The attitude and acceptability towards medical promotional tools and their influence on physicians’ prescribing practices in Jordan and Iraq: a cross-sectional study

The use of medications contributes greatly to improving and maintaining people’s health, including curing acute illness, relieving signs and symptoms, managing chronic disease and preventing future diseases [1]. However, deciding which drug to use for the illness involves weighing potential benefits over possible harm. To make an informed decision as to which drug should be used, there is a need for information about the goals of the therapy, the way to use it properly, how it works, the benefits and adverse effects, how this medicine compares to other available treatment and also the relative cost-effectiveness [2, 3].

Two main sectors serve the healthcare system in Jordan: the public and the private sector. A significant portion of the Jordanian population also receives healthcare through programmes led by the United Nations and non-governmental humanitarian agencies.

Primary healthcare centres in Jordan provide various types of quick medical services, including vaccination, chronic disease management services, and maternity and child care [4]. Around 70% of the Jordanian population and 55% of the Kingdom’s overall population are covered by health insurance. In 2012, the total healthcare expenditure reached 7.58% of the gross domestic product (GDP), with over 60% of the spending in the public sector [4].

The Iraqi healthcare system is mainly central, with a specific proportion of government funding directed toward this sector yearly. According to the World Bank, the Iraqi government spending on healthcare increased from 2.7% of the GDP in 2003 to 8.4% in 2010 [5, 6]. Despite this, only 3.6% of the Iraqi population are covered by health insurance and currently there is no health insurance system to serve the general public [5].

Physicians, pharmacists, and other healthcare professionals play a key role in prescribing appropriate medications and ensuring that they are used properly [7]. Due to growing concerns over medication safety, there has been a focus on the relationship between healthcare professionals and the pharmaceutical industry in recent years, particularly the influence of the pharmaceutical industry on prescribing decisions due to various promotional methods that may affect prescribing patterns [8‐10]. This effect can lead to less than optimal medication choices, which may sometimes adversely affect patient health [11].

Pharmaceutical companies spend more than one-third of their sales revenue on marketing and promotion to retain and maximise their market share [12]. Companies use several effective methods to promote their products, mainly through formularies and medical journals and presentation of new drugs at conferences and workshops. Other promotional tools used include sending medical representatives (MRs), online and direct mail contact with physicians, giving free drug samples to distribute to patients, and low-cost or high-cost gifts [12, 13].

There is evidence that during related pharmaceutical advertising campaigns the rates of diagnosis of specific conditions increase, but the question remains to what extent these conditions require medical treatment and whether the increase in diagnoses is due to benefits in the form of incentives provided by pharmaceutical companies [14, 15]. If the threshold for diagnosis of a health condition shifts to include minor health problems, increased rates of diagnosis and treatment do not necessarily lead to health benefits [2]. A previous study in Jordan reported that the acceptance of pharmaceutical companies’ gifts by physicians is at a high level, and statistically there is a substantial impact of pharmaceutical companies’ gifts on physicians’ prescribing behaviour and practices [16]. Another study in Lebanon confirmed the fact that interactions between physicians and MRs are frequent. While these interactions may be beneficial, they can also negatively impact drug prescription and dispensing practices [17]. In Iraq, a study found that Iraqi physicians accept various types of gifts, free samples and sponsored conference invitations from pharmaceutical companies, and this can impact physicians’ prescribing practices and result in early acceptance of new medications based on promotional information, even in the absence of clinical evidence about the drug’s safety and efficacy. This unethical interaction between physicians and pharmaceutical companies may have a negative effect on physicians’ prescribing practices and, in turn, may result in unwanted consequences for the patients and may negatively affect patients’ health [18].

The aims of this study is to explore the attitude toward and acceptability of medical promotional tools and their influence on physicians’ prescribing practices. Additionally, this study will explore the characteristics of medical promotion provided by pharmaceutical companies through their MRs to physicians in Jordan and Iraq.

Pharmaceutical companies in Jordan and Iraq, as in almost all countries, urge physicians to prescribe their pharmaceutical products due to the increasing number of pharmaceutical companies and the intense competition between them. The marketing efforts by MRs and other advertising tools are considered the main factor influencing physicians’ prescribing practices. Previous studies have found a direct correlation between pharmaceutical promotional tools and physicians’ prescribing practices [13, 16, 18, 20, 21].

