Effects of pharmaceutical promotions on antibiotics prescribing behavior of Nigerian private medical practitioners

INTRODUCTION

Pharmaceutical companies spend a huge amount of money on product advertisements and promotions, in hopes of convincing physicians to prescribe the product.^[1] In 2015, the pharmaceutical industry spent an estimated USD 69.2 billion on various forms of pharmaceutical promotion and advertising in 31 countries.^[2] Drug companies that deal with prescription drugs operate in a very competitive environment because of the existence of various brands of generic drugs. The competitive nature of the business environment makes it mandatory for them to develop and implement strong promotional strategies to gain and maintain a reasonable share of the market.^[3] Most of the promotional strategies for prescription drugs include product detailing by pharmaceutical sales representatives, free drug samples, hospital unit meetings, gifting of branded promotional items, physicians’ sponsorship, scientific conferences, clinical trials, and journal advertisement, among others.^[2,3] There may be a slight difference in the mode of execution of a strategy, depending on culture and existing pharmaceutical marketing regulations in a country. In the US, for example, the Sun Shine Act of 2007 which is now a part of the Patient Protection and Affordable Care Act that mandates disclosure of payments and gifts to physicians has somewhat restricted pharmaceutical sales representatives’ physical visits to physicians.^[4,5] As a result pharmaceutical companies are now devising other alternatives for reaching out to prescribers, including emails, direct mail, and peer-to-peer programs.^[5] However, in emerging markets such as Nigeria, pharmaceutical sales representatives continue to directly visit prescribers to detail their products and lobby for prescriptions using various gift items and sponsorships to physicians.

The World Health Organization’s Geneva Convention of 1988 defined pharmaceutical promotion as “all informational and persuasive activities by manufacturers, the effect of which is to induce the prescription, supply, purchase, and/or use of medicines.”^[6] In line with the WHO definition, evidence abounds to demonstrate that pharmaceutical promotions affect the physicians’ prescribing behavior.^[2,7-9] Similarly, the previous studies report that several factors influence antibiotics prescribing behavior, including the physicians’ attitudes, patient-related factors, or health-care system-related factors. [10] However, there is a paucity of data on the influence of pharmaceutical promotion on antibiotics prescribing behavior.

Antibiotics are pharmacological agents that selectively kill or inhibit the growth of bacterial cells; while having little or no effect on the mammalian host.^[11] They are categorized as prescription-only medicine – meaning that they can only be obtained from the pharmacy with valid prescription from a licensed medical practitioner.^[12] This is why the primary target of pharmaceutical companies that sell antibiotics is physicians and other health-care practitioners. Inappropriate prescriptions of antibiotics have been faulted as a contributing factor to the increasing rates of antimicrobial resistance worldwide,^[13] demanding a detailed study into what really drives physicians’ antibiotics prescribing behavior.

As pharmaceutical spending continues to escalate and drug safety becomes a key concern in pharmacotherapy, physician-directed outreach efforts have come under mounting public scrutiny.^[14] Pharmaceutical firms, therefore, need to design their marketing strategies without affecting the ethical code of practice. Furthermore, drug companies need to understand how their marketing mixes influence the doctors’ choice of prescription drugs so as to know how to channel their marketing effort to achieve a good return on investment. Moreover, the knowledge of the effect of pharmaceutical promotions on prescription practices will be useful to policymakers and pharmaceutical regulators in designing educational interventions that will help foster rational antibiotics prescribing practices.^[15] Therefore, the objective of this study is to assess the effects of pharmaceutical promotions on antibiotics prescribing behavior of private medical practitioners. Furthermore, it will evaluate, based on the physicians’ reports, which pharmaceutical promotional strategy is the most common or has the strongest influence on the physicians’ antibiotics prescribing behavior.

MATERIALS AND METHODS

RESULTS

The most common pharmaceutical promotional strategy

Data in [Figure 1] show that product detailing by pharmaceutical sales representatives is the most common form of pharmaceutical promotion across the various practice settings, based on the number of respondents to the question “which pharmaceutical promotion is the most common in your practice setting?”

