the influence of drug promotion techniques on …
TRANSCRIPT
THE INFLUENCE OF DRUG PROMOTION TECHNIQUES ON PRESCRIBING DECISIONS
AMONG PHYSICIANS IN SANA’A CITY, YEMEN
MAHMOUD ABDULLAH HUSSEIN AL-AREEFI
UNIVERSITI SAINS MALAYSIA
2013
THE INFLUENCE OF DRUG PROMOTION TECHNIQUES ON PRESCRIBING DECISIONS AMONG PHYSICIANS IN SANA’A CITY,
YEMEN
By
MAHMOUD ABDULLAH HUSSEIN AL-AREEFI
Thesis Submitted in Fulfilment of the Requirements for the Degree of
Doctor of Philosophy
July 2013
i
DEDICATION
This thesis would be incomplete without a mention of the support given me by my brother, Abdulmajied Abdullah, to whom this thesis is dedicated.
ii
ACKNOWLEDGEMENT
The completion of this thesis would not have become a reality without the invaluable
support, sacrifices, encouragement, and inspiration of several individuals and
organisations. Hence, I wish to present my appreciation to all those who extended
their support in many different ways.
I would firstly like to thank my supervisor Professor Mohamed Izham
Mohamed Ibrahim, PhD for guiding my development till I am able to complete a
project of this magnitude. He has worked faithfully to teach me the steps necessary
to develop a well built proposal necessary to get my research started on a solid
ground, and helped to develop this thesis to its full potential. He showed a great deal
of interest in reading, reviewing and giving critical feedback on all aspects of my
thesis. His profound level of knowledge and experience, his constructive criticism
helped keep me constantly focused and enabled me to make the significant progress
required to complete this thesis. Also, I am grateful to him for his continuous
support, morally and financially, that help to push me to a higher level of
achievement than I often thought possible.
I also acknowledge with gratitude the intellectual support of my co-
supervisor Associated Professor Mohamed Azmi Ahmad Hassali, PhD who has
provided me with valuable assistance, especially in the qualitative phase. He helped
open my mind to the techniques and skills handling qualitative research. Also, I am
very grateful for his friendly support and enthusiasm. For both of my supervisors, a
hearty thank you.
I am also grateful for the service and support I received from other staff in the
department of Discipline of Social and Administrative Pharmacy at Universiti Sains
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Malaysia. Many thanks go to the newly elected Programme Chair, Associated
Professor Asrul Akmal Shafie, PhD. My sincerest appreciation also goes to Mr.
Firdauz and all other staff.
I would like to acknowledge my gratitude to Ministry of Public Health &
Population Yemen for its sponsorship, granting me a scholarship to achieve my
doctorate. Particular thanks also go to Dr. Fisal Al-Quhaly the Director of Ministerial
Office of Ministry of Public Health & Population Yemen. Also I owed special
gratitude to Dr. Gamal Nasher, the Deputy Minister, Planning and Development
Sector, Ministry of Public Health & Population Yemen. My special appreciation is
also extended to my friends, Dr Abdullah Al-Dahbly, Dr Yehaya Al-Marany and Dr
Mahfudh Al-Musally, for moral support and encouragement.
Last but not least, I wish to give a heartfelt thanks to my father and mother
who offered their endless support and constant prayers. I’d also like to express my
love and appreciation to my beloved wife, my lovely sons and daughters for their
help and patience for my long absence pursuing this study. Finally, I want to take the
opportunity to thank my brothers and sisters and cousins for their constant support
and encouragement and for reading and providing feedback on early drafts of this
work. I want to express my sincere thanks to them all. This academic journey would
not have been possible without their love, patience, and sacrifices along the way.
iv
TABLE OF CONTENTS
DEDICATION .............................................................................................................. i
ACKNOWLEDGEMENT ........................................................................................... ii
TABLE OF CONTENTS ............................................................................................ iv
LIST OF TABLES .................................................................................................... xiii
LIST OF FIGURES .................................................................................................. xvi
LIST OF ABBREVIATION ................................................................................... xviii
PUBLICATIONS ...................................................................................................... xix
ABSTRAK ................................................................................................................. xx
ABSTRACT ............................................................................................................ xxiii
CHAPTER 1 GENERAL INTRODUCTION .............................................................. 1
1.1 Background ................................................................................................... 1
1.2 Country profile and pharmaceutical sector background ................................ 3
1.3 Problem statement ......................................................................................... 4
1.4 Rationale for and importance of the study .................................................... 6
1.5 Significance of the study’s findings .............................................................. 8
1.6 Objectives .................................................................................................... 11
1.7 Thesis overview ........................................................................................... 12
CHAPTER 2 LITERATURE REVIEW ..................................................... 13
2.1 Introduction ................................................................................................. 13
2.2 Concepts and terminology ........................................................................... 14
2.3 An overview of the factors that influence physicians’ prescribing decisions ......................................................................................................................15
2.4 Sources of drug information ........................................................................ 19
2.4.1 Classification of drug sources of information ...................................... 20
2.4.2 Availability and access to up-to-date drug information ....................... 21
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2.4.3 The role of commercial information sources in prescribing and the adoption of a new drug ....................................................................................... 22
2.5 Drug promotion ........................................................................................... 24
2.5.1 Pharmaceutical promotion techniques ................................................. 25
2.5.2 Medical students' exposure to drug promotion techniques .................. 26
2.5.3 Interactions between MRs and physicians in training.......................... 27
2.5.4 Physicians’ interactions with medical representatives ......................... 29
2.5.5 Attitudes toward interactions with medical representatives................. 31
2.5.6 Physicians’ perceptions for appropriateness of pharmaceutical promotional techniques ....................................................................................... 35
2.5.7 Relationships between physicians’ attitude to and their interaction with medical representative activities ................................................................. 38
2.5.8 Influence of pharmaceutical promotion techniques on physician prescribing practices ........................................................................................... 40
2.5.9 Characteristics of physicians frequently see medical representatives .. 47
2.5.9(a) Gender ........................................................................................... 47
2.5.9(b) Age ................................................................................................ 48
2.5.9(c) Physicians’ experience .................................................................. 48
2.5.9(d) Specialty........................................................................................ 49
2.5.9(e) Other practice setting factors ........................................................ 49
2.6 Background theory of research conceptual framework ............................... 51
2.6.1 Contextual factors influencing prescribing .......................................... 51
2.6.1(a) Marketing mix............................................................................... 57
2.6.2 Theoretical background of factors influencing prescribing ................. 58
2.7 General conclusions .................................................................................... 61
2.8 Development of research conceptual framework ........................................ 63
2.9 Research questions ...................................................................................... 65
2.10 Research hypothesis .................................................................................... 66
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CHAPTER 3 RESEARCH PHASE 1: QUALITATIVE ............................. 70
3.1 Introduction ................................................................................................. 70
3.2 Objective of the study .................................................................................. 71
3.2.1 General objective: ................................................................................ 71
3.2.2 Specific objectives: .............................................................................. 71
3.3 Overview of qualitative methodology ......................................................... 72
3.3.1 Sample size in qualitative research ...................................................... 73
3.3.2 Selection of sampling approach for this study ..................................... 74
3.3.3 Data collection and analysis ................................................................. 74
3.3.4 Validity and reliability of qualitative data ........................................... 76
3.4 Part 1: Study exploring medical representatives views on current drug promotion techniques in Yemen ............................................................................. 78
3.4.1 Introduction .......................................................................................... 78
3.4.2 Methodology ........................................................................................ 80
3.4.3 Result ................................................................................................... 81
3.4.3(a) Theme 1: Use of educational materials as a drug promotion technique .......................................................................................................82
3.4.3(b) Theme 2: Provision of free medical samples ................................ 83
3.4.3(c) Theme 3: The role of organising symposia and other scientific meetings in drug promotion ............................................................................ 85
3.4.3(d) Theme 4: Strategies employed to strengthen relationships between prescriber and company .................................................................... 86
3.4.3(e) Theme 5: The role of gift and incentive provision in drug promotion activity ........................................................................................... 86
3.4.3(f) Theme 6: Provision of commercial offers .................................... 88
3.4.3(g) Theme 7: Personal views on current pharmaceutical promotion practices in Yemen .......................................................................................... 89
3.4.4 Discussion ............................................................................................ 90
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3.5 Part 2: Physicians' perceptions of pharmaceutical representative visits in Yemen .................................................................................................................... 93
3.5.1 Introduction .......................................................................................... 93
3.5.2 Methodology ........................................................................................ 95
3.5.3 Result ................................................................................................... 96
3.5.3(a) Physicians’ interaction with pharmaceutical representatives ....... 97
3.5.3.a.1 Theme 1: Welcoming interactions with all representatives ....... 98
3.5.3.a.2 Theme 2: Selecting representatives to meet with....................... 98
3.5.3.a.3 Theme 3: Avoiding meetings ..................................................... 98
3.5.3(b) Reasons for receiving representative visits ................................... 99
3.5.3.b.1 Theme 1: Mutual benefits .......................................................... 99
3.5.3.b.2 Theme 2: Convenient access to new information .................... 100
3.5.3.b.3 Theme 3: Perceived legitimacy of representatives as providers of information ............................................................................................ 100
3.5.3.b.4 Theme 4: Moral duty; social contracts with MR .................... 101
