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 [1-3]. That is why such a combination often gives rise to calls for stringent regulatory action, meanwhile generating significant volumes of research. Examples include a combination of clinical and commercial communication in cosmetic surgery [4,5], medical tourism [6,7], and robotic surgery [8,9]. Recent years have also witnessed a lot of alarm surrounding the surge of illicit online pharmacies that sell prescription drugs without a physician’s prescription, and are notorious for the use of hard-line marketing techniques such as mail spamming and search engine contamination [10-12]. On the other hand, remarkably little controversy or research surrounds the websites of regular, licensed community pharmacies. However, as we will argue, community pharmacy websites are gaining increasing importance as online “health care hubs” where patient consumers may submit electronic prescriptions, order prescription and over-the-counter medication, consult pharmacists about a chronic condition, obtain a prescription for a minor ailment, download software to monitor their health, and order personal care and household products, among others. They are also one of the major mainstream venues where professional clinical and commercial communication come together on the Internet [13-17], and this could be a potential minefield where many patients can easily confuse commercial communication for professional advice.

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: To what extent do present-day licensed community pharmacy websites combine clinical and commercial communication? This question was investigated through a systematic content analysis of licensed community pharmacy websites from Australia, Canada, Great Britain, and the Netherlands. Besides gauging a picture of the combination of clinical and commercial content on officially licensed community pharmacies’ websites in a number of Western countries nowadays, this study also provided an overview of the range of clinical and commercial services put forward on present-day community pharmacy websites, guided by the subquestions: What types of clinical services are mentioned on present-day licensed community pharmacy websites? and What types of commercial services are mentioned on present-day licensed community pharmacy websites? Finally, although cross-national comparisons were not the study’s aim, the study could also answer the subquestion: What cross-national differences exist in the types of clinical and commercial services mentioned on community pharmacy websites? Implications for public health education are also discussed.

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 [18]. Also for instance the Israel Medical Association upheld a long-lasting public doctors’ strike after the Israeli government proposed a loosening of the absolute ban on physician advertising in the country [19]. Professional clinical providers also typically have strong adverse attitudes toward marketing and advertising their services [20-22]. On the Internet, this is mirrored in the continuous effort by diverse medical and health associations to establish quality standards for professional health information. This can be seen with examples such as the “Health on the Net Foundation Code of Conduct” (HONcode) which states that “advertising should be clearly distinguished from editorial content.” Similarly, the guidelines of the American Medical Association state that on the Internet “advertising and commercial sponsorship must not influence any editorial content and advertising must be easily discernible from editorial content” [23-25].

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 [26,27]. The premise is that trust is a central feature of clinical professionals’ relationship with their patients, and commercial communication could compromise this trust [3,20]. In persuasive communication literature, the trust that people have in the accuracy and reliability of an information source is referred to as “source credibility.” It is one of the oldest [28] and most frequently studied factors in persuasive communication research [29]. Research exploring the role of source credibility in the acceptance of online health information often shows that online health information is seen as more credible and convincing when the source is a perceived expert, such as a physician or professional health organization, than a lay person [30-34]. A commercial service mentioned on a physician or hospital’s website will thus be likely to be seen as a higher-quality service than the same service featured on, for instance, the website of a brand or an online retailer, such as Amazon.

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 [35], to Kenya [36], Peru [37], and the Vatican [38].

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 20^thcentury, when the “golden age of doctoring” was in its heydays and pharmacists’ role largely hinged on those of physicians [15,39,40]. As one pharmacist said about his time in a community pharmacy in the 1970s, “We were discouraged from talking to patients for fear we would disrupt the doctor-patient relationship” [41]. Pharmacies since, however, have taken on a more patient-centered role and are becoming increasingly more involved in patient therapy [42,43]. Moreover, in recent years many countries such as China, Great Britain, New Zealand, and Switzerland have installed programs for clinical services to be delivered by community pharmacies, in an effort to control the steep rise in costs of clinical care delivered by family physicians and hospitals [44-46]. Community pharmacies’ clinical role thus has risen “like a phoenix from the ashes” [39]. Present-day clinical services offered through community pharmacies may range from patient education, to consultations for patients with chronic conditions, to primary care provision, to actual prescribing [39,47-50]. For instance, Walgreens pharmacy in the United States currently has 400 so-called “health care clinics” across the country where the public may obtain treatment for minor illnesses. Similarly, Boots pharmacy in the United Kingdom features a number of “online clinics” where people can obtain prescription-only medication without going to the doctor for conditions such as erectile dysfunction, period delay, and malaria prevention.

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 [51,52]. Thus, this study aimed to fill the void in knowledge by documenting the types of clinical and commercial services present on licensed community pharmacies’ websites in 4 Western countries and the extent to which the websites contain a combination of clinical and commercial services.