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Figure 1:

The most common pharmaceutical promotional strategies.

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Level of influence of pharmaceutical promotions on physicians’ prescribing behavior

Data from [Figure 2] indicate that product presentation or CME by pharmaceutical companies has influenced on the antibiotics prescribing behavior of a higher percentage (28%) of physicians, followed by product detailing (25%), then cash gifting (15%), and free drug samples (14%). On the other hand, advertisements in medical journals and conference sponsorship have the least influence on the physicians’ prescribing behavior [Figure 2].

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Figure 2:

Level of influence of pharmaceutical promotions on physicians prescribing behavior.

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DISCUSSION

The findings of this study revealed that pharmaceutical promotions affect physicians’ antibiotics prescribing behavior. These data are also in line with results from related studies.^[2,3,8,9] The present study also demonstrated that product detailing by pharmaceutical sales representatives is the most common form of pharmaceutical promotion while company-sponsored product presentation or “CME” has effect on the prescription practice of a greater number of the physicians. Ijoma et al.^[3] in a similar study conducted in the southeastern part of the country reported that 60% of doctors who attended a company’s drug presentation felt influenced to prescribe the drug. Serhat et al.,^[7] in a cross-sectional exploratory survey of primary health-care physicians in East Turkey, reported that the main source of prescribing information for majority (73.7%) of the physicians was commercial information provided by pharmaceutical sales representatives. Oshikoya et al.^[18] are another questionnaire survey of medical doctors in a Nigerian teaching hospital observed that the physician used drug information from pharmaceutical sales representatives as resources to determine their prescribing behavior. In our study, the majority of the physicians believe that the pharmaceutical sales representatives are knowledgeable enough to pass drug-related information to medical doctors. However, a previous study has shown that drug information provided by a pharmaceutical sales representative may not be completely accurate.^[19] Mintzes et al.^[20] in a prospective cohort study conducted in Canada, where a sample of primary care physicians was randomly recruited to report on sales visit of pharmaceutical companies’ staff, using a structured questionnaire, noted that a pharmaceutical sales representative, in an effort to influence the physician’s prescription, may downplay or skip the untoward effects of a drug when detailing the product to the physician. More also, pieces of evidence abound to show that interactions of physicians with pharmaceutical sales representatives may reduce prescription quality. A systematic review of 58 studies revealed that information provided by pharmaceutical company did not improve physicians’ prescribing but rather was associated with higher prescribing frequency, higher costs, or lower prescribing quality.^[21]

Our findings revealed that most physicians will feel comfortable receiving non-cash gifts from pharmaceutical companies, and this places the physician under obligation to prescribe the drug company’s product. This is also in line with literature evidences that accepting gifts from pharmaceutical companies influence doctors’ prescriptions.^[22] Giving free samples of a drug product to a physician can influence the prescription of that product. The most of the respondents in this survey admitted that they have received free antibiotics samples from a drug company and also felt obliged to prescribe same drug because of the free drug sample. It is believed that drug samples are among the most effective marketing tools that pharmaceutical companies have. A similar study has shown that giving physicians drug samples every week or fortnightly, provides pharmaceutical sales representatives the opportunity to interact directly with the physicians.^[18] Usually, the argument supporting the use of free drug sample is that it gives the physician opportunity to confirm the efficacy and safety before using it.^[23]

Sponsorship of clinical studies and drug advertisement in medical journals is also important promotional strategies of drug companies. Pharmaceutical companies sponsor clinical studies as a way of gaining prescribers confidence for that product. Our respondents supported the opinion that an independent data monitoring committee should be appointed for any pharmaceutical company-sponsored drug study. The most of the drug company-sponsored studies are primarily for marketing purposes.^[19] The majority of the physicians in this survey rely on product advertisements on medical journals as their source of antibiotics prescribing information. However, a previous study reported that printed advertisement does not meet regulations and guidelines in various countries.^[2]