3.5.3(c) Reasons for not receiving representatives’ visits ........................ 102
3.5.3.c.1 Theme 1: Commercial context ................................................ 102
3.5.3.c.2 Theme 2: Obligations; lack of conviction about the product .. 102
3.5.3.c.3 Theme 3: Lack of credibility of representatives ..................... 103
3.5.3.c.4 Theme 4: Inappropriate timing of visits .................................. 104
3.5.3(d) Theme 5: Skepticism toward pharmaceutical representatives .... 104
3.5.4 Discussion .......................................................................................... 106
3.6 Part 3: The factors that influence physicians’ prescribing decisions and the role of pharmaceutical marketing firms.......................................................... 109
3.6.1 Introduction ........................................................................................ 109
3.6.2 Methodology ...................................................................................... 110
3.6.3 Result ................................................................................................. 113
3.6.3(a) Theme 1: Indications .................................................................. 114
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3.6.3(b) Theme 2: Patient characteristics/contexts ................................... 115
3.6.3(c) Theme 3: Drug characteristics .................................................... 116
3.6.3(d) Theme 4: Drug company marketing activities ............................ 117
3.6.3.d.1 Theme 1: Engagements with different companies ................... 120
3.6.3(e) Theme 5: Environmental factors................................................. 120
3.6.3(f) Theme 6: Physicians’ factors ...................................................... 122
3.6.3.f.1 Experiential knowledge ........................................................... 122
3.6.3.f.2 Preference for a local company ................................................ 123
3.6.3.f.3 Curiosity about the drug ........................................................... 123
3.6.3(g) Theme 7: The complexity of prescribing and the role of pharmaceutical companies ............................................................................ 123
3.6.4 Discussion .......................................................................................... 124
3.7 General conclusions .................................................................................. 126
CHAPTER 4 QUANTITATIVE RESEARCH ......................................... 128
4.1 Introduction ............................................................................................... 128
4.2 Quantitative methodology ......................................................................... 128
4.2.1 Research design .................................................................................. 129
4.2.2 Ethical considerations ........................................................................ 129
4.2.3 Study location .................................................................................... 129
4.2.4 Study duration .................................................................................... 130
4.2.5 Study population and sampling .......................................................... 130
4.2.5(a) Sample size ................................................................................. 131
4.2.6 The development of the survey instruments ...................................... 133
4.2.7 Study variables ................................................................................... 135
4.2.7(a) Independent variables (IV) ......................................................... 136
4.2.7.a.1 Sources of information ............................................................. 136
4.2.7.a.2 Physicians’ interactions with MRs ........................................... 136
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4.2.7.a.3 Belief in the appropriateness of accepting promotional items from pharmaceutical companies (Subjective norm) .................................. 137
4.2.7.a.4 Attitude toward interactions with MRs .................................... 138
4.2.7.a.5 Perceived behavioural control .................................................. 139
4.2.7.a.6 Physicians’ characteristics and practice-setting factors ........... 140
4.2.7(b) Dependent variables (DV) .......................................................... 141
4.2.7.b.1 Physicians’ interactions with MRs ........................................... 141
4.2.7.b.2 Prescribing decision behaviours............................................... 141
4.2.8 Data collection ................................................................................... 142
4.2.9 Data analysis ...................................................................................... 143
4.2.9(a) Descriptive analysis .................................................................... 144
4.2.9(b) Inferential analysis ...................................................................... 145
4.2.9.b.1 Independent t-test analysis ....................................................... 145
4.2.9.b.2 Mann–Whitney test .................................................................. 145
4.2.9.b.3 Analysis of variance (ANOVA) ............................................... 146
4.2.9.b.4 Kruskal-Wallis test ................................................................... 146
4.2.9.b.5 Multiple regression analysis .................................................... 147
4.2.9.b.6 Test assumption of multiple linear regressions ........................ 148
4.3 Results ....................................................................................................... 150
4.3.1 Results (section 1) .............................................................................. 151
4.3.1(a) Response rate .............................................................................. 151
4.3.1(b) Physicians’ characteristics and practice-setting factors .............. 152
4.3.2 Results (section 2): factors influencing physicians’ interactions with MRs .............................................................................................................154
4.3.2(a) Descriptive statistics ................................................................... 154
4.3.2.a.1 Belief in the appropriateness of accepting drug company promotions ................................................................................................. 154
4.3.2.a.2 Attitude of physicians toward drug promotion activities ......... 155
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4.3.2.a.3 Physicians’ interactions with MRs ........................................... 158
4.3.2(b) Goodness of fit of the selected measures .................................... 160
4.3.2.b.1 Factor analysis results of physicians’ interactions with MRs’ promotional techniques ............................................................................. 161
4.3.2.b.2 Factor analysis results of belief in the appropriateness of accepting promotional techniques ............................................................. 163
4.3.2.b.3 Factor analysis results of attitudes toward drug promotion activities ..................................................................................................165
4.3.2.b.4 Reliability measurement .......................................................... 168
4.3.2(c) Comparing the score of different variables included in study model 1 across groups of physicians’ characteristics and practice-setting factors .. 169
4.3.2.c.1 Comparing the score of attitude of physicians toward drug promotion activities across groups of physicians sorted by characteristics and practice-setting factors ........................................................................ 170
4.3.2.c.2 Comparing the scores of “belief in the appropriateness of accepting pharmaceutical companies’ promotional techniques” across groups of physicians’ characteristics and practice-setting factors ............ 174
4.3.2.c.3 Comparing the score of “physicians’ interaction with MRs” across groups of physicians’ characteristics and practice-setting factors . 176
4.3.2(d) Hypothesis testing survey model 1: Factors influencing physicians’ interactions with MRs ................................................................ 180
4.3.2.d.1 Descriptive statistics and correlation analysis ......................... 181
4.3.2.d.2 Test assumption of multiple linear regressions ........................ 182
4.3.2.d.3 Result of multiple regression (testing of hypothesis) survey model1 ..................................................................................................183
4.3.3 Results (section 3): the factors that influence physicians’ prescribing decisions............................................................................................................ 188
4.3.3(a) Descriptive statistics ................................................................... 188
4.3.3.a.1 Sources of information about new drugs ................................. 188
4.3.3.a.2 Physicians’ perceptions about the factors which influence their prescribing decisions ......................................................................... 189
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4.3.3.a.3 Physicians prescribing behaviour............................................. 191
4.3.3(b) Goodness of fit of the selected measures .................................... 193
4.3.3.b.1 Results of factor analysis—sources of information ................. 194
4.3.3.b.2 Results: Factor analysis—physicians’ perceptions of the factors which influence their prescribing decisions .................................. 196
4.3.3.b.3 Reliability measurement .......................................................... 198
4.3.3(c) Comparing the score of different variables included in study model 1 across groups of physicians sorted by characteristics and practice-setting factors.................................................................................................199
4.3.3.c.1 Comparing the score of sources of information across groups of physicians sorted by characteristics and practice-setting factors .......... 199
4.3.3.c.2 Comparing the score of physicians’ perceptions of factors which influence their prescribing decisions across groups of physicians sorted by characteristics and practice-setting factors. ............................... 203
4.3.3.c.3 Comparing the scores of the prescribing decisions scales across groups of physicians sorted by characteristics and practice-setting factors ..................................................................................................206
4.3.3(d) Hypothesis testing of survey model-2: Factors influencing physicians’ prescribing decisions .................................................................. 209
4.3.3.d.1 Descriptive statistics and correlation analysis ......................... 211
4.3.3.d.2 Test assumption of multiple linear regressions ........................ 212
CHAPTER 5 DISCUSSION ...................................................................... 217
5.1 Introduction ............................................................................................... 217
5.2 Part 1: The factors which influence physicians’ interactions with MRs ... 217
5.2.1 Physicians' belief in the appropriateness of accepting promotional techniques ......................................................................................................... 217
5.2.2 Physicians’ attitudes toward interactions with MRs .......................... 219
5.2.3 Physicians’ interactions with MRs ..................................................... 223
5.2.4 Study model 1: factors which influence physicians’ interactions with MRs .............................................................................................................226
5.3 Part 2: The factors that influence physicians’ prescribing decisions ........ 228
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5.3.1 Sources of information about new drugs ........................................... 228
5.3.1(a) Company-direct information sources.......................................... 230
5.3.1(b) Company-indirect information sources ...................................... 231
5.3.1(c) Non-company information sources ............................................. 232
5.3.2 Physicians’ perceptions of the factors which influence their prescribing decisions......................................................................................... 233
5.3.3 Perceived influence of MRs’ activities on physicians’ prescribing practices .............................................................................................................236
5.3.4 Model 2: the factors that influence physicians’ prescribing decisions .............................................................................................................237
CHAPTER 6 THESIS CONCLUSION AND RECOMMENDATION .... 239
6.1 Study summary and conclusions ............................................................... 239
6.2 Limitations of the Study ............................................................................ 243
6.3 Strengths of the study ................................................................................ 244
6.4 Recommendations ..................................................................................... 245
