This is a cross-sectional study with a convenience sample of pharmacy customers recruited from community pharmacies in Tromsø, a medium size municipality in Norway (77,000 inhabitants). Persons (aged ≥16 years) able to complete a questionnaire in Norwegian were asked to participate in the study. The study aimed to include respondents during September and October 2020. Due to COVID-19 restrictions, social media was also used to recruit medicine users.

The research team developed a structured questionnaire to collect views on the internet as a source of medicine information. The questionnaire included 12 questions, and the first 7 collected background variables such as age, gender, education, and rural or urban area of residence. We also asked if the respondents were health professionals or not (yes/no). Questions about the number of medicines used during the previous week (none, 1-4, 5-7, 8-10, and ≥10) and if they used regular prescription medicines (yes/no) were added. Regular medicine use was defined as answering yes to the following question: “Do you use prescription medicines regularly? This includes tablets, mixtures, medical creams, eye drops, etc.”

The main questions have been validated in previous research from Finland [21,31]. “In the past 12 months, from which sources did you receive information on the medicine you have been using (both prescription and self-medication)?” The question was followed by a list of available options: physician, pharmacist, package leaflet, nurses, relatives/friends, advertising, and the internet. The respondents could choose more than one option. Those who had chosen the internet option were further asked “In the last 12 months, which websites have you used to obtain medicine information?” Available options provided were the Norwegian public health portal (Helsenorge.no), other official health information sites, pharmacy websites, web-based questions and answers from health professionals, general health and lifestyle sites, and social media. The respondents could include other sources than those provided in the lists above as free text. An additional question registered how much they trusted the web-based sources they used, both in general and for the specific websites listed: “How much do you trust the medicine information you find on the internet/specified website?” Participants were also asked to indicate their level of trust in health personnel as a source of medicine information for comparison: “How much do you trust the medicine information you receive from health personnel?” Lastly, the respondents were asked to indicate why they were searching for medicine information with the following options: to acquire information on how the medicine works, possible side effects, how to take the medicine, or the recommended dosing, or they received insufficient information from health personnel.

The questionnaire was piloted to assess the face and content validity. A total of 8 persons assessed the questionnaire for clarity, ease of completion, and functionality. No modifications were required after the piloting. The pilot data were not included in the analysis.

The main outcome measures were the proportion of respondents who reported using the different medicine information sources, the level of trust in the different sources, and the proportion of respondents reporting reasons for seeking information. The participants rated the level of trust in the different sources and websites using a 4-point scale: completely trustworthy, somewhat trustworthy, not much trustworthy, and not trustworthy.

Managers at 12 pharmacies were asked if they would allow distribution of questionnaires at their premises. Eleven pharmacies agreed to participate, and the questionnaires were distributed to customers in person by one of the researchers (VS). The researcher invited customers to complete a 4-page questionnaire. Those who consented to participate received an information sheet and the questionnaire. The questionnaire was available both on paper and as a web-based version. They were asked to return the completed questionnaire in a prepaid envelope or to complete the survey on the internet. The link to the web-based form was included in the information sheet. They also had the opportunity to complete the questionnaire at the pharmacy. The questionnaires were numbered to keep track of the number of respondents and avoid duplicates. Customers who declined to participate were registered as such. We report the response rate as defined by American Association for Public Opinion Research [50].

After 6 weeks of data collection, the distribution of questionnaires in the pharmacies was stopped due to new COVID-19 restrictions, but we continued distributing questionnaires using social media. Only those who confirmed that they had used a prescription or nonprescription medicine during the last week were included via social media (n=15).

Data were analyzed using IBM SPSS Statistic 25 (IBM Corp). Demographics and responses to the questions about the medicine information sources used, reasons for use, and trust were analyzed using descriptive statistics. Pearson ² test was used to explore univariate association between categorical variables, whereas t test or Mann-Whitney test was used for continuous variables depending on their distribution. We used logistic regression to assess the association of explanatory variables and the use of the internet for medicine information. We included age, gender, education, urban and rural residence, whether the respondents were health personnel, and if they used regular prescription medicines as independent variables. We used a stepwise model with backward selection to decide the final model. The results are presented as odds ratio (OR) and 95% CI. A P value of ≤.05 was considered statistically significant.

