News Media Coverage of the Problem of Purchasing Fake Prescription Medicines on the Internet: Thematic Analysis

Background More people are turning to internet pharmacies to purchase their prescription medicines. This kind of purchase is associated with serious risks, including the risk of buying fake medicines, which are widely available on the internet. This underresearched issue has been highlighted by many newspaper articles in the past few years. Newspapers can play an important role in shaping public perceptions of the risks associated with purchasing prescription medicines on the internet. Thus, it is important to understand how the news media present this issue. Objective This study aimed to explore newspaper coverage of the problem of purchasing fake prescription medicines on the internet. Methods Newspaper articles were retrieved from the ProQuest electronic database using search terms related to the topic of buying fake prescription medicines on the internet. The search was limited to articles published between April 2019 and March 2022 to retrieve relevant articles in this fast-developing field. Articles were included if they were published in English and focused on prescription medicines. Thematic analysis was employed to analyze the articles, and the Theory of Planned Behavior framework was used as a conceptual lens to develop the coding of themes. Results A total of 106 articles were included and analyzed using thematic analysis. We identified 4 superordinate themes that represent newspaper coverage of the topic of buying prescription medicines on the internet. These themes are (1) the risks of purchasing medicines on the internet (eg, health risks and product quality concerns, financial risks, lack of accountability, risk of purchasing stolen medicines), (2) benefits that entice consumers to make the purchase (eg, convenience and quick purchase, lower cost, privacy of the purchase), (3) social influencing factors of the purchase (influencers, health care providers), and (4) facilitators of the purchase (eg, medicines shortages, pandemic disease such as COVID-19, social media, search engines, accessibility, low risk perception). Conclusions This theory-based study explored the news media coverage of the problem of fake prescription medicines being purchased on the internet by highlighting the complexity of personal beliefs and the range of external circumstances that could influence people to make these purchases. Further research is needed in this area to identify the factors that lead people to buy prescription medicines on the internet. Identifying these factors could enable the development of interventions to dissuade people from purchasing medicines from unsafe sources on the internet, thus protecting consumers from unsafe or illegal medicines.


Background
People are increasingly turning to the internet for many of their needs, and it is anticipated that the number of people obtaining their medicines via the internet will also increase significantly in the near future [1]. This shift is attributed to the advantages that the internet marketplace of medicines offers for consumers, such as convenience, privacy, and accessibility 24 hours a day and 7 days a week [2]. It contrasts with traditional "brick and mortar" pharmacies, which are associated with longer queues, less privacy, and shorter opening times. Additionally, the COVID-19 pandemic has accelerated the purchase of medicines via the internet [3]. A study conducted by researchers from Hungary found that the rate of medicines purchased on the internet increased from 4.2% in 2018 to 44.2% in March 2020 [3].
Many illegal sellers of medicines operate on the internet and fail to meet national or international pharmacy regulations [4]. These sellers offer a wide range of medicines, including prescription medicines, without a prescription being issued and without medical supervision. According to an estimate, 95% of pharmacies on the internet are operating illegally [5]. Several researchers have explored the internet availability of prescription medicines offered by illegal sellers and the accessibility of those medicines without the need for prescriptions. Researchers from the United States conducted an internet-based study to check the availability of prescription psychiatric medicines using Google [6]. They found that 147 (88%) of 167 internet-based pharmacies offered psychiatric drugs without a need for a prescription. In another study, the availability of antibiotics was explored using Yahoo and Google search engines [7]. A total of 20 unique URL addresses were analyzed. The researchers found that 16 (80%) of 20 websites offered antibiotics without a need for a prescription.
The internet availability and accessibility of prescription medicines in the absence of medical oversight present many patient safety risks. Risks include the possibility of misusing medicines and consuming contraindicated medicines [5]. One of the most serious risks associated with purchasing medicines on the internet relates to purchasing and consuming fake medicines (ie, falsified medicines). Fake, falsified, or counterfeit medicines are terms that have been used interchangeably in many studies. All these terms refer to medicines produced under illegal and unregulated conditions [8]. However, some health organizations differentiate between these terms. Counterfeit medicine "are medicines that do not comply with intellectual property rights or that infringe trademark law," while falsified medicines are "fake medicines that are passed off as real medicines" [9]. In other words, counterfeit medicines are linked more to the infringement of intellectual properties, while the term falsified describes medicines that threaten public health. The term "fake medicines" has been deemed to be the best term for communicating with the public about falsified medicines [10]. Our study focuses on falsified medicines, with the term "fake medicines" used to represent these kinds of medicines.
Illegal sellers of medicines on the internet are a potential source of fake medicines, and according to the World Health Organization (WHO), 1 of 2 medicines sold on the internet is fake [11]. A report published by the UK government in July 2022 confirmed that over 285,000 fake medical products were seized across the United Kingdom by Interpol [12]. Thus, people could put themselves at serious risk if they purchase and consume medicines from the internet.
To combat the internet sale of fake medicines, Interpol established Operation Pangea in 2008, which targeted the illegal sellers of medicines (ie, the supply side) [13]. This operation has resulted in the detection and confiscation of millions of fake medicines, as well as many illegal sellers' websites being closed. On the demand side (ie, people who purchase medicines from the internet), several public awareness campaigns have been run by different national and international organizations to alert consumers about the risks of fake medicines available on the internet (eg, Alliance for Safe Online Pharmacies campaigns, #FAKEMEDS, and Fight the Fake campaigns). Besides warning consumers about the risks of fake medicines available on the internet, these campaigns aim to educate them on how to purchase medicines on the internet safely. Despite the abundance of those campaigns, some people continue to buy their prescription medicines over the internet without input from a health care professional. For example, in the United Kingdom, which has a well-established health care system, it was estimated that 1 in 10 people had bought a fake medical product from illegal sellers via the internet in 2020 [12]. This underresearched issue has been highlighted in newspaper articles in the past few years, particularly during the COVID-19 pandemic, when more people turned to the internet to obtain various products [14]. Newspaper coverage of this problem can act in 2 ways. First, taken at face value, this coverage can provide accurate information, for example, on the views and experiences of public and health professionals, including patients, experts, and special authorities that fight fake medicines bought through internet sources (eg, Interpol, WHO, and pharmaceutical companies). There is precedence for using newspapers as a source of data in research [15][16][17][18]. Second, newspaper coverage can have a direct effect on what people think by sharping the news agenda and influencing peoples' views. Thus, newspapers can influence people based on what they emphasize or deemphasize through their content and how this content is curated and presented [19][20][21]. In the context of this study, newspaper stories could potentially help influence social norms.
Accordingly, this study aims to explore the newspaper coverage of the problem of purchasing fake prescription medicines on the internet using the Theory of Planned Behavior (TPB) as a conceptual lens to develop a coding of themes to encapsulate how this issue is presented through news stories.