6.5 Suggestion for future studies ..................................................................... 248
REFERENCES ......................................................................................................... 250
Appendices ............................................................................................................... 269
Appendix A Interview guidelines ............................................................................ 270
Appendix B Letters .................................................................................................. 285
Appendix C Questionnaire ....................................................................................... 290
Appendix D Tables .................................................................................................. 307
Appendix E Figures ................................................................................................. 318
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LIST OF TABLES
Table 3. 1 Demographic characteristic of the participants ......................................... 81
Table 3. 2 Physicians' characteristics (n=32) ............................................................. 96
Table 3. 3 Physicians' practice setting ....................................................................... 97
Table 3. 4 The index drugs ....................................................................................... 112
Table 3. 5 Classification framework of physicians’ reasons for prescribing or not study drugs ............................................................................................................... 113
Table 4. 1 Response rate .......................................................................................... 131
Table 4.2 Physicians’ characteristics and practice factors ....................................... 153
Table 4.3 Factor analysis of physicians’ interactions with MRs’ promotional techniques ................................................................................................................. 161
Table 4.4 Belief in the appropriateness of accepting promotional techniques ........ 163
Table 4.5 Factor Analysis: attitude of physicians toward drug promotion activities .................................................................................................................................. 165
Table 4.6 Reliability measurement .......................................................................... 169
Table 4.7 Differences in attitude toward pharmaceutical companies among groups of physicians’ characteristics and practice-setting factors ....................................... 171
Table 4.8 Differences in “attitude toward ethical pharmaceutical promotion” among groups of physicians’ characteristics and practice-setting factors ............... 172
Table 4.9 Differences in attitude toward MRs among groups of physicians’ characteristics and practice-setting factors............................................................... 173
Table 4.10 Differences in “belief in the appropriateness of accepting high-value promotions” among groups of physicians’ characteristics and practice-setting factors ....................................................................................................................... 175
Table 4.11 Differences in “belief that it is appropriate to accept low-value promotions” among groups of physicians’ characteristics and practice-setting factors ....................................................................................................................... 176
Table 4.12 Differences in “received low-value promotions” among groups of physicians’ sorted by characteristics and practice-setting factors............................ 177
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Table 4.13 Differences in “received high-value promotion” among groups of physicians sorted by characteristics and practice-setting factors ............................. 179
Table 4.14 Summary of the construct’s variables in survey model 1 ...................... 182
Table 4. 15 The relationship between independent variables and physicians’ interactions with MRs .............................................................................................. 184
Table 4. 16 The relationship between independent variables and physicians’ interactions with MRs .............................................................................................. 185
Table 4.17 Results of factor analysis: rotated component matrix—sources of information ............................................................................................................... 194
Table 4.18 Result of factor analysis—physicians’ perceptions about which factors influence their prescribing decisions ........................................................................ 197
Table 4.19 Reliability measurement ........................................................................ 199
Table 4.20 Differences between company-direct information sources among groups of physicians sorted by characteristics and practice-setting factors ............. 200
Table 4.21 Differences in score of company-indirect information sources among groups of physicians sorted by characteristics and practice-setting factors ............. 201
Table 4. 22 Differences in score of non-company information sources among groups of physicians sorted by characteristics and practice-setting factors ............. 202
Table 4.23 Differences in the scores of motivation factors (drug promotion-related factors) among groups of physicians sorted by characteristics and practice-setting factors ....................................................................................................................... 204
Table 4.24 Differences in score of company scientific discourse among groups of physicians sorted by characteristics and practice-setting factors ......................... 205
Table 4.25 Independent t-test differences in score of drug attribute among groups of physicians sorted by characteristics and practice-setting factors ......................... 206
Table 4.26 Independent t-test results of the differences in score of prescribing decisions among groups of physicians sorted by characteristics and practice-setting factors ....................................................................................................................... 208
Table 4. 27 Multiple regressions analysis the relationship between independent variables and physicians’ prescribing decisions ...................................................... 212
Table 4. 28 Multiple regressions analysis the relationship between independent variables and physicians’ prescribing decisions ...................................................... 213
Table 4. 29 Perceptions of physicians toward drug promotion techniques.............. 308
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Table 4. 30 Attitude of physicians toward drug promotion activities ...................... 309
Table 4. 31 Physicians’ interaction with MRs promotion techniques ..................... 310
Table 4. 32 Sources of information about new drugs .............................................. 311
Table 4. 33 Physicians perception about the factors influence prescribe ................ 312
Table 4. 34 Multiple Comparisons (Tukey HSD)categories of No. of MR per week: attitude toward pharmaceutical company ...................................................... 313
Table 4. 35 Multiple Comparisons (Tukey HSD)categories of No. of MR per week: attitude toward MRs ...................................................................................... 313
Table 4. 36 Multiple Comparisons (Tukey HSD) categories of No. of MR per week: Received low value promotion ...................................................................... 314
Table 4. 37 Post-hoc analysis with Mann-Whitney test compare received high value promotion score across physicians position ................................................... 314
Table 4. 38 Post-hoc analysis with Mann-Whitney test compare received high value promotion score across number of MRs per week groups ............................. 315
Table 4. 39 Multiple Comparisons (Tukey HSD) categories of No. of MR per week: company direct information source ............................................................... 315
Table 4. 40 Multiple Comparisons (Tukey HSD) categories of No. of MR per week: company indirect information source ............................................................ 316
Table 4. 41 Multiple Comparisons (Tukey HSD) categories of No. of MR per week: scores of drug promotion related factors ....................................................... 316
Table 4. 42 Multiple Comparisons (Tukey HSD) categories of No. of MR per week: scores of prescribing decisions ...................................................................... 317
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LIST OF FIGURES
Figure 1. 1 Thesis overview flow chart ...................................................................... 12
Figure 2. 1 Factors influencing prescribing – complexity (Sterky et al., 1991; Tomson, 1991) ........................................................................................................... 52
Figure 2. 2 Factors at different levels in society influencing physicians’ drug prescribing behaviour in clinical practice (Rahmner, 2009). ..................................... 53
Figure 2. 3 Influences on physicians’ prescribing behaviour (Spiller and Wymer, 2001) .......................................................................................................................... 54
Figure 2. 4 Proposed model of prescription decision making for a physician in an Outpatient Setting (Gallan, 2004). ............................................................................. 55
Figure 2. 5 Drivers of uptake of new medicines in secondary care (Chauhan and Mason, 2008). ............................................................................................................ 56
Figure 2. 6 Exploration of direct and indirect influences on prescribing from the scenario (Kyle et al., 2008) ........................................................................................ 57
Figure 2. 7 Marketing mix ......................................................................................... 58
Figure 2. 8 Theory of planned behaviour (Ajzen, 1991)........................................... 59
Figure 2. 9 Drug choice model (Denig et al., 1988; Denig, 1994) .......................... 60
Figure 2. 10 Factors that potentially affect physicians’ control beliefs and perceived behavioural control (Lambert et al., 1997)................................................................. 60
Figure 2. 11 Survey model 1: conceptual framework of factors which influence physician interactions with MRs ................................................................................ 64
Figure 2. 12 Survey model 2: conceptual frameworks of factors which influence physicians’ prescribing decisions ............................................................................... 65
Figure 3. 1 Stages of thematic analysis ...................................................................... 75
Figure 4. 1 Flow chart of sampling frame and response rate ................................... 152
Figure 4. 2 Belief in the appropriateness of accepting drug company promotions .. 155
Figure 4. 3 Positive attitudes statements toward drug promotion activities ............ 156
Figure 4. 4 Negative attitudes statements toward drug promotion activities ........... 158
Figure 4. 5 Physicians’ interactions with MRs ........................................................ 160
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Figure 4.6 Survey model 1: Conceptual framework of factors which influence physician interactions with MRs .............................................................................. 180
Figure 4. 7 Sources of information about new drugs ............................................... 189
Figure 4. 8 Physicians’ perceptions of the factors which influence their prescribing decisions ................................................................................................................... 191
Figure 4. 9 Belief influences on the prescribing decision ........................................ 191
Figure 4. 10 Perceived influences of MRs on prescribing decisions ....................... 192
Figure 4. 11 Changes in drug prescribing behaviour ............................................... 193
Figure 4.12 Survey model 2: conceptual frameworks of factors which influence physicians’ prescribing decisions ............................................................................. 209
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LIST OF ABBREVIATION
BNF British National Formulary
CME Continuing Medical Education
GDP Gross Domestic Product
GPs General practitioners
MEMI Middle East Medical Index
MIMS Monthly Index of Medical Specialities
MoPHP Ministry of Public Health & Population
MRs Medical Representatives
SBDMA Supreme Board of Drug and Medical Appliances
WHO World Health Organization
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PUBLICATIONS AND CONFERENCE ATTENDANCE
Al-Areefi, M. A., Hassali, M. A. & Ibrahim, M. I. M. (2012). A qualitative study exploring medical representatives’ views on current drug promotion techniques in Yemen. Journal of Medical Marketing: Device, Diagnostic and Pharmaceutical Marketing, 12, 143-149.
