community pharmacy website was coded for the presence of the 3 above-mentioned roles of community pharmacy, specifically:
Commercial services were defined as all services mentioned on the community pharmacy websites that are not typically restricted to licensed health care professionals. Again, 3 categories of commercial goods and services were distinguished. The first category reflects pharmacies’ traditional role of the sale of health-related goods and services such as cold and cough medicine or pain relievers to ease and combat ills. The second category, the sale of nonhealth services, reflects the rise of the “drugstore” and “convenience store” concept in community pharmacy with an expanded focus on the sale of a range of everyday products such as cosmetics, snacks, and cleaning supplies. Finally, the third category reflects the move away from the brick-and-mortar commercial sale only, to an e-commerce model with the integration of a Web shop in community pharmacy websites.
In the coding procedure, each community pharmacy website was coded for the presence of the above-mentioned commercial roles of community pharmacy, specifically:
Another part of the coding gauged the combination of clinical and commercial services on (1) the website menu and (2) through website images. The focus thereby was on the homepage as the place where users “land” after opening a pharmacy website.
The menu on the homepage of a community pharmacy website is the main tool that allows users to navigate to specific services. The menu can list items that connect to clinical services on the website (eg, “prescriptions,” “immunizations”), items that connect to commercial services (“fragrances,” “gifts”), or items that connect to other services (eg, “site map,” “home”). In the screenshot of the website of Medsen Pharmacy from the Netherlands in
To gauge the presence of a combination of clinical and commercial services on the homepage menus, each item on the homepage menu was coded as connecting to a clinical service or a commercial service, using the definitions of clinical and commercial services as given above. A category “other” was used for menu items connecting to other utilities or services such as “contact” or “pharmacy locator.”
Images on community pharmacy homepages are usually either static pictures or sliding pages (“carousel format”). They can serve to highlight clinical pharmacy services, such as a photo of a patient having his blood pressure taken (see example of Hollywood pharmacy in
The units of analysis were the community pharmacy websites. Chi-square tests of independence were used to test if the presence of a combination of clinical and commercial services on the community pharmacy websites was contingent on pharmacy types (chain pharmacies and single pharmacies), or country (Australia, Canada, Great Britain, and the Netherlands). Phi coefficients gauged associations between the presence of different categories of services on the websites. Significance levels of
An overview of the specific clinical services listed on the community pharmacy websites can be found in
Disease prevention and detection services came as the second most often category of clinical services presented on the community pharmacy websites, with 79.5% (N=159/200) of the websites mentioning specific services of this type. Among these, blood pressure tests, stop smoking counseling, and flu vaccinations were the most frequently mentioned services. Clinical consultation services were presented on less but still a substantial share of 65.0% (N=130/200) community pharmacy websites. The number one specific clinical consultation service thereby was “medication therapy review and management,” which is used here as an umbrella term for a recognized clinical pharmacy service aimed at optimizing therapeutic outcomes through an assessment of a patient’s patterns of medication use, therapeutic responses, and potentially adverse reactions. Depending upon country, the service is known as medication use review, medication therapy management, or home medicines review [
Presence of clinical services on community pharmacy websites in Australia, Great Britain, Canada, and the Netherlands.