About the TBP
The TPB is a behavioral theory introduced by Ajzen in 1991 ( Figure 1). The logic for using it in this study is that it can be used to interpret peoples' behaviors based on their intentions [22]. This theory stipulates that peoples' actual behavior is determined by their intentions, which in turn, are predicted by their attitude toward the behavior, subjective norms, and perceived behavioral control [22]. Each of these 3 direct predictors of intention is influenced by indirect determinants, which are a set of salient beliefs, namely, behavioral beliefs, normative beliefs, and control beliefs. Behavioral beliefs about the consequences of a behavior (ie, beliefs about the risks and benefits of a specific behavior) produce an attitude toward the behavior. Normative beliefs about the behavior (ie, consumers' beliefs about how other people would like them to perform) will generate subjective norms. Finally, control beliefs (ie, consumers' beliefs about the facilitators or barriers that influence their ability to control the behavior) will generate the perceived behavioral control in relation to the behavior [23]. The TPB was employed in this study as a conceptual framework to develop the coding of themes.

Data Collection
Data were collected using ProQuest, one of the largest newspaper databases on the internet. The objective was to retrieve articles covering the purchasing of fake prescription medicines on the internet by members of the public. By a consensus among the authors (HA, NP, and PD), the search was carried out using the following search strategy: No article was excluded based on the country of origin or source so that we could obtain a diversified view of the research topic. Figure 2 illustrates the flow diagram of the selection process. The searches revealed 16,357 articles, from which duplicates were removed; these were articles with the same content published in different versions of a newspaper (eg, Sunday and weekday editions) and articles that appeared in both print and web versions of the same newspaper (eg, appearing in both The Telegraph and telegraph.co.uk). Additionally, articles that did not focus on prescription medicines and those that only covered the supply side of fake medicines (eg, efforts to combat illegal sellers of fake medicines) were excluded. The articles yielded were then reviewed by the first author (HA), who screened the titles and content of each article and collected all potentially ambiguous articles for discussion with the second and third authors (NP and PD). After evaluation of the articles using the exclusion criteria, 106 articles remained and constituted the study sample. Multimedia Appendix 1 shows the characteristics of the selected articles (ie, titles, publication date, publishers, and locations).