Al-Areefi, M. A., Hassali, M. A. & Mohamed Ibrahim, M. I. The role of pharmaceutical marketing and other factors in prescribing decisions: The Yemeni experience. Research in Social and Administrative Pharmacy. In Press
Al-Areefi MA, Izham MIM, Hassali MA. (2013). Physicians’ Perceptions, beliefs and attitudes toward interactions with pharmaceutical company medical representatives. First international conference bioethics and professional practice. International Medical University, Kuala Lumpur, Malaysia. 8 - 9 May 2013.
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PENGARUH TEKNIK PROMOSI UBATAN ATAS KEPUTUSAN
MEMPRESKRIPSI DALAM KALANGAN DOKTOR DI BANDAR SANA’A,
YEMEN
ABSTRAK
Industri farmaseutikal melabur banyak dalam promosi dan ia menggunakan berbagai
strategi promosi untuk mempengaruhi keputusan doktor untuk mempreskripsi.
Tujuan kajian ini adalah untuk meneroka faktor-faktor yang digunakan untuk
mempengaruhi keputusan doktor mempreskripsi dan peranan mereka dalam proses
membuat keputusan. Khususnya, kajian ini menyiasat hubungan antara doktor dan
wakil industri farmaseutikal dan untuk mengenal pasti persepsi doktor, kepercayaan
dan sikap ke arah interaksi dengan wakil industri farmaseutikal tersebut, dan untuk
meneroka faktor-faktor yang berpotensi diubah suai yang mempengaruhi interaksi
mereka; untuk mengenal pasti sumber utama maklumat doktor gunakan untuk
mendapatkan pengetahuan mengenai ubat-ubatan baru dan untuk meneroka
bagaimana mereka mempengaruhi keputusan doktor mempreskripsi; dan untuk
menyiasat hubungan ciri-ciri doktor dan faktor penempatan amalan dengan faktor-
faktor yang lepas. Kajian ini telah dijalankan menggunakan kaedah langkah demi
langkah. Dalam fasa pertama, kaedah kajian kualitatif telah digunakan untuk
memahami secara mendalam fenomena berkaitan persekitaran dan sejauh mana
masalah teknik promosi ubat. Dalam fasa kedua, kaedah kuantitatif, iaitu kajian
keratan lintang telah digunakan. Kajian dilaksanakan di Sana’a, Yemen. Doktor di
hospital awam dan swasta telah diselidiki. Kesemua instrumen telah diuji ukuran
kebolehkepercayaan dan kesahihannya. Analisis deskriptif dan inferensi termasuk
xxi
taburan frekuensi, peratusan, min (sisihan piawai), median (julat interkuartail), ujian-
ujian t sampel tidak bersandar, Mann–Whitney, analisis varians, Kruskal-Wallis,
analisis faktor, dan analisis regresi linear berganda telah digunakan. Paras signifikan
adalah 0.05. Dapatan kajian fasa satu mendedahkan bahawa kebanyakan wakil-
wakil industri farmaseutikal yang ditemuramah tidak mempunyai pengetahuan
mengenai tatakelakuan, dan penggunaan teknik-teknik promosi mereka yang berbeza
bergantung pada strategi syarikat, pertimbangan dan/atau kemahiran mereka sendiri,
dan tekanan daripada doktor dan jabatan jualan industri farmaseutikal. Kebanyakan
doktor didapati menyambut baik kunjungan wakil penjual dan menganggap
menerima sampel percuma, hadiah dan pelbagai sokongan sebagai amalan biasa.
Walaupun doktor melaporkan kumpulan faktor yang mempengaruhi proses
mempreskripsi seperti indikasi ubat-ubatan, sifat-sifat ubat, konteks pesakit, faktor-
faktor persekitaran dan pemasaran farmaseutikal, mereka masih bergantung kepada
pengalaman peribadi mereka apabila membuat keputusan mempreskripsi. Selain itu,
keputusan mereka untuk memilih ubat tertentu mungkin berdasarkan hubungan
mereka dengan wakil syarikat dan aktiviti pemasaran firma. Penemuan daripada fasa
kedua kajian mendedahkan bahawa sebahagian besar doktor melaporkan telah
menerima sampel ubat-ubatan (n=432, 96.2%), hadiah kecil (n=384, 85.5%) dan
telah dijemput untuk seminar atau simposium oleh syarikat farmaseutikal (n=381,
84.9%) dalam tempoh enam bulan sebelum menjawab soal selidik ini. Lebih
daripada 80% (n=375; 83.5%) responden menganggap wakil syarikat sebagai satu
cara yang berguna untuk belajar tentang ubat-ubatan baru, dan majoriti (n=383,
85.1%) menegaskan bahawa mereka akan terus untuk bertemu dengan wakil
syarikat. Selain itu, kekerapan lawatan wakil syarikat untuk doktor didapati berkaitan
dengan pemberian barangan promosi yang lebih. Doktor yang mempunyai komitmen
xxii
pekerjaan lebih masa dan mempunyai kaitan akademik adalah lebih cenderung secara
signifikan untuk menerima barangan promosi yang bernilai rendah. Walau
bagaimanapun, doktor lelaki, doktor am dan pakar yang mempunyai komitmen
pekerjaan hari biasa dan mempunyai klinik swasta adalah jauh lebih cenderung
secara signifikan untuk menerima barangan promosi yang bernilai tinggi.
Kepercayaan doktor dalam kesesuaian penerimaan mereka terhadap item-item
promosi, di samping, sikap terhadap syarikat-syarikat farmaseutikal telah didapati
mempunyai peranan penting dalam meramalkan interaksi doktor dengan syarikat
farmaseutikal (Adj. R2=0.208). Juga penemuan yang diperolehi daripada model
regresi kajian ini mencadangkan bahawa, kepercayaan doktor dalam kesesuaian
penerimaan mereka terhadap barangan promosi, interaksi dengan syarikat
farmaseutikal, penerima barangan promosi bernilai rendah dan sumber maklumat
langsung daripada syarikat mempunyai peranan dalam meramalkan keputusan
mempreskripsi oleh doktor (Adj. R2=0.422). Doktor mempunyai sikap yang
bercampur-campur terhadap perkhidmatan maklumat yang disediakan oleh wakil
syarikat. Majoriti doktor mempercayai bahawa kebanyakan teknik promosi tidak
menimbulkan masalah etika utama. Kajian ini menjelaskan peranan syarikat-syarikat
farmaseutikal dalam mempengaruhi keputusan mempreskripsi, dan meneroka
pelbagai faktor yang berkaitan yang mempengaruhi proses membuat keputusan
doktor.