The Data Protection Officer at the University Hospital of North Norway approved the study protocol (Project No. 02578). The participants received both written and oral information about the study. Completing the questionnaire was considered as giving informed consent. We included persons aged ≥16 years as they can buy medicines, fill prescriptions, and give informed consent to participate in surveys. The data were handled according to local security requirements. We used the “Good practice in the conduct and reporting of survey research”—a checklist by Kelley et al [51]—to ensure structure and style of this manuscript.

This study found that 125 (41.3%) respondents used the internet to obtain medicine information, and the only factor associated with internet use was age. The odds of using the internet as a source was inversely associated with age and declines 5% per year increase in age. The model showed no association between internet use and gender, level of education, regular medicine use, residency, or if they were health professionals. The main purpose for using the internet was to obtain information about side effects. Other sources of medicine information were physicians, pharmacy personnel, and package leaflets, while 1 in 8 (n=36, 12%) did not ask for or obtain medicine information during the last year. A total of 9 in 10 participants trusted health professionals as a source of medicine information, while almost half of those using the internet trusted the information they found on the internet regardless of sources. The websites considered most trustworthy were the national health portals and other official health information websites.

To our knowledge, this is the first study investigating internet use to obtain medicine information among Norwegian pharmacy customers. Studies from other countries have reported that the use of the internet for medicine information started increasing during the 2000s [31,33-35] and reached up to 37% in 2019 [6,21]. There seems to be an increasing trend in seeking web-based medicine information, and this is supported by our study. Seeking health information on the internet can improve the patient-physician relationship, involvement in one’s own health, and increase shared decision-making [52].

Age was the only variable associated with internet use to obtain medicine information in this study. Not surprisingly, there is a positive association between being young and using the internet for medicine information. This finding is in line with previous research [9,21,31]. Older persons often consider their physician as their main information source, and they are less aware of other sources [31]. Younger persons may consider it easier to find information by using the internet instead of asking health professionals [31,53]. The Eurobarometer from 2014 identified people aged 40-54 years to be the most frequent users of the internet as a source of health information, with 62% using it daily or almost daily [54]. Medicine information-seeking behavior and the use of medicine information sources are influenced by gender and education [31]. Some patients and specific medicine users use the internet more than the general population. For example, studies have reported that 60% of pregnant women and 68% of patients with chronic conditions use the internet for medicine information [24,43]. We found that regular medicine use could potentially influence internet use for medicine information, but this association was not statistically significant. This could be due to selection bias or a limited number of respondents. The frequency of using the internet for medicine information according to regular medicine use, as well as different medicine user groups, should be analyzed in a larger population sample.

This study demonstrates that almost half of those using the internet for medicine information trust the information they find on the internet. When asked which specific websites they trust, public health portals and other validated sites run by government organizations are considered most trustworthy, but pharmacy sites are also considered trustworthy. A very low proportion trusted general health and lifestyle sites and social media. These results suggest that people are aware of the potential for misinformation on websites, which is consistent with previous research [55]. The Eurobarometer study found that >90% of people using the internet state that they know how to navigate the internet to find information about health-related questions, but 40% did not believe the information source was trustworthy [1]. Recognizing trustworthy sites of information is crucial for an evidence-based approach to health care [56]. One recent systematic review found that the mean quality score across web-based health information sites remained good, but few were very good, and none were excellent [39]. The authors found that information from government organizations ranked highest and was most reliable. As our respondents use and trust national health portals and other official health information sites, they seem to be trusting high-quality websites.