In recent times, unethical pharmaceutical promotions have been a topic of concern among health-care fraternities. There have been several litigations and court cases bordering on wrong pharmaceutical promotions such as false claims and off-label promotions where the erring pharmaceutical companies were slammed with heavy fines running into billions of dollars. In the US, court cases involving multinational pharmaceutical companies have uncovered a range of promotional activities raising strong ethical and public health concerns.^[24] A few of such litigations involving big pharmaceutical companies are mentioned below. In 2010, two subsidiaries of Johnson and Johnson, Ortho-McNeil Pharmaceutical and Ortho-McNeil-Janssen, agreed to pay more than USD 81 million to settle all civil and criminal liability as a result of the companies’ illegal marketing of its anti-epileptic drug.^[25] Furthermore, in the previous year, according to information from the US Department of Justice, another pharmaceutical giant, Pfizer in what was the largest pharmaceutical settlement in the U.S. history as at that time, reached a USD 2.3 billion settlement with the Department of Justice to resolve criminal charges and civil claims under the False Claims Act, for promoting four of its medicines outside the Food and Drug Administration (FDA) approved indications.^[26]

Pharmaceutical companies are business organizations and so deserve to make profit to offset operational costs to keep their business running. The profits of pharmaceutical companies are heavily dependent on marketing and promotional activities, which are key factors driving sales volumes. However, when product sales are given priority over public health, promotion can lead to over-prescribing as well as poor quality prescribing and medicine use. This, in turn, may lead to an increased risk of adverse effects and higher health-care costs. It is important, therefore, to regulate pharmaceutical marketing communications and promotional activities to ensure good marketing ethics and the protection of patients’ interests at all times. Pharmaceutical marketing communications are regulated by appropriate regulatory agencies in different countries. For example, in Nigeria, there is the “National Agency for FDA and Control” (NAFDAC) which regulates the advertisement of all pharmaceutical products.^[12] In the United Kingdom, there is the “Medicine and Healthcare Products Regulatory Agency” performing similar roles like NAFDAC in Nigeria,^[27] while in the US, the Federal Trade Commission is responsible for regulating all “OTC” drug advertisement, and the FDA regulates advertisement of prescription drugs.^[28]

Our study is not without limitations. First, it employed self-administered questionnaires as the research instrument. This may represent a potential limitation to the study findings because the possibility of bias in the responses to the questions cannot be completely ruled out. A majority (30%) of the physicians in this study were over 60 years old. The ability of the physicians to completely recall how, or to what extent their interactions with pharmaceutical sales representatives affected their prescribing practice in the past may also be a potential bias to the present study. The influence of drug promotion on physicians has been noted as one of the difficult research areas because the most of the physicians are either not aware of how far-reaching the effects of drug promotion could be on them or they simply downplay the effects.^[3] Therefore, the future research in this area should incorporate direct prescriptions audit in the methodological design. Second, Fisher’s exact tests demonstrated a weak association between relevant independent variables (pharmaceutical promotions) and the dependent variable (antibiotics prescribing behavior) (P > 0.05). This weak association does not nullify the hypothesis “that pharmaceutical promotions affect physicians prescribing behavior” because majority of the respondents in this study agreed or strongly agreed that pharmaceutical promotions influence their prescription practice. It is important to note also that Fisher’s exact test has some limitations. Some authors have argued that it is conservative and that its actual rejection rate is below the nominal significance level.^[29]

CONCLUSION

Pharmaceutical promotions affect antibiotics prescribing behavior of private medical practitioners. Company-sponsored product presentation was identified as having the strongest influence on physicians’ prescription behavior, while product detailing by pharmaceutical sales representatives is the most common form of the pharmaceutical promotion. Therefore, it is important to regulate pharmaceutical promotions, especially the activities of pharmaceutical sales representatives to guard against unethical practices.