Drug Promotion - What We Know, What We Have Yet to Learn - Reviews of Materials in the WHO/HAI Database on Drug Promotion - EDM Research Series No. 032
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| Drug Promotion - What We Know, What We Have Yet to Learn - Reviews of Materials in the WHO/HAI Database on Drug Promotion - EDM Research Series No. 032 |
Andrew Herxheimer
Joel Lexchin
Peter Mansfield
WHO/EDM/PAR/2004.3
This document has been produced with the financial assistance of the European Community. The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official opinion of the European Community.
© World Health Organization and Health Action International 2005
All rights reserved.
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The World Health Organization and Health Action International do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
The named authors alone are responsible for the views expressed in this publication.
Review 1. What attitudes do professional and lay people have to promotion?
Finding out what people think about promotion, and what effect they think it has on them, is important because it can help us to develop relevant interventions. However, research on this topic cannot provide evidence about the actual effects of promotion. Promotion may affect people in ways that they do not know about, or are reluctant to tell others about.
This review describes studies that examine what people think about promotion. Studies about how people use promotion and other sources of drug information are not included here; these can be found in Review 2.
Research on attitudes to promotion relies heavily on survey methods. It tends to provide estimates of how many people agree with or disagree with certain statements, mostly about the appropriateness and effect of various forms of promotion. There are some more complex studies, which attempt to explore other variables associated with different attitudes to promotion. These try to find out what kinds of people have different opinions on promotion. Such studies are more useful.
There is little qualitative research on people’s attitudes to promotion, and this is a major gap. In order to understand people’s perspectives and values more clearly, in-depth interviews are needed. People should be express themselves in their own way about what they think about promotion and how it affects them. Ethnographic research, in which the researcher spends time with doctors and tries to understand how promotion fits into their working lives, would also be useful.
Review 2. What impact does pharmaceutical promotion have on attitudes and knowledge?
Many descriptive studies clearly show that much promotional material contains inaccuracies, or at least presents very selective accounts of the evidence about the drug presented62,63,64. The question this review addresses is whether and how far promotion (including these inaccuracies and biases) affects the attitudes and knowledge of those who are exposed to it.
Very little research has looked specifically at the effect of promotion on attitudes, much more has examined the effect of promotion on knowledge. The studies here are part of a field of research into the determinants of prescribing - how doctors learn about drugs, and how they come to prescribe new products.
Most of the studies discussed in this review are really about how much doctors report using promotion as a source of information (either for all drugs, or particularly for new drugs) rather than about effects of promotion on attitudes or knowledge. They are included because they provide information relevant to the question of whether promotion affects prescribers’ knowledge.
Some studies look directly at the impact of promotion on attitudes and knowledge, by using an experimental approach65, by interviewing people about previous exposure66, or by following up participants in a promotional event67. Others approach the question in a more sophisticated or indirect way. Ziegler et al.62 look at whether doctors notice and remember errors in promotion. Sansgiry et al.68 look at whether consumers are aware of information missing from advertisements. Others63,64 look at doctors’ attitudes or knowledge in areas where there is disagreement between commercial and scientific information and infer the impact of promotion from this. Ferry et al.69 directly assessed knowledge of prescribing for the elderly and looked at it in relation to self-assessed reliance on promotion.
The methods that have been used in this area are not capable of producing certainty about causal relationships. Firstly both exposure to promotion, and knowledge and attitudes about drugs, are often assessed using self-report data. Secondly the relationship between them is often also assessed using self-report. That is, doctors are asked how much their prescribing is influenced by promotion. Self-report can be misleading when doctors’ beliefs are inaccurate (e.g., they may believe that they are exposed less often than they are), or when their answers to questions are biased towards being more socially acceptable than what they really believe.
Review 3. What impact does pharmaceutical promotion have on behaviour?
This is both the most difficult area to research and the most important. Doctors may not be aware of how much promotion they are exposed to. Therefore, as much as possible, research on the effect of promotion on behaviour should avoid relying on self-report data to show causal relationships. Self-report data are appropriate for finding out what people think is happening, or how they want to present themselves to others, but in this area, that may be far from the reality.
This review looks at the evidence for several different possible effects of promotion on behaviour. These are the impact of promotion on individual prescribing behaviour, on overall drug sales, and on requests for formulary additions; the effect of DTCA on consumers’ decisions, the effect of promotion on the content of continuing medical education courses, and the impact of industry funding on research outcomes.
Review 4. What interventions have been tried to counter promotional activities, and with what results?
This review reports on research on interventions to control or counter promotion, and the effects of such interventions. It is not a comprehensive review of interventions, because there are many descriptive reports on these in the database, which are not included here. These reviews only describe research into the effects of interventions, not descriptions of methods to control promotion, such as guidelines, that do not report any quantitative or qualitative data.
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