Abstract – In Pharmaceutical industry, promotional advertisements are mostly targeted towards physicians but in recent years trend has shifted towards consumer advertisement. In many cases of “Direct to Consumer Advertisement” (DTCA) the pharmaceutical marketers and manufactures creates hype among patients towards disease and ultimately towards brand. It provokes the patients to seek additional information on the brand and push for its prescription generation. Objective of this study is to determine attitude of the physicians towards DTCA, and what extent patients’ request for particular brand leads to actual prescription generation of the advertised drugs. This study reveals that the doctors generally have positive attitude towards DTCA and are willing to provide relevant information to the patients and in some cases even provide sample of medicines or go for direct prescribing, if found relevant, as asked by the patient. This study justifies the pharmaceutical industry manufacturers’ spending in DTCA. It is also thought provoking for health policy makers that prescription drugs are being advertised directly which may lead to increased medication cost and misuse of medicine.
Key words: Direct to consumer advertising, Direct to Consumer Advertised Brand, Over the counter drugs, Prescription drug. Physicians attitude.
I – INTRODUCTION
Companies rely heavily on product detailing to physicians, which are the customer, (Zangla, 2004). To increase overall sales figures marketers started advertising directly to consumers of disease and even drug brands, (Amaldoss & He, 2009). DTCA is not allowed specially for prescription drugs, (Donohue & Berndt, 2010). One argument is that DTCA is a public service message about a particular disease and only plays a role as information provider and motivates people to seek proper treatment if required (Kuhn, 2006). Many researchers found DTCA good for General public health, (Bradford, Kleit, Nietert, & Ornstein, 2005) and beneficial for patient care (Murray, Lo, Pollack, Donelan, & Lee, 2004). So it is considered as DTCA has both merits and demerits, (Murray, 2003)
1.1 – Research Objective
In recent years Pharmaceutical Companies drastically increased their spending on “Direct to Consumer Advertising” (DTCA) (Herzenstein, Misra & Posavac, 2005). In 1997 Federal drug authority (FDA) permitted DTCA and subsequently pharmaceutical companies started increasing their expenditure on direct advertisement to provoke consumers to ask their doctors about the drug (Green, 2007). Patient is more comfortable in using drug brand which is familiar to patient, (Zuvekas, 2008). Consumers have positive attitude towards DTCA and tries to find out additional information about ” Directly to Consumer Advertised Brand” (DTCAB). To get additional information patient consults their doctor, (Herzenstein, Misra, & Posavac, 2005).
Asking questions by patients has strong influence on doctors’ selection criteria of drugs (Iizuka & Jin 2005). General attitude of physicians towards DTCA its impact on prescription generation is still unknown (Herzenstein, et al., 2005).
If physicians have positive general attitude towards DTCA, it may lead to actual prescription generation. Moreover if patients shows more likelihood of searching additional information tries to inquire additional information by asking questions from physician about DTCAB also leads to prescription generation (Herzenstein, et al., 2005). Information inquired from the physician about DTCAB of medicine is taken as second independent variable, pressurizes physicians towards prescribing that specific brand of drugs. Patients’ adherence influenced by DTCA motivates patients’ to seek additional information about the drug from physicians (Amaldoss & Chuan, 2009).
1.2 – Rationale of study
1.2.1 – Increased spending on DTCA from pharmaceutical companies.
Pharmaceutical companies have increased their spending in last decade, and they are planning to do more (Atherly & Rubin, Feb 2008). Physicians are considered to be the best judge to decide medicine , keeping in view the patients and drugs characteristics. Due to information flow and access through electronic and print media, consumer tries to get more information about the drug and disease. With this the pharmaceutical companies started promoting prescription drugs directly to consumers. At the end of many advertisements it is advised to consult your doctor for further information, but ultimate goal is the prescription generation. These advertisements provokes patients to visit their physicians and asking information and if it is appropriate then whether it can be used or not. It is presumed by the companies that doctor will prescribe the medicine as per patient request, but it is still unknown that what is the general attitude of doctors towards direct to consumer advertisement This study will help marketers of pharmaceutical companies in finding the answer to the question, whether they are helping people in getting medication, from physicians perspective, and are they really making returns on this investment on DTCA.
1.2.2 – Health policy makers.