We further found that traditional sources, such as physicians, pharmacy personnel, and packet leaflets, are also used for obtaining medicine information. The physician was the main source. This is expected as the physicians prescribe the medicine and explain why the patient should take the medicine [57]. Pharmacists were the second highest source, which may reflect a need to know how to use the medicine correctly. These findings are in line with other studies reporting medicine information sources [21,30,31,55,57,58]. Our study also found that the proportion obtaining medicine information from pharmacy personnel and package leaflets was higher among younger persons and women than among older persons and men, respectively. Regular medicine users obtained medicine information from health professionals and the package leaflet to a greater extent than respondents with no regular medicines. This is not surprising, as those who use medicine on a regular basis most likely see a physician and collect the medicine at the pharmacy more often. Possibly, they may also need more medicine information. Most of our respondents used 1-3 sources for medicine information, which is in line with previous studies [21,43].

Our respondents reported that they mainly used the internet to obtain information about side effects, how the medicine works, and how it should be used. Previous studies have found that patients are mainly interested in more information about side effects and interactions [57,59,60]. Very few of our respondents sought information about interactions. One reason for this may be that they trust the prescribing physician’s knowledge and that they will receive information if they need to avoid certain medications or foods. Another reason may be that they obtain this information from the pharmacists or pharmacy staff. The leaflets provided with the medication list many possible side effects, while the pharmacists may focus on the main ones to watch out for. Most respondents (n=272, 91%) trusted the information they received from health professionals. This is reassuring since physicians and pharmacy personnel are key counselors on medicine use [43]. As health professionals still are the most preferred and trusted source of information [5,6,55], physicians and pharmacists should continue to provide high-quality medicine information to patients and other medicine users in clinical consultations and encounters at the pharmacy. Health personnel may also help medicine users by providing information that they are unaware they needed.

A higher proportion of health professionals obtained medicine information from physicians, pharmacists, and the internet compared to people who are not health professionals. This was expected as they often handle medicines for patients or clients. Hermes-DeSantis et al [61] have shown that almost 90% of health professionals search the internet for health information daily or several times a week, and the most common questions were about medicines, dosing and administration, drug-drug interaction and adverse events, and safety.

One in 8 of the respondents did not obtain medicine information from any source. A study from Finland has analyzed long-term trends of medicine information sources and found that the proportion of medicine users reporting using no medicine information sources increased more than 7-fold from 4% (77/1944) in 1999 to 28% (467/1671) in 2014. They also demonstrated that medicine information received from physicians declined over time [21]. This trend is worrying as more and more health care services are based on patient involvement and shared decision-making, which requires well-informed patients. More repeated-measure studies should be conducted to monitor this trend. Another worrying trend is the increase in the use of web-based pharmacies where the medicines are delivered to patients by post or courier services. This removes the personal contact between the customers and pharmacy staff, and may reduce the general medicine knowledge among medicine users. Increasing the knowledge about the medicine that one is taking should ensure a better understanding of the purpose and use, and as a result improve adherence, health, and patient satisfaction [45].

This study recruited respondents from all but one pharmacy in a medium size municipality in Norway. Demographic variables such as age, gender, and level of education correspond with previous cross-sectional studies involving pharmacy customers [6,55,62,63]. The survey instrument was robust as it was based on questions used in a national repeated survey from Finland [21] implying a high content validity. The questionnaire was piloted to ensure clarity, ease of completion, functionality, and that the length was acceptable. Another strength of this study is that we managed to include the oldest age group. A total of 76 (25%) respondents were older than 70 years, and 30 (10%) were older than 80 years.

The survey was distributed in community pharmacies, and respondents were approached while they were waiting for a prescription or to be served at the counter. The fact that they had the opportunity to complete the questionnaire at the pharmacy might have improved the response rate. However, we were unable to ask all customers, and this might have introduced selection bias. It is possible that persons showing interest were asked more frequently than those who stated that they were busy. Our respondents might also reflect a population more interested in medicine information and the internet in general. All data were self-reported, and the results must be interpreted accordingly.

Medicine users trust the medicine information they receive from health professionals and the websites run by health authorities. A low proportion trust the information they find on social media and general health and lifestyle websites. This result is reassuring as it suggests that people are aware of the potential for web-based misinformation.

The internet is frequently used as a source of medicine information among Norwegian pharmacy customers, but most still obtain information from health professionals and packet leaflets. Medicine users are aware of the potential for web-based misinformation, and they trust websites run by the health authorities.