Clinical servicesa | Location of community pharmacies | |||||||
Australia | Great Britain | Canada | Netherlands | All | ||||
50 |
50 |
50 |
50 |
200 |
N/A | |||
Online request for refill prescription medicationc | 0 |
45 |
30 |
49 |
124 |
<.001 | ||
Medication multidosage packagingd | 21 |
8 |
36 |
26 |
91 |
<.001 | ||
Medication home deliverye | 11 |
14 |
33 |
28 |
86 |
<.001 | ||
Medication compoundingf | 10 |
0 |
27 |
4 |
41 |
<.001 | ||
Emergency contraception | 0 |
27 |
0 |
0 |
27 |
<.001 | ||
Online physician for ordering prescription medicationg | 0 |
23 |
0 |
0 |
23 |
<.001 | ||
Minor ailment serviceh | 1 |
13 |
7 |
0 |
21 |
<.001 | ||
Hormone replacement therapyi | 2 |
0 |
9 |
0 |
11 |
<.001 | ||
Opioid substitutionj | 4 |
1 |
2 |
0 |
7 |
<.16 | ||
41 |
43 |
37 |
38 |
159 |
<.44 | |||
Stop smoking counseling | 7 |
30 |
13 |
9 |
59 |
<.001 | ||
Travel health advise | 4 |
0 |
3 |
20 |
27 |
<.001 | ||
Healthy eating and weight advise | 10 |
6 |
5 |
2 |
23 |
<.09 | ||
Medication use during Ramadan advise | 0 |
0 |
0 |
11 |
11 |
<.001 | ||
blood pressure | 33 | 15 | 14 | 0 | 62 | |||
diabetes/glucose | 14 | 9 | 5 | 14 | 42 | |||
cholesterol | 15 | 2 | 2 | 1 | 20 | |||
body mass | 12 | 0 | 0 | 0 | 12 | |||
bowel cancer | 6 | 2 | 0 | 0 | 8 | |||
spot check | 1 | 6 | 0 | 0 | 7 | |||
Chlamydia/gonorrhea | 4 | 1 | 1 | 0 | 6 | |||
anticoagulation | 0 | 2 | 0 | 0 | 2 | |||
Allergy | 0 | 2 | 0 | 0 | 2 | |||
flu | 15 | 21 | 22 | 0 | 58 | |||
travel | 0 | 14 | 20 | 0 | 34 | |||
shingles | 0 | 0 | 7 | 0 | 7 | |||
35 |
36 |
41 |
18 |
130 |
<.001 | |||
Medication therapy review and managementk | 20 |
28 |
40 |
2 |
90 |
<.001 | ||
22 |
20 |
20 |
18 |
80 |
<.85 | |||
asthma/COPD | 11 | 9 | 7 | 14 | 41 | |||
diabetes | 8 | 0 | 13 | 13 | 34 | |||
pain | 1 | 10 | 5 | 0 | 16 | |||
sleep apnea | 11 | 0 | 0 | 0 | 11 | |||
cancer | 0 | 4 | 4 | 0 | 8 | |||
urinary incontinence | 1 | 0 | 0 | 7 | 8 | |||
post-hospital discharge | 3 | 2 | 1 | 1 | 7 | |||
hair loss | 0 | 2 | 1 | 0 | 3 | |||
osteoporosis | 0 | 0 | 3 | 0 | 3 | |||
coeliac | 3 | 0 | 0 | 0 | 3 | |||
erectile dysfunction | 0 | 1 | 1 | 0 | 2 | |||
Absence from work certificatesl | 16 |
0 |
0 |
0 |
16 |
<.001 |
aOnly clinical services that were mentioned on more than one website are included.
bOn the basis of the chi-square test of independence
cPatients submit an online request for a refill of a medicine that a physician prescribed to them earlier, after which the pharmacy arranges the order for the refill directly with the physician and makes the refill medication ready for the patient.
dThe pharmacy promises to deliver medication to the patient’s home, or alternatively patients receive a code that will allow them to open a locker where their medication was deposited.
eA blister package (“webster pak”) or roll of sachets containing the medications a patient should take on a specific day and time, often used for patients on a multiple medication regime.
fThe pharmacy prepares a medicine in-house that is tailored to the specific needs of an individual patient.
gPatients obtain prescription medication for specific conditions by filing an online questionnaire that is reviewed and then ordered by a physician hired by the pharmacy.
hPharmacist advises and prescribes medicine for common, non–life threatening conditions such as eczema, headaches, or coughs.
iA therapy for menopause-related symptoms involving medications to artificially boost hormone levels.
jSubstitution medication for patients with an opioid dependence, including the dispensing of methadone.
kConsultation to review a patient’s medication use to check for possible overlaps or interactions, identify and diminish side effects, and improve a patient’s understanding and medication adherence.
lPharmacist issues a certificate as proof of legitimate absence from work, part of the 2009 Australian Fair Work Act.