Drugs are classified in two categories, one is ‘Over the Counter Drugs” (OTC) and other is called “Prescription drugs” (PD). OTC drugs are usual drugs which have comparatively lesser side effects and can be used without consultation of physicians. Conversely the PD which are of either critical use or may be associated with serious side effects, and can only be used if advised by physicians. In like manner promotion of PD were made only to the physicians through detailing. Pertaining to the severity of life and death related to use of PD, DTCA should not be done for PD. But PD are being advertised under the head of “Disease Advertising” (DA). It should be the major concern for health policy maker either the PD are being used appropriately as per physicians advice or not. As extensive DTCA of PD may lead to misuse of medicine, increased treatment cost and unnecessary visits to physicians. DTCA should not have that much impact to generate prescription of DTCAB, if it is then specific policies should be developed to balance the usage of DTCA with its risks.
1.2.3 – Knowledge contribution.
It has already been explored in many researches that DTCA has both merits and demerits. Some physicians generally perceive that DTCA is good for patient overall health but from other school of thought it is just in favor of pharmaceutical companies, only physicians can better decide which drug to be used or not. In medical sciences the selection of medicine is based on mainly three factors, kind of disease, doctors’ judgment, patients affordability and liking or psychological experience factor of any brand (Prosser, Almond and Walley, 2003). In previous researches the impact of both physicians and consumers have been explored. But the combined impact of both variables has not been studied before. This study for the first time explores the combined effect of the two main independent variables. My research will find out the preference of physicians towards DTCA and whether information seeking by the patients leads to prescription generation.
II – LITERATURE REVIEW
Pharmaceutical industry is heavily driven by customers (doctors) and very marketing and selling intensive (Scherer, 1990). Primarily the focus was only on doctors (customers) but recently the trend is also shifting towards addressing consumers directly (Matthews, 2001). The medium used for accessing consumers is electronic media including the internet and television advertisements, consumers are now able to freely access information about drugs and their brands which in some cases can lead to misuse of medicine and increased cost of treatment (Matthews et al., 2001). Pharmaceutical companies are now targeting advertisements towards patients which entice patients to ask for prescription of only advertised drug, the patients’ behavior is also effecting and directing the health systems. Matthews (2001) quoted Dr. Reardon, ex president of “American Medical Association” (AMA), has insightfully noted,
“Patients themselves are also creating a strong impetus for change. Disillusioned by restrictions on coverage and care, they are increasingly demanding choice of physician, hospital, and even type of health plan. More than ever, patients see physicians as the essential point of trust in a changing system, and demand choice and stability in their vital relationships with their doctors. At the same time, patients themselves are becoming better educated, not only about insurance options but also about medical treatments. Today, thanks to the Internet, trends in product advertising, and the massive proliferation of medical information, patients are better equipped to take part in their care than ever before. Rather than simplifying the physician’s job, however, this increased patient knowledge base is creating new challenges.”
The other argument that supports DTCA says that it encourages hard to reach sections of populations to seek information about diseases, but it should be balanced against the increased cost of medicine from unnecessary requests generated by DTCA (Murray & Pollack & Donelan and Lee, 2003). DTCA has both positive and negative effects on health behaviors, health service utilization (Murray et, al., 2003). Almost five years back ads for prescription drugs were very rare but these are becoming very common in recent years, and are being advertised like any consumer goods, direct to consumer advertising (DTCA) has grown rapidly (Scherer, 2004). On the other side consumers behavior is supportive towards DTCA and would like to get more information and ask for a particular brand from physicians (Herzenstein, 2004). Another research shows that DTCA had no statistically significant effect on the choice of antidepressant (Donohue & Berndt, 2004). There are three variables involved in prescription choice, one is Patient characteristic, second is features of medication and third is physicians preference for medication choice, moreover detailing is found to be the most effective in physicians preference for medication choice (Donohue & Berndt, 2004). Increase in pharmaceutical pricing is due to increase in expenditure incurred on DTCA.
2.1 – Conceptual framework
Now the question arises that whether there is an impact of DTCA on sales or not (Scherer, 2004). It is also found that DTCA encourage patients to visit physicians and use specific brand medicine (Iizuka, 2005). It is agreed that DTCA has decreased the time between diagnosis and use of medicine and promotes the patients to consult their physician.
2.1.1 – Inquiry about additional information or request for prescription.