xxiii
THE INFLUENCE OF DRUG PROMOTION TECHNIQUES ON
PRESCRIBING DECISIONS AMONG PHYSICIANS IN SANA’A CITY,
YEMEN
ABSTRACT
The pharmaceutical industry invests heavily in promotion, and it uses a variety of
promotional strategies to influence physicians’ prescribing decisions. The purpose of
this study is to explore those factors used to influence physicians’ prescribing
decisions and their role in decision-making process. Specifically, this study
investigates the relationships between physicians and medical representative (MRs)
and to identify physicians’ perceptions, beliefs and attitudes toward interactions with
those MRs, and to explore the potentially modifiable factors influencing those
interactions; to identify the main sources of information physicians use to obtain
knowledge about new drugs and to explore how they influence physicians’
prescribing decisions; and to investigate the relationship of physicians’
characteristics and practice-setting factors with previous factors. This study was
conducted in a step-wise approach. In the first phase, a qualitative research method
was adopted to have an in-depth understanding of the phenomenon surrounding
the nature and extent of drug promotion techniques. In the second phase, a
quantitative method was applied using the cross-sectional. Research was conducted
in Sana’a, Yemen. Physicians in public and private hospitals were surveyed. All
instruments were tested for its reliability and validity measures. Descriptive and
inferential statistical analyses including frequency distributions, percentages, means
(sd), median (IQR), independent samples t-test, Mann–Whitney test, ANOVA,
Kruskal-Wallis test, factor analysis, and multiple linear regression analysis were
xxiv
applied. Level of significance (α) is equal to 0.05. Findings of phase one study
revealed that most medical representatives interviewed did not have knowledge
about any code of conduct, and their use of different promotional techniques depends
on company’s strategy, their own judgment and/or skills, and pressures from
physicians and pharmaceutical company sales departments. Most physicians were
found to be welcoming representatives’ visits and consider receiving free samples,
gifts and various kinds of support as a normal practice. Although physicians reported
group of factors that influence the prescribing process such as drug indications, drug
attributes, patient context, environmental factors and pharmaceutical marketing, they
still rely on their personal experiences when making prescribing decisions. Further,
their decisions to choose a particular drug may be based on their relationships with
MRs and firms’ marketing activities. Findings from phase two of the study revealed
that a high proportion of physicians reported having received drug samples (n= 432;
96.2%), small gifts (n = 384; 85.5%) and having been invited to seminars or
symposia by the drug company (n= 381; 84.9%) in the six months preceding the
administering of the questionnaire. More than 80% (n=375; 83.5%) of the
respondents considered the MRs to be a useful means of learning about new drugs,
and majority (n=383; 85.1%) asserted that they would continue to meet with MRs.
Moreover, the frequency of visits of MRs for physicians were found associated with
provision of more promotional items. Those physicians who have overtime
occupational commitment and have academic affiliation were significantly more
likely to receive low-value promotional items. However, male physicians, GPs and
specialists who have normal day occupational commitment and have private clinic
were significantly more likely to receive high-value promotional items. The
physicians’ belief in the appropriateness of their acceptance of those promotional
xxv
items, in addition to, attitude toward pharmaceutical companies were found to have
significant role in predicting physicians’ interactions with MRs (Adj. R2 = 0.208).
Also findings obtained from regression model of this study suggested that,
physicians’ belief in the appropriateness of their acceptance of promotional items,
interactions with MRs, receiver of low value promotional items and company-direct
information sources have a role in predicting physicians’ prescribing decisions (Adj.
R2 = 0.422). Physicians had mixed attitudes toward the informational services
provided by MRs. The majority of physicians appeared to believe that most
promotional techniques do not pose major ethical problems. This study clarifies the
role of pharmaceutical companies in influencing prescribing decisions, and explores
a variety range of related-factors that affects physicians’ decision-making process.
1
CHAPTER 1 GENERAL INTRODUCTION
GENERAL INTRODUCTION
1.1 Background Over the past two decades, interactions between physicians and the representatives of
pharmaceutical companies have received increased scrutiny both within the medical
field and among the public, as they create conflicts of interest which pose the risk of
biasing physicians’ decisions in prescribing medications (Zipkin and Steinman,
2005; Raad and Appelbaum, 2012). According to Gagnon and Lexchin (2008),
pharmaceutical companies in the United States spent almost $57.5 billion on
promotions, which amounts to approximately $61,000 per physician. Interactions
between drug companies and physicians are pervasive and these interactions begin in
medical school, continue throughout physicians’ residency training, and persist
throughout a physician’s career (Blumenthal, 2004). These relationships take the
form of advertisements, printed materials, contacts made by medical representative
(MRs), gifts, samples, non-educational gifts (i.e., pens, mugs), educational materials
such as textbooks, journals and reprints of industry publications, social events which
may include meals and funding for travel or lodging to attend educational symposia,
the sponsorship of physicians’ Continuing Medical Education (CME), honoraria,
research funding, and even direct employment (Orlowski and Wateska, 1992;
Wazana, 2000; Austad et al., 2011). One significant consequence of such
relationships has been that they often result in a conflict of interests between a
physician’s duties to their patient on the one hand and the pharmaceutical industry’s
interest in maximising the sale of its products on the other, which may contribute to
the over prescribing of medications and additional negative effects on patient health
and the economy.(Gagnon and Lexchin, 2008).
2
Marketing is a common activity in business. The definition of marketing
differs based on the opinions of the researcher. The most recent definition for
marketing, released by the American Marketing Association (2008), includes the role
marketing plays within society at large, and defines marketing as a science, an
educational process and a philosophy—not just as a management system. “Marketing
is the activity, set of institutions, and processes for creating, communicating,
delivering, and exchanging offerings that have value for customers, clients, partners,
and society at large” (Gundlach and Wilkie, 2009).
Pharmaceutical marketing is the business of advertising or otherwise
promoting the sale of drugs. The World Health Organization (WHO) defines
pharmaceutical promotion as “all information and persuasive activities by
manufacturers and distributors, the effect of which is to induce the prescription,
supply, purchase and/ or use of medicinal drugs” (Norris et al., 2005). In this regard,
the WHO and several NGOs are concerned with the unethical and inappropriate
approach to the promotion of pharmaceutical products. At the 1997 roundtable on the
WHO’s Ethical Criteria for Medicinal Drug Promotion, for instance, there was firm
agreement among participants that the inappropriate promotion of medicinal drugs
remained a problem both in developing and developed countries (World Health
Organization, 1988). Apart from the concern over unethical and inappropriate drug
promotion techniques, there has also been increasing concern over the irrational,
inappropriate and, at times, harmful prescribing practices of physicians (Carthy et al.,
2000).
The WHO’s code which governs the promotion of drugs unfortunately has
not yet been implemented by most member countries; Yemen is one of them; as
such, it has had a minimal impact on global standards of drug promotion. The
3
International Federation of Pharmaceutical Manufacturers’ code, compliance with
which is essentially voluntary, has been proven to be ineffective (Joel Lexchin,
1995). As a result of such concerns, the efforts of pharmaceutical companies to
promote prescription drugs have attracted the attention of policymakers, because
such activities may affect the rate at which different drugs are prescribed and
consumed, the total amount spent on health care and, ultimately, health outcomes.
1.2 Country profile and pharmaceutical sector background Yemen is a medium size country with an area of 527,968 sq km. The country is
situated in Middle East in the Southwest corner of the Arabian Peninsula, bordering
the Arabian Sea, Gulf of Aden to the South, and Red Sea to the West, between Oman
to the East, and Saudi Arabia to the North. The population of Yemen was estimated
at 23,833000 in 2011. About 32% of total population are living in urban areas
(MoPHP, 2011 ).
Yemen is a low-income country, with a per capita Gross Domestic Product
(GDP) of $926. The main natural resources of Yemen are petroleum, fish, rock salt,
marble; small deposits of coal, gold, lead, nickel, and copper; fertile soil in West.
Petroleum accounts for roughly 25% of GDP and 70% of government revenue.
However, Yemen is facing difficult long term challenges, including declining water
resources and a high population growth rate (MoPHP, 2011 ).
Total expenditure on health as a percentage of GDP is 5.63%, while the
budget of the Yemeni Ministry of Health, as a percentage of the government’s
budget, is 3.58%; out-of-pocket expenditures on health-related services as a
percentage of total health expenditures are 66.33% (MoPHP, 2011 ). Public health
services are not free; the patient is expected to pay a prescription fee, the ex-store
4
cost of the medicines plus 10% and the cost of any required diagnostic tests (Al-
qubati and Ahmed, 2007)
In Yemen, as in many other developing countries, public and private health
services are primarily available in major cities. The annual statistical health report
(2010) of the Ministry of Public Health & Population (MoPHP) shows a total of
3,092 private pharmacies and a total of 5,974 physicians, including dentists (MoPHP,
2010).
The Yemeni pharmaceutical market is an open market overseen by the
Supreme Board of Drug and Medical Appliances (SBDMA). In the last decade, the
drug manufacturing industry in Yemen has experienced rapid growth; in 1990, there
was one local pharmaceutical manufacturer, whereas there are currently nine
manufacturers operating in the country. Local manufacturers account for only a small
portion of the total market (6.85% in 2006 and 10.8% in 2010); medicines imported
via private sector agents cover most of the country’s needs (approximately 85%).
The number of registered medicines has reached 12,596 (Al-Hamdi et al., 2012). The
Yemeni pharmaceutical market was estimated to be worth $297 million total as of
2010, compared with a $70 million estimate as of 2000 (a compounded annual
growth rate of 17.42%) (SBDMA, 2010)
1.3 Problem statement
The prescription drug market is unique in the sense that the end user is not the
person tasked with choosing the product to be purchased, since it is the physician
who is responsible for selecting the correct medication for patients from among the
various available options. Companies therefore seek to direct their promotional
efforts toward physicians in an effort to influence their choices, thus setting as the
5
primary purpose of promotion to increase sales, despite any negative effect doing so
might have on patient health and the economy.