Data Analysis
Our aim was to analyze the retrieved articles to deconstruct and then reconstruct data to explore the newspaper coverage of the problem of purchasing fake prescription medicines on the internet. To do this, thematic analysis was employed according to the procedure set out by Braun and Clarke [24]. This process was carried out by the first author (HA) and reviewed step-by-step by the other authors (PD and NP). In summary, newspaper articles were read and reread in depth before being coded. Then, the articles were coded and organized into initial thematic groups (themes). The articles were then analyzed and organized using NVivo software (version 12; QSR International). Finally, we reviewed and gathered the initial themes into overarching themes (superordinate themes) in an iterative process guided by our study aim.

Ethics Approval
No ethical approval was required as all the newspapers analyzed are available in the public domain.
The thematic analysis of the included articles revealed four superordinate themes: (1) the risks of purchasing prescription medicines on the internet, (2) the benefits that entice consumers to purchase prescription medicines on the internet, (3) social influencing factors, and (4) the facilitators of purchasing prescription medicines on the internet. A detailed mind map is shown in Figure 3.

Risks of Purchasing Medicines on the Internet (Behavioral Beliefs)
The first superordinate theme to appear presented the risks associated with purchasing prescription medicines on the internet (Table 1).
There was a belief by part of the public that medicines offered on the internet possess a health risk due to the absence of medical oversight, as patients could engage in self-medication, which increases the possibility of misusing or abusing medicines. An additional serious risk highlighted was the risk of fake medicines being available on the internet. For example: Another risk highlighted by the news articles was the possibility of purchasing low-quality medicines, as these might be ineffective due to an absence of active ingredients or an incorrect quantity of these ingredients. Moreover, medicines available on the internet might not meet the standards of quality and hygiene, might not have been stored correctly, and could even contain expired ingredients.

Benefits That Entice Consumers to Purchase Prescription Medicines on the Internet (Behavioral Beliefs)
Another theme that appeared was the benefits that consumers could experience if they decide to purchase prescription medicines on the internet (Table 2).
For example, there was the belief that buying prescription medicines on the internet is more convenient because medicines can be purchased easily and delivered promptly to the consumer's home: There was also the belief that purchasing prescription medicines on the internet could save time and effort by avoiding long waiting times to book an appointment with a doctor, which could be over 2 years in some situations. In contrast, if consumers select the internet route, they can obtain their medicines within days to weeks. The following extract illustrates this point from the perspective of a transgender woman who would otherwise face a long wait for the hormonal medicine they wanted:  The privacy of an internet purchase was highlighted as a factor that averts the need to consult a doctor or obtain a prescription. This is especially the case for sensitive health issues, where the shame of admitting a condition acts as a barrier to seeking care (eg, disclosing sexual dysfunction, addiction to psychoactive medicines, or using slimming pills for weight loss). The following newspaper excerpt highlights this:

Social Influencing Factors (Social Beliefs)
This superordinate theme focuses on the social factors that influence the purchase of prescription medicines on the internet (Table 3).

Facilitators of Purchasing Prescription Medicines on the Internet (Control Beliefs)
Several facilitators and facilitating conditions that can trigger consumers to purchase medicines via the internet were highlighted in the newspaper articles (Table 4). Another facilitator highlighted by the newspaper articles was the outbreak of pandemic viruses, such as COVID-19. Illegal web-based pharmacies took advantage of the high market demand for medicines and personal protection products as well as panic buying (ie, purchasing prescription medicines on the internet from any source during the COVID-19 pandemic due to fears over prescription medicines running out of stock) to make mass profits from the sale of (fake) medicines: The The accessibility to prescription medicines without a need for a prescription was highlighted as another facilitating factor. For example: The "skinny jabs," which contain a prescription-only appetite suppressant known as Saxenda, are meant only for people with a BMI of over 30  Finally, consumers' low perception of the risks associated with purchasing medicines via the internet was discussed by the newspaper articles as another facilitating factor: The survey findings demonstrate that American consumers believe they are more knowledgeable regarding online pharmacies than they are in reality. Further, most are unaware of the risks associated with their use or how to find legitimate sources versus rogue outlets, exposing millions more US consumers to the risk of potential fraud and criminality online.