It has been argued that patient may demand the product just because of the attractiveness and persuasion of the advertisement, rather than look in to the effectiveness of the drug and go for proper consultation from doctor (Bradford, 2005). This is not unusual in pharmaceutical, as is a significant change from the traditional emphasis on physicians’ detailing, it has been found that the traditional selling of pharmaceutical brands to physicians is changing and prescription drugs is being marketed directly to consumers, as other consumer goods, as detailing and price are found to be complementary strategies for the firms in addition to the traditional detailing, (Brekkea, 2006)
2.1.1 – Actual prescription generation.
Still questions arises about the impact of DTCA on welfare of patients, if allowed then will lead to More visits to physicians, and they pressurizes to get prescription of desired medicine. (Brekkea et al., 2006). It is also shown that the pharmaceutical manufacturers are also facing challenges from DTCA because they has to do extensive detailing to physicians because of DTCA is also being done, so it should be banned as to keep focus on detailing (Brekkea et al., 2006). It will induce demand for new users of antidepressant medicines and can exaggerate the usage if already that medicine is being used, and will lead to misuse of brand (Chad & Meyerhoefer, 2007). Direct to consumer advertising is very important and of course controversial part, advertising in journals, detailing and distribution of samples are used along with direct to consumer advertising which may leads to induce demand and generate more sales (Pasdirtz, 2009)
III – RESEARCH METHODOLOGY
Research methodology is a system or methods followed by particular discipline of an inquiry or investigation into a subject in order to discover or revise facts, theories, applications etc. (Oxford Dictionary, 2007). This study is an applied form of research leading to the basic knowledge contribution, and is an extension of work done by Zachry, (2003). As pharmaceutical industry is very important, it has to play an important role, on one side it claims to be for better health of patients but no doubt they are making huge profits, here comes the role of health policy makers to make it justified. Moreover it is to find out the general attitude of physicians about DTCA and information asked by patients about any particular DTCAB, and its relation with actual prescription generation if asked by patient.
3.1 – Problem Statement & Hypothesis
Pharmaceutical companies in Pakistan are promoting their brands directly to consumers (patients), now the question is
“What is the attitude of physicians towards DTCA, and do they provide relevant information and prescribe medicine if asked by patient. Positive attitude of physicians and information asked by patients of advertised medicine leads to prescription generation “
Now the objective of study is qualitative estimation of attitude, and what physicians are most likely to do if patient inquires information after exposure of pharmaceutical advertisement. Even patient may ask for prescription of specific drug, then what is the usual response of physician.
3.2 – Hypothesis
H-1 : Attitude of physicians towards Direct to consumer advertisement is positive.
H-2: Physicians provides information of drug which is asked by patient after exposure to pharmaceutical advertisement.
H-3: If found relevant, physicians prescribe the particular drug which is requested by patient on exposure to pharmaceutical advertisement.
H-4: Positive attitude of physicians towards DTCA and query about information of a particular brand of medicine leads to actual prescription generation.
ATTITUDE3.3 – Model
Independent Variable – 1
Attitude of Physicians towards “Direct to Consumer Advertising” of prescription drugs
Actual Prescription Generation on request from patient of DTCAB medicine
Reaction on request of information about particular DTCAB medicine
Independent Variable – 2
Actual Prescription Generation on request from patient of DTCAB medicine 3.4 – Data Collection
Data was collected in field setting, respondent were general practicing Doctors/Physicians in hospital setting, as per previously done by (Friedman, 2006) to know the attitude of doctors. We selected hospitals because it has been found that hospitals play an important role in direct to consumer advertising (Adeoye & Bozic, 2007),.
3.5 – Sample and Population
we choose leading hospitals of Rawalpindi/ Islamabad which have high patient turnover, i.e Pakistan institute of medical Sciences, Rawalpindi general hospital, Nescom Hospital and Shifa International. Within these hospitals we selected doctors on judgmental basis, as doctor who is dealing with more than 50 walk-in patients as previously done by (Taneja, Arora and Kaushik, 2007) and found appropriate. Sample size was taken 250, as per sample size taken by other researchers for the same kind of purpose (Bhanji, Baron, Benjamin, Lacy, Gross, Goin, Summner, Fischer, and Slaby 2008).