Our study confirmed the findings of previous studies and found that physicians are influenced by pharmaceutical companies’ promotional techniques to prescribe promoted drugs. Over two-thirds (69.2%) of the participating physicians reported that MRs have an impact on physicians’ prescribing practices. In 2014, an Iraqi study reported that 77% of physicians preferred to prescribe newer medications presented to them by MRs [18]. A previous study in Yemen found that the majority of the physicians believed that they were under marketing pressure to prescribe certain medicines due to the promotional methods used by pharmaceutical companies [14]. Similar findings were reported in previous studies conducted in other countries such as Turkey, United Kingdom, and the United States [20, 22‐24]. Physicians practice characteristics including working in primary healthcare centres (and having high work load) and having 5 years of experience or lower were important predictors that affected physicians prescribing practices significantly [20].

MRs receive one-third of total marketing expenses and are considered the key promotional tool of the pharmaceutical industry [12]. Previous literature has reported that physicians consider MRs as “information providers”; however, in this study, the participating physicians reported the use of medical textbooks and academic journals as references in case of problems during prescribing, and said that they considered MRs to be information providers for new drugs. A previous study that was conducted in Turkey reported that there is a lack of continuous medical education provided by the public sector to practicing physicians, and 53.0% of the participating physicians reported that they only participated in in training courses of pharmaceutical companies [20]. This increases physicians’ reliance on information provided by pharmaceutical companies solely. Commercial information makes up provided by pharmaceutical companies for the lack of training in healthcare services, and this is even more common in developing countries where the drug industry influence is greater [25, 26]. This source of information could lead to poor prescribing habits if implemented improperly [27, 28].

Our study shows that visits of MRs (face-to-face visits) (76.5%) are the main promotional tool that influence physicians’ prescribing practices due to the relationship built between physicians and MRs. Additionally, most of them reported their preference for receiving information directly from MRs and having discussions and interactions. They also used the new medication directly after they had compared it with other products and possessed evidence about it. This was clearly demonstrated when the frequency of visits by MRs was high and on monthly basis [20]. Our findings confirmed this and found that frequent MR visits certainly affect physicians’ prescribing practices. This could be due to the fact that face-to-face visits encourage reliability and trust [20]. Physicians are also concerned about patients’ safety and a face-to-face explanation may give them more reassurance about the new product. Nonetheless, some studies have shown that MRs have a minimal effect on physicians’ prescribing practices in the US and some European countries. They have reported that the effect of MRs on the prescribing practices of physicians might be minimal or absent [29]. These results may indicate different influences due to the differences in the healthcare systems and regulations that guide prescribing and promotion of medical products between different countries [12, 13, 18].

Regarding gift acceptance, it has been shown that most physicians (86.8%) have received marketing promotional tools from MRs during their visits; a large number of physicians (63.2%) claimed to have accepted gifts and marketing tools, mainly drug samples to use with their patients or as a reminder, which confirms the results of previous studies. A previous study in the United States reported that 61% of the participating physicians received meals, tickets to entertainment events, or free travel from pharmaceutical companies, and 13% received various types of benefit including financial incentive [30]. A recent study in Sudan showed that 91.2% of the participating physicians received drug samples and considered that receiving them was ethically acceptable and a benefit for their patients who cannot afford the medicines [12, 18, 19, 31].

Concerning gifts with a high cost, this study showed that just over half of Jordanian and Iraqi physicians consider their acceptance as unethical (52.1%). The same applies to the continuous supply of high-cost gifts (49.7%). In a previous study in Lebanon, 74.8% of the participating physicians considered the acceptance of expensive gifts inappropriate and unethical, and in Libya, only 10% of physicians were comfortable with accepting such gifts. It is very important to mention that gifts, whether they are cheap or expensive, cost the pharmaceutical company money that surely will be added to the price of the medication [18, 19, 31].