In the specific context of Yemen, as has been mentioned earlier, there is
significant increase in the numbers of registered drugs and as a consequence of this
the competition among drug companies highly intensified. This has meant that there
has been a greater need for more intensive marketing and expanded promotional
activities. In this context, the contacts and relationships between the pharmaceutical
industry and its representatives on the one hand and physicians on the other have
been seen as a vital part of marketing and promotional activities. There are currently
no national drug promotion regulations in Yemen, however, nor is there any clear
mechanism by which to monitor the promotional activities of the pharmaceutical
industry. Apart from the absence of any comprehensive regulations controlling drug
promotion, there is also very little information regarding both the nature and extent
of the interactions between pharmaceutical companies and physicians as well as the
attitudes of physicians regarding such interactions. Similarly, little is known about
whether these attitudes are present from an early stage or develop during the course
of a physician’s career through the influence of the pharmaceutical companies. As a
result of this lack of information, the drug promotion practices in Yemen and their
impact on the prescribing decisions of physicians continue to remain a mystery to
many stakeholders in the public health sector.
Bearing in mind the above concerns, this study aims to investigate the nature
and extent of the relationships between pharmaceutical companies and physicians in
Yemen. In doing so, this study will focus on investigating Yemeni physicians’
sources of information regarding new drugs as well as drug promotion practices and
their impact on physicians’ prescribing decisions in Yemen.
6
The objectives of this study are thus, first, to gain insight into the nature and
extent of Yemeni physicians’ relationships with MRs and their influence on
physicians’ prescribing decisions and, second, to develop models which are able to
explain the potentially modifiable factors which influence physicians’ prescribing
decisions. In order to achieve these objectives, this study will adopt a mixed-mode
methodology of quantitative and qualitative approaches.
1.4 Rationale for and importance of the study
There are a number of reasons for concern over the impact pharmaceutical
companies’ marketing strategies may have on a physician’s prescribing decisions.
These include: (Buckley, 2004)
• the fact that drug promotion is often misleading;
• the risk of disease-related fear-mongering;
• the increasing costs of drugs within the national health system; and,
• the fact that new drugs are the ones most heavily promoted, and these are
the ones with the least well-understood safety profiles.
Interactions between physicians and the medical representatives (MRs) of
pharmaceutical companies therefore raise a number of scientific and ethical
questions.
Thus, there is a need for more research regarding the causal relationships
between pharmaceutical companies and physicians’ prescribing behaviours. Such a
need is succinctly summarised in the WHO-sponsored review on drug promotion
where Norrie and his associates (2005) found gaps in evidence regarding more high-
7
quality studies which establishes causal relationship between drug promotional
activities and attitudes and physicians’ prescribing behaviours, and they stressed for
a need of qualitative studies exploring the relationships between physicians’ attitude
towards pharmaceutical promotions and their other characteristics. They also
highlighted in their review that all the previous evidence related to drug promotional
studies, are from developed countries and there is lack of such study from developing
countries (Norris et al., 2005).
Gallan (2005) developed a general theoretical model of physicians’
prescribing behaviour in an outpatient setting, which was based upon the factors
enumerated in the literature review. According to Gallan, the body of evidence
pertaining to the factors which influence physicians’ prescribing of pharmaceuticals
is relatively small, and more research is needed to better identify the correlation of
factors and their effect on how physicians’ actually prescribe pharmaceutical
products. (Gallan, 2004)
Based on the above-mentioned scientific and ethical considerations and in the
context of Yemen, it is imperative to conduct a comprehensive study which explores
the potentially modifiable factors that influence both physicians’ interactions with
MRs and physicians’ prescribing decisions, and which evaluates the possibility of
using these factors to manage pharmaceutical companies’ promotional techniques
through the development of appropriate models.
In this regard, to the best of the researcher’s knowledge no study on the
impact of drug promotion practices which focused in particular on the prescribing
decisions of physicians has yet been conducted in the Yemeni context. This study
through mixed-methods therefore aims to investigate the impact of the nature and
8
extent of the relationship between pharmaceutical companies and physicians in
Yemen and will attempt to develop models capable of explaining the potentially
modifiable factors which influence the prescribing decisions of physicians.
1.5 Significance of the study’s findings
The findings from the study conducted have several potential benefits as discussed
below:
1. This study findings will help to clarify the issues pertaining to
pharmaceutical promotion techniques and how these affect prescribing
practices in Yemen .The findings are expected to identify the benefits to
the various parties in the pharmaceutical sector in Yemen, which include
policymakers, the MoPHP, the SBDMA, physicians’ professional
organisations, medical boards, individual physicians, health-related
colleges, MRs and pharmaceutical companies.
2. This information may prove important to currently practicing physicians
who interact with pharmaceutical companies. Identifying the potential
influences of pharmaceutical companies’ marketing techniques on their
own prescribing practices will be important in order to make appropriate
judgments about the information and compensation they receive from the
pharmaceutical companies.
3. The findings of this study will provide much-needed information for
professional physicians’ organizations and medical boards as they attempt
to develop and disseminate standards of care, professional guidelines and
9
scopes of practice, and may choose to develop guidelines which are
related to physicians’ interactions with pharmaceutical companies.
4. The findings of this study will provide much needed information
regarding the nature and extent of MRs’ marketing techniques and their
relationships with physicians, and the impact these factors have on
physicians’ prescribing decisions. Such findings will allow policymakers
in the public and private health sector in Yemen, and especially the
SBDMA, to better manage and control the promotional activities of MRs
and develop suitable policies and regulations pertaining to drug
promotion, as well as to develop guidelines which set out what should be
considered appropriate interactions between physicians and MRs, while
seeking to diminish if not eliminate the apparent ethical conflicts of
interest inherent to the relationship between the two sectors.
5. The findings will provide insight into and a better understanding of intern
and postgraduate students’ attitudes and behaviours in response to
pharmaceutical promotions and the effect of physicians’ interactions with
the representatives of a given pharmaceutical company. This information
will be important to faculty members, as medical schools will then be able
to address the issue of pharmaceutical companies’ influence over the
curriculum, to prepare medical and postgraduate students to critically
assess the information they receive from pharmaceutical sources while in
training and their critical decision-making processes as they relate to
prescribing medications in a clinical setting.
10
6. The findings of the study can make a significant contribution by
identifying the factors potentially able to be modified which influence
physicians’ interactions with MRs and their prescribing decisions. The
findings of this study will be of great importance for industry
organisations as they attempt to develop effective self-regulations and
local codes of conduct and encourage the pharmaceutical companies to
comply with the ethical marketing practices and self-regulation thus
developed.
7. This study will provide insight into those factors which influence
physicians’ prescribing behaviour with regard to new-to-market drugs,
which is important for understanding the role of pharmaceutical
marketing in influencing prescribing decisions. The findings of this study
will therefore be important to all stakeholder groups as they attempt to
design and evaluate those interventions aimed at pharmaceutical
promotion practices and effecting behavioural change among physicians.
11
1.6 Objectives
The aims of this study are as follows:
1. To identify the main sources of information physicians use to obtain
knowledge about new drugs.
2. To identify physicians’ perceptions, beliefs and attitudes toward
interactions with pharmaceutical company MRs.
3. To explore the potentially modifiable factors which influence
physicians’ interactions with medical representatives.
4. To explore the potentially modifiable factors which influence
physicians’ prescribing decisions.
5. To identify the relationship of physicians’ characteristics and practice-
setting factors with their perceptions about the factors influencing
their prescribing decisions, beliefs, attitudes toward interaction with
MRs and sources of information.
12
1.7 Thesis overview
Figure 1.1 shows the chapter-by-chapter content of this thesis, as well as the study
phases.
Figure 1. 1 Thesis overview flow chart
Phase one Phase two
Chapter 1: Introduction • Problem statement. • Rational of the study. • Significance of the study • Study Objectives.
Chapter 2: Literature review • Theoretical background • Previous study
Chapter 3: Qualitative phase • Qualitative methodology • Result and discussion part 1
(MRs interviews) • Result and discussion part 2
(Physicians interviews) • Result and discussion part 3
(Physicians interview) • Chapter summary
Chapter 4: Quantitative phase • Quantitative methodology
(Physicians Survey) • Result part 1: Factors influencing physicians' interaction with MRs • Result part 2 : Factors influencing prescribing decision
Chapter 6: Thesis conclusion and recommendation
Chapter 5: Discussion (Quantitative phase) Part 1: Factors influencing physicians' interaction with MRs Part 2: Factors influencing prescribing decision
13
CHAPTER 2 LITERATURE REVIEW
LITERATURE REVIEW
2.1 Introduction
The aims of this study are firstly to gain insight into the nature and extent of
Yemeni physicians’ relationships with medical representatives (MRs) and their
influence on physicians’ prescribing decisions and secondly to develop models
which are able to explain the potentially modifiable factors which influence
physicians’ prescribing decisions.