3.6 – Instrumentation
A questionnaire was adopted from two authors. Questionnaire has three parts, in first part general attitude of physicians towards direct to consumer advertising (Donhue & Berndt, 2004), and in second part the likelihood behavior of physician if patient asks for more information related to drug being advertised directly, and in last part the likelihood of physician if patient asks for prescription of certain medicine (Zachry,Dalen, and Jackson, 2003).
3.7 – Data Analysis
These two were independent variable and one variable of prescription generation is dependant variable. Quantitative method were used, Microsoft Excel and SPSS was used to calculate percentages and relative comparison in questions through as per previous research done by Bhanji, 2008.
IV — FINDING AND ANALYSIS
4.1 – Data Reliability and Normality
Collected data is validated from Cronbach’s-Alpha value which is used by many researchers like Zachry; Dalen, and Jackson, (2001,2003). The value came up to 0.8 which is acceptable as it should beis more than 0.6. Taneja, Arora and Kaushik, (2007) used descriptive statistical data analysis, I moreover used SPSS to regress two independent variable with dependent variable.
4.2 – Descriptive Statistics of Respondents
4.2.1 – Independent variable – 1, attitude.
In first part of questionnaire it is found that 40 % agree and 20 % strongly agree that it makes patients better informed and 46% agree with 32% strongly agree that it causes them to seek medical doctor. 40% agree that it also informs about side effects, although the data shows that there is increase in medication cost. Little agreement on suggesting medicine from patients. More that half percent of people suggested that it is good trend in health care, and causes more time spent in front of doctor while discussing disease. 42% agree that this also helps in increases motivation towards treatment. 39% think that it not only provokes patients to visit doctor for better health but also encourages, 41%, patients to talk to their doctor about right concern. 41% agree that it also helps in following treatment instructions and 58% with 7% strongly agree that it improves the understanding of medical conditions and treatment.1 is for strong agreement, 2 is for agreement, 3 is neutral and 4 is for disagreement while 5 is strongly disagreement.General description and frequency analysis is given in Table 4.1
OVERALL ATTITUDE OF PHYSICIANS TOWARDS “DIRECT TO CONSUMER ADVERTISING” “ATTITUDE”
Make patients better informed about their medical problems
Motivate patients to seek medical care
Provide enough information on other treatments
Do a good job of informing patients of side effects
Have less or no impact on increase in medication cost
Helps doctors in suggesting medicines from patients
Are a positive trend in health care
Increase in time spent with doctor
Increases motivation towards treatment, overall drug consumption
Increase more doctor visit for better health
Encourages patients to talk to their doctor about their right concerns
Encourages people to follow treatment instructions or advice from their doctors
Helps patients get treatments they would not otherwise get
Have less of no impact on driveing up the cost of prescription drugs
Improves people’s understanding of medical conditions and treatments
4.2.2 – Independent variable – 2, information.
44% agree that they become frustrated, 37% get annoyed but 52% agree and 32% strongly agree that they answer patient question about medication if asked. Only 35% agree that they provide more information. General description and frequency analysis is given in Table 4.2
LIKELLIHOOD OF PHYSICIANS WHEN ASKED FOR SPECIFIC BRAND DUE TO DTCA “INFORMATION”
You become frustrated with patient for asking for more information about disease or medicine
You become annoyed with patient for asking for more information about disease or medicine
Answer patient questions about the medication
Provide more information to patient beyond original inquiry
Attempt to change subject rather than discuss the medication
Explains that the information is probably beyond patients comprehension
4.2.3 – Dependent variable, actual prescription generation.
It is revealed from data that 37% get frustrated, 36% get annoyed if asked to prescribe certain brand and 36% feel uncomfortable with this request, and even less willing to communicate to the patient 33%, mostly 41% are neutral. With this if samples are available then 61% agree and 17% strongly agree to provide samples on patient request, it is also supported by agreement of 51% and strong agreement 24% that they will prescribe medicine if no medicine is available. But if found relevant, as while asking question of simply prescribing the medicine if is anyway relevant , to satisfy the patient then the agreement was 47% and only 8% with strong agreement. General description and frequency analysis is given in Table 4.3
LIKELIHOOD OF PHYSICIANS ON REQUEST OF PATIENT FOR SPECIFIC BRAND “PRESCRIPTION GENERATION”
Become frustrated with patient for asking to try the medication
Become annoyed with patient for asking to try the medication
Feel uncomfortable with the medication request
Communicate to the patient your discomfort with the medication request
Attempt to prescribe different medication to keep from promoting patient to ask for medication, if available
Provides samples of the medication, if available
Provide prescription of the medication if no samples available
Simply prescribes the medicine if is anyway relevant, to satisfy the patient
4.3 – Correlation & Regression Analysis
SPSS was used to show the relationship between two independent variables i.e attitude of doctors towards DTCA and behavior likelihood if information asked by the patient and its impact on dependent variable which is actual prescription generation if requested by the patient.