Presence of commercial services on community pharmacy websites in Australia, Great Britain, Canada, and the Netherlands.
Commercial services | Location of community pharmacies | ||||||
Australia | Great Britain | Canada | Netherlands | All | |||
25 |
31 |
44 |
25 |
119 |
<.001 | ||
Over-the-counter medicineb | 30 |
31 |
29 |
25 |
115 |
ns | |
Complementary and alternative medicine | 24 |
30 |
29 |
24 |
107 |
ns | |
Home medical aidsc | 33 |
19 |
24 |
22 |
98 |
.03 | |
Diet productsd | 28 |
27 |
17 |
22 |
94 |
ns | |
32 |
30 |
32 |
32 |
126 |
ns | ||
Cosmetic products | 32 |
30 |
32 |
32 |
126 |
ns | |
Foods and beverages | 0 |
5 |
13 |
6 |
24 |
<.001 | |
E-commerce | 20 |
30 |
9 |
32 |
91 |
<.001 |
aOn the basis of the chi-square test of independence
bProducts dispensing of some of the specific classes of over-the-counter drugs can be restricted to pharmacists or drug store owners only. This concerns only a very small portion of the wide range of over-the-counter medicines available.
cTools to mitigate medical treatment or impairment, such as mattress covers, crutches, or shower seats. Usually sold, but sometimes also for hire, through the pharmacy.
dProducts that replace or complement conventional foods, taken for health or cosmetic reasons, such as slimming shakes, vitamins, and gluten-free foods.
The overview of the commercial services presented on the community pharmacy websites in
Although cross-national comparisons were not this study’s primary aim, the last columns in
Presence of services on chain pharmacy websites and single pharmacy websites.
Presence of services | Pharmacy business type | |||
Chain pharmacy |
Single pharmacy |
|||
Dispensing services | 147 (100%) | 53 (100%) | N/A | |
Clinical consultation services | 101 (68.7%) | 30 (57%) | ns | |
Disease prevention and detection services | 120 (81.6%) | 31 (59%) |
<.001 | |
Health-related commercial services | 104 (70.7%) | 22 (42%) | <.001 | |
Nonhealth-related commercial services | 114 (77.6%) | 13 (25%) | <.001 | |
E-commerce | 85 (57.8%) | 7 (13%) | <.001 |
aOn the basis of the chi-square test of independence
The analyses focusing on a combination of clinical and commercial services on community pharmacy websites showed that nearly three quarters (N=145/200, 72.5%) of the community pharmacy websites were a mix of clinical and commercial services. The remaining pharmacy websites presented clinical services only (N=55/200, 27.5%). This confirms that having a combination of clinical and commercial services on the website of licensed community pharmacies is widespread. Although the share of pharmacy websites containing a combination of clinical and commercial services was at least 62% (31/50) in each country, a chi-square test of independence further showed that combinations were not equally common across the 4 countries,
Phi coefficients for the presence of categories of clinical and categories of commercial services on the community pharmacy websites (Φ, 200).