The vast majority (92.0%) of the physicians in our study mentioned that there is a need to strengthen ethical norms to regulate the physician-pharmaceutical industry interaction, and that MRs should have professional and ethical certification to practise their profession [32]. This confirms a study in India, where 80.2% of physicians thought the same [33]. This view should inform pharmaceutical companies that their relationships with physicians must be modified, because while many physicians admit that gifts and frequent MR visits are considered to be an expression of appreciation, they also influence the prescribing of specific products. This is important in Middle Eastern and low socioeconomic countries where physicians’ salaries are not good. Therefore, the influence of pharmaceutical companies and their gifts may be observed even more [34].

Continuing medical education conferences and free medical samples also produce a positive and significant impact on preference for particular pharmaceutical companies’ products. Such products may provide financial benefits to patients and may help patients who cannot pay for their drugs. Physicians are aware that receiving free medical samples impacts their prescribing practices. However, they believe that drug samples are ethical if they benefit the patients [12, 18]. Additionally, 96.3% of the physicians reported that the number of visits of MRs to physicians should be regulated to cause less inconvenience, not exhaust the physicians in terms of taking up a lot of their time, reduce the high number of weekly visits, and restrict discussions on topics not related to the matter in hand.

In our study, 69.9% of the physicians reported that they would change their clinical practice after participating in conferences or meetings, and 81.9% of them agreed that pharmaceutical companies can invite physicians to international congresses. In 2014, a study in Peru reported that 88% of respondents believed that receiving gifts and attending lunches sponsored by pharmaceutical firms did not affect their prescribing practices [35].

About 40% of the participating physicians in this study reported that MRs had a negative attitude toward competitors’ products, compared to 30.5% who were neutral. A negative attitude toward competitors’ products could be defined as ignoring the advantages and only paying attention to the weaknesses of competitive products. Although it is not clear whether the MRs’ attitude toward competitors affects prescribing practices, physicians confirmed that a positive reaction and mutual respect between competing MRs led to a positive view of the companies and their products.

Based on the findings of our study, it is recommended that laws should be structured to include ethical guidelines for drug promotion, enabling monitoring and encouraging compliance by pharmaceutical companies. This will ensure that medical promotion provided by pharmaceutical companies is solely aimed at providing physicians with the latest information on pharmaceutical products available in the market and their most suitable indications, without influencing their prescribing practices. This would lead to better health outcomes for the patients. Ethical training for MRs is always recommended, with more focus on ethical courses during pharmacy undergraduate studies. Additionally, it is important to have more implementation of medical and clinical guidelines, which makes the margin for choosing different brands of medications very narrow, therefore leading to more safety and better outcomes.

There are a limited number of studies that have addressed this topic globally, and very few of them have been in Middle Eastern countries. This study is among the first in the Middle East region to explore the acceptability of medical promotion tools and their influence on physicians’ prescribing practices. This study examined the characteristics of medical promotion provided by pharmaceutical companies through their MRs to physicians in Jordan and Iraq. It provides detailed information about the characteristics of medical promotion in Jordan and Iraq and its influence on physicians’ prescribing practices. We did not restrict our sample to physicians working in specific healthcare settings or specific specialities. However, this study does have some limitations. Military physicians were not included in this study due to restricted access. In addition, the use of convenience sampling might have affected the generalisability of our findings as a non-probability sampling technique was employed in this study. Some of the promotional concepts used were unknown to some physicians and the questionnaire was anonymous, which may lead to desirability bias. To minimise the possibility of this common bias we distributed the study questionnaire extensively to cover the majority of the working physicians from different specialities in different healthcare settings in Amman and Baghdad (the capital cities of Jordan and Iraq, where the majority of registered physicians practise). This should increase the generalisability of our findings. Despite the fact that in the original study Workneh et al. reported that they used a structured, pre-tested instrument, there was no information on the psychometric properties and the validity of the instrument; therefore, our findings should be interpreted carefully.

Medical promotion tools have a clear influence on physicians’ prescribing practices in Jordan and Iraq. Therefore, medical promotion should be controlled and guided by clear and country-specific ethical guidelines. This will ensure safe medical promotion to physicians and optimise healthcare practices provided to patients.