The present chapter begins with an explanation of the concepts and
terminology used in the research (section 2.2), with a brief general overview of the
factors that influence physicians’ prescribing decisions (section 2.3) followed by a
comprehensive review of the different sources of drug information and the role of
industry sources in drug prescribing decisions (section 2.4). An overview of drug
promotion is then presented, including a comprehensive review of physicians’
interactions with medical representatives and the attitudes and perceptions which
result from their interactions with those medical representatives (section 2.5). After
thoroughly reviewing all the factors influencing prescribing decisions, the theoretical
background is explained (section 2.6). General conclusions are presented (section
2.7). Based on the theoretical models reviewed through the previous sections, the
conceptual framework of this study is developed (section 2.8), research questions are
presented (section 2.9) and finally the hypotheses of the research are presented
(section 2.10).
14
2.2 Concepts and terminology For a proper understanding of the information provided in this thesis, some of the
terms and concepts are defined below.
Pharmaceutical Medical Representatives: Their job is to meet individually with
physicians and promote company products, visit physicians on a regular basis, over a
week or month, promote a drug’s advantages and even push the physicians toward
using their products (Al-Hamdi, 2012). Pharmaceutical detailing is a marketing
technique used by pharmaceutical companies to educate a physician about a vendor's
products in the hope that the physician will prescribe the company’s products more
often (Rouse, 2011).
Interns: Interns are physicians gaining supervised practical experience in hospital
after graduating from medical school (Mari, 2008)
General practitioners (GPs): Those physicians who have no additional
qualifications after their graduation (MBBS) are classified as ‘general practitioners’
(GPs) (Mari, 2008).
Residents: A resident is a physician serving a residency in which he or she obtains
medical training and education. This normally follows graduation from medical
school and becoming licensed to practice medicine. The resident completes his
medical school training and/or an internship and goes through the process of
receiving specialized training (Mari, 2008).
Physicians: Physicians are skilled health care professionals trained and licensed to
practice medicine. They are also known as doctors of medicine (Mari, 2008).
Marketing: A business philosophy involving the expectation of the customer’s need
and recognition of his problem, and thereafter fulfilling of these with products,
services and information in a profitable way (Lexicon, 1998).
15
Theory of planning behaviour constructs
Attitude: Personal evaluation of behaviour.
Subjective Norm: These are beliefs about whether key people approve/disapprove
of the behaviour.
Perceived Behavioural Control: The belief that one has and can exercise control
over performing behaviour (Fishbein and Ajzen, 1975; Ajzen, 2005).
2.3 An overview of the factors that influence physicians’ prescribing decisions
Many studies have been conducted to explain the prescribing decisions of physicians
and factors affecting their prescribing patterns. Various factors were mentioned in
the literature which influence the prescribing decisions of physians. However, most
of these studies were conducted in developed countries. One of these studies
conducted in United Kigdom highlighted the importance of the pharmaceutical
industry through their medical representatives in raising the awareness of new drugs
and consequently affected the prescribing decision of physicians (Prosser et al.,
2003). Another study in the United Kingdom also cited commercial sources of
information as a factor influencing prescribing decisions (Jacoby et al., 2003).
Medical representatives were an important source of information about new drugs for
physicians, which were also mentioned in a study conducted by Jones et al. (2001).
There are few other considerable factors which affect the prescribing decisions of
physicians such as detailing, direct contacts with MRs and promotional activities
directed towards medical students and trainee physicians (Naik et al., 2009).
However, drug companies do not only offer information to influence prescribing
decisions, but also provide samples via MRs to influence the prescribing of new
drugs (Tobin et al., 2008). Also, Pitt and Nel (1988) mention that promotional tools
16
and sales calls by MRs can be perceived as the most influential factors. However,
contradicting this, a study mentioned that direct-to-consumer advertising, visual
reminders (such as pens and drug samples) and the possession of honorariums were
considered as having little or no influence on prescribing decisions (Nutescu et al.,
2005). The next stage of prescribing decisions is the evaluation of the drug, which
involves multi-factorial influences from several sources. However, the most
frequently cited influence was the medical representative (Prosser and Walley,
2003a). (Pitt and Nel, 1988)
Other factors influencing prescribing decisions mentioned in the literature
generated in developed countries were drug attributes including efficacy, adverse
drug events, safety, tolerability, cost, and the pharmacological functions of the index
drugs (Freeman et al., 1993; Miren I. Jones et al., 2000; Jacoby et al., 2003;
Buusman et al., 2007; Tobin et al., 2008; Theodorou et al., 2009; Tušek-Bunc et al.,
2010). Other researchers include the availability of drug samples, company
marketing practices, levels of risk aversion, previous clinical experience with certain
drugs, the improved regimens of drugs, as well as cost or drug price (Miren I Jones et
al., 2001; Jacoby et al., 2003; Klein et al., 2006; Buusman et al., 2007; Ljungberg et
al., 2007). Although many physicians consider the cost of the medicine to be a
secondary factor affecting their prescribing decisions and they were more reluctant to
prescribe new drugs due to the effects of increased pressure of drug and fund-holding
budgets (Miren I Jones et al., 2001). Therefore, the price was considered to be an
important factor by GPs (Buusman et al., 2007). In compliance with that, a study
from UK explored cost effectiveness as the main reason behind the maximum use of
lansoprazole rather than omeprazole from the general practitioner (Miren I Jones et
al., 2001). Also, many consultants reported that cost was a factor which
17
influenced their decision, with the exception of one respondent who stated that cost
was not a factor (Miren I. Jones et al., 2000). Other factors mentioned in the
literature included formulary status, the drug’s efficacy and the presence of drug use
restriction policies (Nutescu et al., 2005). It was also mentioned that patient
characteristics were found to be important considerations when physicians prescribe
medication (Ljungberg et al., 2007). Among these were patient knowledge, patient
convenience and the acceptability of the new drug, along with the patient’s economic
level and social security (Prosser et al., 2003). Also an important character is patient
expectation or a patient request for a drug (Theodorou et al., 2009; Tušek-Bunc et al.,
2010). It was reported in the literature that patient demand was one of the most
common reasons given by physicians for use of drugs (Schwartz et al., 1989).
However, patients requests for specific drug were found to be inspired by direct-to-
consumer advertisements (Naik et al., 2009).
An important factor influencing physicians’ prescribing decisions in
developed countries is what is known as social knowledge or peer pressure (Tušek-
Bunc et al., 2010). This pressure was exerted in form of professional peers, pharmacy
advisors, colleagues and/or specialists recommendation (Jacoby et al., 2003;
Ljungberg et al., 2007; Tobin et al., 2008). Some researchers mentioned that
recommendations made by colleagues in informal discussion are the second most
important determinant in prescribing decisions (Pitt and Nel, 1988). Also, habit and
peer pressure were blamed by physicians for their non-scientific prescribing
(Schwartz et al., 1989). Department heads and colleagues in the same specialty were
also mentioned as a factor affecting decisions about which drugs can be prescribed to
patients (Kisa, 2006).
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In addition to all above factors, a common factor reported in the studies
conducted in developed countries was personal experience (Pitt and Nel, 1988;
Schwartz et al., 1989; Nutescu et al., 2005; Prosser and Walley, 2006; Ljungberg et
al., 2007). Hospital consultants and observation of hospital prescribing were cited the
second most frequently (Prosser et al., 2003). Others groups included external factors
such as independent written literature and health authority medical and pharmacy
advisors or what they called scientific knowledge (Jacoby et al., 2003; Prosser and
Walley, 2006).
When it comes to developing countries, a study conducted in Turkey revealed
that, same as in developed countries, the majority of participants reported that MRs
were the main information source regarding the new drugs launched onto the market
(Kisa, 2006). According to another study, also conducted in Turkey, general
practitioners (GPs) mentioned that their prescribing decisions were affected by their
involvement in drug companies’ training activities as well as frequent visits by MRs.