Clinical services | Commercial services | |||
Health-related | Nonhealth-related | E-commerce | All commercial services | |
Dispensing services | .09 | .01 | −.17a | .00 |
Consultation services | .19b | .00 | −.15a | .09 |
Disease prevention and detection services | .14a | .26b | .11 | .26b |
a
b
One of the main elements of community pharmacy websites is the homepage menu that allows users to navigate to specific services on the website. On nearly half of the pharmacy websites’ homepages, namely 99/200 homepages (49.5%), the homepage menu was a combination of clinical and commercial service items. The occurrence of this combination of clinical and commercial services on the homepage menus was further contingent on country and occurred most often on the Canadian websites (37/50, 74%), followed by the British (N=30/50, 60%), Australian (N=24/50, 48%) and finally the Dutch (N=6/50, 12%) websites,
Another way of combining clinical and commercial content on the homepages of the community pharmacies’ websites is through the inclusion of clinical and commercial images on the homepage. More than half of the homepages of community pharmacy websites contained a combination of clinical and commercial images (N=107/200, 53.5%). A combination of clinical and commercial images occurred most often on the homepages of the British pharmacy websites (N=40/50, 80%), followed by the Australian (N=25/50, 50%), Canadian (N=24/50, 48%), and finally the Dutch (N=24/50, 48%) homepages,
Community pharmacy websites are playing an increasingly important role in clinical health care nowadays as they have moved from a static reflection of local premises for dispensing medication to an online “health care hub.” Here, patient consumers can submit electronic prescriptions, order prescription and over-the-counter medication, consult pharmacists on the management of a disease, download software to monitor one’s health, and order vaccinations, personal care, and household products, among other things. Pharmacy licensing however lags behind these developments and often does not include specific regulations about a combination of clinical and commercial services on pharmacy websites. The present study is situated amidst these developments, which may be a significant “social force” as online retail continues to grow but has not received much attention in the literature so far in the context of pharmacy websites [
Through a content analysis of representative samples of licensed community pharmacy websites in Great Britain, the Netherlands, Australia, and Canada, it was found that around three quarters of the websites of licensed community pharmacies currently present a combination of clinical and commercial services. Particularly disease prevention and detection services such as stop smoking counseling and travel health advice were often combined with the sale of commercial services on the websites. This shows, first, that a controversial combination of clinical and commercial services is a common feature of licensed community pharmacy websites nowadays. Furthermore, particularly the inclusion of disease prevention and detection services on the pharmacy websites signals an appeal to a broad group of customers to maintain their health through a combination of timely disease detection and prevention and purchasing health and wellness products such as over-the-counter medicine, diet shakes, and aromatherapy oils.
Up to three quarters of community pharmacies in our sample operate under a chain pharmacy’s retail brand name, and the findings showed that a combination of clinical and commercial services is particularly common on chain pharmacies’ websites, although also nearly half of the single pharmacy websites included a combination of clinical and commercial services. One explanation is that commercial content for chain pharmacy websites is created in the head offices, whereas single pharmacy owners may not have similar resources. Another explanation may be that single pharmacy owners attempt to avoid the controversial combination of clinical and commercial contents on their websites more than chains in an attempt to emphasize adherence to the trade’s traditional values and present as different from the chain pharmacy competition in this respect. Single community pharmacies have been found to prioritize the profession’s fiduciary role more than chain pharmacies [
A final notable finding from this study is that there were few differences across countries in the categories of clinical services mentioned on the community pharmacies websites, and both dispensing services and disease detection and prevention services were mentioned equally often on the community pharmacy websites across countries. This suggests that community pharmacy websites generally include the same scope of services across the four high-income countries. However, there was substantial variation within, as well as across, countries in regard to specific clinical services mentioned on the community pharmacy websites. This can in part be explained by the specific national context. For instance, online pharmacies that are (actually or supposedly) “Canadian” obtained a negative reputation in recent years for allegations of illegitimate e-commerce practices [
Regarding the generalizability of the findings, it is important to note that the present study endeavored to gain insight into the combination of clinical and commercial communication on present-day community pharmacy websites. No claim regarding a one-to-one relationship with the actual services offered at a pharmacy’s premises is made, as this falls outside this study’s aims. It is of further relevance to note that the community pharmacy websites in our sample likely render a somewhat conservative picture of the combination of clinical and commercial content on community pharmacy websites worldwide. First, because the focus of this study was on websites of licensed community pharmacies, rather than the more heavily studied phenomenon of online pharmacies involved in illicit practices [
This paper has drawn attention to the websites of licensed community pharmacies as one of the major online venues in health care where a combination of clinical and commercial services is common practice. One implication is a further recognition in the literature on online DTCA and medical marketing that this is an important area of health care communication on the Internet nowadays. Effects on online patients’ reactions have yet to be studied but, as mentioned in the introductory section, patients often see online health information as more credible and persuasive when it comes from a source that is perceived as having relevant expertise [
chronic obstructive pulmonary disease
direct-to-consumer advertising
American Federal Trade Commission
None declared.