Principal Results
As more people are turning to the internet to purchase prescription medicines, newspaper coverage of this problem has also increased. This is the first study that analyzed newspaper coverage of the problem of purchasing fake prescription medicines on the internet. The analysis of the included articles revealed four major themes relating to purchasing prescription medicines on the internet, which include (1) the risks associated with the purchase, (2) the benefits that entice consumers to make the purchase, (3) the social influencing factors, and (4) factors that facilitate the purchase. Many of the analyzed articles included more than 1 theme.
Although this study explored newspapers in several countries, which have different health care systems as well as cultural differences among consumers, there was a consensus about the growing serious public risks and patient safety concerns associated with purchasing fake prescription medicines on the internet. Of course, this analysis reports on what newspapers covered rather than the truth of their coverage. In that sense, the articles are treated as data and taken at face value.
The newspaper articles highlighted that consumers were enticed by the convenience, low prices, and privacy afforded by purchasing prescription medicines on the internet. However, assurances of quality, efficacy, and safety cannot be guaranteed if the medicines are purchased via the internet from an illegal source. Moreover, if any unpleasant consequences occur (eg, financial scams, purchasing fake medicines), there is no accountability from the illegal sites. These findings are in line with those of several other studies [2,[25][26][27][28][29].
The newspapers also highlighted several external facilitating conditions that could affect consumers' decision to purchase prescription medicines from the internet, such as medicine shortages. Shortages of medicines caused by a political event (eg, Brexit) or supply chain issues can open the doors to sellers of prescription medicines on the internet. When there are limited sources available to obtain much-needed prescription medicines, this is likely to lead people to use internet sources, even if they are illegal and unsafe. Relating this to the previous literature, this finding is in line with that of a multinational study, which found that oncology medicines affected by shortages were available and accessible on the internet without the need for a medical prescription [30]. Furthermore, in an earlier study conducted in the United States that explored the internet availability of vaccines in shortages, it was suggested that vaccine shortages may lead some patients to seek out alternative sources (including the internet) even if they are not safe [31]. In line with this, a multinational study, which explored consumer behavior of purchasing lifestyle medicines from the internet, found that some consumers were willing to accept safety risks and buy prescription medicines on the internet during emergencies, such as medicine shortages [28].
Pandemics such as COVID-19 were highlighted by many newspaper articles as a facilitating condition that could trigger the panic buying of prescription medicines from any source available on the internet, mostly caused by the fear of prescription medicines running out of stock and feelings of desperation due to an absence of effective COVID-19 cures. Additionally, newspaper articles described how COVID-19 limited access to health care services due to overburdened hospitals and medical staff, which could drive some people to purchase prescription medicines on the internet. Interestingly, we found that many newspaper articles highlighted the impact of COVID-19 on the on internet purchases of prescription medicine; however, few studies have explored this issue [25,32]. Thus, further research might be needed to clarify the impact of COVID-19 on the purchasing of prescription medicines via the internet.
Another important facilitator highlighted by the newspaper articles was the easy accessibility of prescription medicines offered by illegal sellers without the need for a prescription. This result is in line with a study conducted in 2012 [33], which found that 55% (41/75) of the study sample preferred to purchase tramadol (a controlled prescription medicine) on the internet due to its easy access, especially when the doctor refused to prescribe this medication. Likewise, a recent study conducted in the United Kingdom [25] purported that the easy accessibility to prescription medicines on the internet without the need for a prescription can lead people to purchase these types of medications from the internet.
An interesting finding of this study was the ways in which the impact of social media on the purchase of prescription medicines via the internet was described in newspapers. Relating this to research findings, a multinational study found that pregnant women were influenced by support groups available on social media, which provided advice on how to use the medicines or where to source these medicines [34]. Another study conducted in Sweden uncovered many Facebook groups that sold illegal substances, including prescription medicines. The results of this study provide lend further support to the idea highlighted by the newspapers that social media can be a facilitator of communication between buyers and sellers that encourages the purchasing of prescription medicines on the internet [35].
This theory-based study also noted that purchasing fake prescription medicines on the internet can have implications for practice in terms of patient safety. Policy makers should take note of the potent power of news media as an influencer of the public. Newspaper articles are not only reporting and covering the topic of fake medicines available on the internet but can also influence people's decisions and might help protect consumers from the risks of this purchase. To develop a full picture of this problem, additional studies are needed that explore and interpret this consumer behavior and provide behavioral change strategies that could deter people from purchasing prescription medicines on the internet.

Limitations
The findings of this study are subject to some limitations. First, non-English language articles were excluded, which might affect the generalizability of our findings and increase the risk of bias. Another limitation relates to the sample of news sources selected for exploration. This study was limited to newspaper articles and internet news websites and thus excludes perspectives from other news media such as social media, television, and magazines.

Conclusion
This study explored the news media coverage of the problem of purchasing prescription medicines on the internet by highlighting the risks associated with this purchase, the potential benefits that entice consumers to make this purchase, social influencing factors, and the facilitators of the purchase. Policy makers must consider the power of news media as an influencer of the public, as the news media could influence peoples' decisions to purchase prescription medicines over the internet. Future research conducted in this area is needed to identify the factors that lead people to buy prescription medicines via the internet. This will aid the development of interventions to reduce the purchasing of prescription medicines from unsafe internet sources, thus protecting people from the health and safety risks of taking fake medicines.