They also stated that the pharmaceutical companies’ drug guides were the most
frequent sources used in case of any problems in prescribing decisions (Vancelik et
al., 2007). In both Turkey and Slovenia, GPs mentioned that attitudes towards drug
marketing and personal involvement in drug promotional activities were important
influencing factors in prescribing decisions (Tušek-Bunc et al., 2010). Also, a recent
study conducted in China by Weihui et al. (2011) systematically summarized various
factors related to prescribing behaviour. According to that study, the factors that
influence physicians’ prescription behaviour can be classified in seven ways: the
physician factor, the patient factor, the disease factor, the prescription factor, the
medicine supplier factor, the medicine factor and the policy factor. The most
important influences on physicians’ prescribing behaviour were the physician factor,
19
the disease factor and the drug factor. However, the patient factor and policy factor
were not included in the first ten influential factors (Weihui et al., 2011).
From a comprehensive analysis of above studies, the researcher found that
both qualitative and quantitative studies addressed the issue of factors that influence
physicians’ prescribing decision and that each of them looked at different aspects of
the question. Often, the physicians’ prescribing decisions were assessed by using a
self‐reporting survey questionnaire or an interview in the case of qualitative studies.
Some qualitative studies focused on the reasoning behind initiating drug therapy and
the prescribing decisions of new drugs launched in the market. Most reviewed
studies suggested that prescribing decisions were multi-factorial and were often
influenced by more than one factor. A lot of evidence generated from both
qualitative and quantitative studies suggesting that pharmaceutical companies
influence prescribing decisions of physicians through their medical representatives in
terms of raising awareness of new drugs and other drugs promotion activities.
2.4 Sources of drug information
Prescribing is a very complex process that requires an informed decision about the
medicine of choice for the treatment of a particular patient. Therefore, up-to-date,
high quality information is a powerful tool for making it possible for physicians for
better prescribing decisions in order to offer their patients optimal healthcare. The
pharmacological basis of therapeutics prescription requires a complex array of
information, and clinical decision making is assumed to be based on evidence-based
medicine information resources.
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The physicians depend on various sources of drug information (Oshikoya et
al., 2011). A wide variety of sources of drug information are included in the literature
such as pharmacists, colleagues, the British national formulary (BNF), information
supplied by patients, the monthly index of medical specialties (MIMS), medical
journals, the internet, direct mail advertising, symposia/conferences, free samples,
medical representatives, literature from pharmaceutical companies, pharmaceutical
company material, drug information centres (DICS)/ drug information units
(hospital-based), medical books, drugs and therapeutics bulletins, journal
advertisements, physicians’ desk reference, regular meetings at hospitals, domestic
and international conferences, continuing medical education (CME), medical school
lectures, sponsored meetings, professional contacts, national standard treatment
guidelines and the extra pharmacopoeia (Strickland-Hodge and Jeqson, 1980; Peay
and Peay, 1990; Verhoeven et al., 1995; Lundborg et al., 1998; McGettigan et al.,
2001; Spiller and Wymer, 2001; Layton et al., 2007; Rohra et al., 2007; Tumwikirize
et al., 2007; Othman et al., 2009; Lua et al., 2011; Oshikoya et al., 2011).
2.4.1 Classification of drug sources of information
Sources of information are classified in the literature into two main categories;
professional sources and commercial sources and others (Eaton and Parish, 1976;
Peay and Peay, 1984; Peay and Peay, 1990). Also Strickland-Hodge and Jeqson,
(1980) categorized sources of information into professional and industrial, while
each of these two categories were further categorized into ‘active’ information and
‘passive’ information (industry active or passive and professional active or passive).
A review of 17 studies was conducted by Williams and Hensel (1991) to explain the
sources, importance and use of information about drugs by physicians. They
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categorized the drug source of the information into two dimensions, personal/non-
personal and commercial/non-commercial. Personal variables included pharmacists,
colleagues, detailing, and conferences /meetings/ conventions. Non-personal sources
included journal articles, journal advertising, and direct mail. Commercial sources
(i.e., marketer controlled) were defined as journal advertising, direct mail, and
detailing. Non-commercial sources included journal articles, meetings, conventions,
pharmacists, and colleagues. (Williams and Hensel, 1991)
2.4.2 Availability and access to up-to-date drug information
Sources used by doctors to find medical knowledge include textbooks, journals and
electronic databases. However, doctors face the challenge of finding up-to-date
information that satisfies the needs of their individual patients, and they may always
be overwhelmed by the volume of information provided to them (Smith, 1996). In
developing countries, medical representatives are commonly the sole source of
information about drugs (Norris et al., 2005). A study in Uganda has revealed that all
doctors in private, district, general and teaching hospitals were found to be deficient
in terms of their access to current medical information due to problems such as
having a lack of time to consult standard pharmacology textbooks and the lack of a
reliable internet connection. Also, high cost is an important obstacle to accessing up-
to-date information from journal publications and most recent textbooks
(Tumwikirize et al., 2007). However, although physicians in developed countries
have relatively better access to objective sources of information to counterbalance
what the industry promotes, a Swedish survey has revealed that most GPs miss
verbal information from non-commercial sources and that they perceive information
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differently in terms of what they actually have and what they would like to receive
(Lundborg et al., 1998).
GPs generally use the resources that are easily accessible to them in their
offices. Textbooks are the most preferred means, followed by consulting with
colleagues and journal articles that are available in their offices. GPs are less likely to
use medical libraries because of access problems (including the amount of time
involved), a lack of skill in using catalogues and databases and difficulty in applying
research literature to clinical situations (Cullen, 1997). However, use of the Internet
is undoubtedly increasing. A study conducted among GPs in New Zealand revealed
that the Internet was ranked higher than medical libraries as a source of information
(Cullen, 2002).
2.4.3 The role of commercial information sources in prescribing and the
adoption of a new drug
Introduction of a new drug usually occurs proactively by means of wide drug
promotion including a visit by a medical representative and direct one-on-one
conversations between medical representatives and physicians. Several studies
reported that the adoption of new drugs had been at the centre of physicians’ interest.
Anyhow, physicians favouring non-commercial drug information sources (Peay and
Peay, 1990; Lundborg et al., 1998; Spiller and Wymer, 2001; Layton et al., 2007).
Despite that, information from commercial sources was received more often than
information from non-commercial sources (Lundborg et al., 1998). Medical
representatives represented the most frequent source of information about new
drugs (Strickland-Hodge and Jeqson, 1980; Rohra et al., 2007). Despite what is
revealed by an Australian study (1984), that MRs were not considered to be a
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reputable information source, they were still the most often quoted source of
information about a new drug, and were the major source among others referred to in
order to prescribe (Peay and Peay, 1984)
Several studies conducted in UK revealed that while the professional sources
such as the British National Formulary (BNF), medical journals and consultant’s
recommendations are used more to evaluate sources about the medical value of a
new drug, commercial sources such as the Monthly Index of Medical Specialities
(MIMS), medical representatives, direct mail industrial material and advertisements
in medical journals were more often used as source of information which was helpful
for getting information about whether a medicine exists in the market (Eaton and
Parish, 1976; Hibberd and Meadows, 1980; Strickland-Hodge and Jeqson, 1980).
Results similar to those revealed in UK were also obtained from a study conducted in
Thailand by Layton et al. (2007). However, although the medical representatives
were considered as being very proficient in offering information about new drugs,
information obtained from them was perceived by the physicians as likely to be
biased.
Also, many studies were conducted to rate the importance of different
information sources about doctors’ prescribing. Some of those studies rated
colleagues as the most frequent sources of information, followed by books and
journals. Also, conferences came before MRs as an important information source in
rural areas (Verhoeven et al., 1995). Other studies rated information from industry as
having the highest importance among other sources, and among industry sources;
while some mentioned MRs as the most important, others listed colleagues, reference
books, MRs, promotion materials, scientific papers, journals, the internet and
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products launched in drug promotion forums as possible sources of information with
no wide differences in their pattern of use (Oshikoya et al., 2011).
From the above studies it could be concluded that drug promotion in general
and medical representatives have a specific significant influence on increasing the
tendency of doctors to prescribe new drugs. Although this influence varies in
strength and can sometimes be shown to not to be significant, in general it should be
considered as an important factor in shaping the physicians’ prescribing behaviour
for new drugs. Also it was found that, with exception of availability and access to
up-to-date drug information, no major differences in commercial sources of drug
information between developed and developing countries. Lack of availability of
official and scientific sources of information make the physicians in developing
countries more reliant on commercial sources of information.
2.5 Drug promotion
Promotion refers to used persuasion tools used by companies to increase the use or
sales of their products. According to the European Pharmaceutical Market Research
Association pharmaceutical market research terms and definitions, promotion is
defined as “the communication with individuals, groups, or organisations to directly
or indirectly influence audience members attitudes in order to accept/purchase an
organisation’s products/service” (Lexicon, 1998). The World Health Organization
(WHO) defines pharmaceutical promotion as “all information and persuasive
activities by manufacturers and distributors, the effect of which is to induce the
prescription, supply, purchase and/ or use of medicinal drugs” (Norris et al., 2005).