4.3.1 – Model summary and ANOVA.
R value shows 40% relationship between dependent variable and independent variables. R square shows 16.6% of the variant in dependent variable can be predicted by the combination of two independent variable. Durbin Watson value is 2.08 showing that there is very less multicollinearity.
ANOVA statistics shows overall model significance, f value is 15.09, and sig value is less than 0.00 which is less than 0.05, and is the indicator of significance, so that we can go for regression analysis of independent variables on dependent variables. Durbin Watson value should be between 1.5 to 2.5 means that there is no or less multicollinearity, here the value is 2.08, it shows less chances of multicollinearity.
4.4 – If two independent variables combined collectively, Information + Attitude
Data results with individual variables shows very weak relationship. with model significance. So It is considered combined effect of both independent variables on dependent variables.
4.4.1 – Model summary and ANOVA.
Model Summary shows overall model significance, which is less than 0.05, showing overall model fit, R value shows 78% dependence of dependent variable on independent variable. R square value is 0.61 showing magnitude of relationship between independent variable with dependent variable. 1% change in independent variable with 61 % change in dependent variable. Adjusted R square is the pure magnitude of relationship which is always less than the R square, 0.60. F Change statistics is 239.45 which is more than 1 then we can go for coefficients.
ANOVA shows overall model significance with less than 0.05 value, it means the regression analysis be proceeded. Additionally according to second school of thought the regression sum of square should be greater then residual sum of square for better model fit.
4.4.1 – Coefficient
If t value is greater then 2 means it is significant. And significance value should be less than 0.05 to make a significant relationship. Here t value is 15.47, showing significant relationship, and sig value is less than 0.000.
4.2. – Discussion
This is similar finding with Ryan & Vaithianathan, (2009). Which shows that the attitude of consumer is positive towards information provision to patient if asked and similar with the Brekke & Kuhn, 2006 study which shows that the doctors rely on the information provided to them through DTCA.
I accept the hypothesis that physicians have positive attitude towards DTCA. And it is accepted that the physicians are comfortable in providing information if asked by patents about any DTCAB. According to statistics shown by Data analysis I accept the hypothesis of positive relationship between general attitude of physicians towards DTCA and behavior of physicians if patient asks information has positive relationship and are correlated with actual prescription generation. Very interestingly it is found that information asking by physician and general attitude are weakly negatively correlated, it can be the area for further research that if more information is asked by patients about any brand may lead to negative attitude of physicians towards DTCA.
It is found that through DTCA and patients, it is a way of putting pressure on physicians to change their prescribing behavior, (Ryan & Vaithianathan, 2009) It was major concern showed by (Morgan, Mintzes & barer, 2003) that the regularities authorities should consider DTCA regulations if it has impact on prescribing behavious, and in this study it has shown that the consumer advertising is creating impact in prescription choosen. This study is providing valueable information for pharmaceutical manufacturers and marketers. If more patients would ask for further information of specific drug, it may lead to the actual prescription generation.
This study is also a thought provoking study for physicians that in choosing brands they are influenced by patients which may lead to increased cost and unnecessary medicines prescription. This study can be an eye opener for regularity authorities, DTCA is considered as good by physicians but it should be clearly monitored because it also creates pressure on physicians to prescribe certain brands.
VI – CONCLUSION
Physicians have positive attitude towards DTCA and consider it supplementary in overall health care system. It stimulates patients to visit physician and seek appropriate treatment. Physicians feel comfortable in providing relevant information about DTCAB if asked, and they do not hesitate to prescribe the medicine if it is relevant to disease and patient economic characteristics. Focus of this study was to find the combined impact of attitude and information gathering on actual prescription generation. In future it may be further extended to specific disease area. However pharmaceutical companies should be monitored by regulatory authorities to check DTCA messages. Companies should focus on disease awareness rather on brand focused advertisements.
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Lack of Impact of Direct-to-Consumer Advertising on the