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 [53], and this would significantly hinder identification of the population of licensed pharmacies in these countries. Finally, the United States and New Zealand were excluded because they currently are the only two countries in the world where direct-to-consumer advertising (DTCA) of prescription medication is permitted [3]. This exceptional regulatory status may restrict the generalizability of the findings regarding commercial content on community pharmacy websites, to most other countries in the world where DTCA of pharmaceuticals is prohibited. All in all, this study involved a content analysis of community pharmacy websites from Great Britain, the Netherlands, Canada, and Australia as countries with highly institutionalized and enforced pharmacy legislation and a ban on DTCA for medical drugs. Without making unsubstantiated claims regarding the representativeness of these 4 countries for community pharmacy websites worldwide, this likely renders a conservative rather than exaggerated picture of combinations of clinical and commercial services on community pharmacy websites worldwide nowadays.

Figures 1-4 show screenshots of community pharmacy websites from the sample. Each community pharmacy website in the sample obtained a binary code for the presence or absence of specific categories of clinical and commercial services on the website. Since a number of discrete products and services are concerned that obtain their meaning from the trade’s definition of these products/services, measures of intersubjective agreement were not deemed relevant here and the coding was done by a single author. Below is a rationale for and overview of the coding categories employed.

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 P<.05 were used for all tests.

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, χ²₃ (N=200)=10.91, P=.01. They were most common on the Canadian community pharmacy websites (N=44/50, 88%), followed by the Australian (N=38/50, 76%), British (N=32/50, 64%), and finally the Dutch (N=31/50, 62%) community pharmacy websites. Moreover, whereas more than 4 in every 5 websites from chain pharmacies contained a combination of clinical and commercial services (N=120/147, 82.8%), slightly less than half of the single pharmacy websites did (N=25/53, 47%), resulting in a significant chi-square relationship (χ²₁ (N=200)=24.12, P<.001). A combination of clinical and commercial services on community pharmacy websites was thus more commonly seen on the websites of pharmacies operating under a chain brand than single pharmacies.

Table 5 renders phi coefficients for the degree of association between the presence of specific categories of clinical services and specific categories of commercial services on the community pharmacy websites. It can be seen that specifically the mention of disease prevention and detection services (eg, stop smoking counseling, flu vaccinations, diabetes tests) was significantly associated with the mention of commercial services on the websites. The mention of dispensing services, on the other hand, was unrelated to the mention of commercial services on the websites, whereas there was a significant negative association with the presence of e-commerce services.

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 [47-50]. This study addressed the pertinent question as to what types of clinical and commercial services are mentioned on present-day licensed community pharmacy websites and to what extent the websites currently present a combination of clinical and commercial services. Such a combination is regarded as highly controversial in the clinical professions and tends to frequently raise calls for codes of conduct, regulatory action, or straightforward bans to protect vulnerable patient groups from the undue influence on their preferences for treatment [1-3].

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 [16,58].

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 [59]. It appears that licensed community pharmacies from Canada therefore more often did not include e-commerce options than other countries. Other cross-national differences can be explained by national pharmacy legislation. For instance, receiving a prescription from an online physician through a community pharmacy website occurred only on British pharmacy websites because it is prohibited in the three other countries in our sample [60], while vaccinations through pharmacies, for instance, are not allowed in the Netherlands [61]. The larger share of the cross-national variation however cannot be explained by nation-specific context or legislation, suggesting that the community pharmacies’ offerings are not only shaped by clinical considerations, but also by other factors. Possible factors include insurer-based remuneration programs [62], as well as government- and industry-sponsored health and disease campaigns [1,63].

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 [10-12]. Second, regulations surrounding commercial communication in health care are typically enforced more heavily in the countries in our sample than in middle- or low-income countries [53]. Third and lastly, mass merchants and supermarkets with pharmacy departments were excluded from the present sample since these websites would not allow a clear separation between services mentioned as part of pharmacy departments, versus other store departments. The websites of some of the largest mass merchants in the world such as Wal-Mart, Tesco, and Costco frequently have pharmacy sections as well, which leads to the combination of clinical services with a vast range of commercial services. Although caution is warranted due to a lack of empirical data, the combination of clinical and commercial communication found in this study likely forms a lower bound, rather than an upper bound, of those found on community pharmacy websites across the board.

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 [30-33]. With the increasingly expanding role of community pharmacies in clinical health care provision, this suggests for policy makers and regulatory agencies that the combination of clinical and commercial services on community pharmacy websites is able to impact patients’ beliefs and preferences. It should thereby be noted that, likening to contemporary advertising formats such as sponsored content and native advertising [64,65], the distinction between services restricted to licensed pharmacists versus commercial services is nearly never clearly marked on community pharmacy websites. Due to this, patients cannot immediately tell if a service or product, such as a magnetic therapy service or insect repellent, featured on a community pharmacy website is clinical or commercial. The extant research shows that people are rarely motivated, or able, to distinguish commercial content from editorial content in the absence of clear disclosures [65,66]. All in all, community pharmacy websites clearly are no longer just an online version of a medication dispensing facility alone and should be regarded as a significant party in the controversy over combinations of clinical and commercial communication on the Internet nowadays.