This cross-sectional and exploratory study was performed with the participation of 152 GPs working at primary health centers and hospitals in order to find the effect of pharmaceutical promotion on prescribing decisions. According to the self report of the GPs, their prescribing decisions were always or sometimes affected significantly if they had participated in any educational activity of pharmaceutical companies and if they were working in primary health care centers, respectively (p < 0.05 for both). The self-reported effect of pharmaceutical promotion on the prescribing decisions of GPs was significantly higher if the GPs were visited by SRs frequently, i.e. more than once a month; examining 60 or more patients per day, and year of practice was 5 years and under, respectively (p < 0.05 for all).
The rate of SRs visits to GPs who had a high burden of patient per day was higher. These GPs also reported high influence by the activities of SRs. These findings may be the key factors to show the effect of pharmaceutical companies on prescribing decisions of GPs. Prosser et al. stated that the characteristics and working conditions of the GPs were generally underestimated while investigating the pathways of the effect of pharmaceutical promotion on GPs [8]. Like Prosser et al, we found that if the GPs were working at primary health care centers and had an experience less than 5 years after graduation, they reported higher influence on their prescribing decision. Additionally, the GPs under heavy burden of high number of patients per day could provide limited time per patient, which may affect the rational prescribing decision in a negative manner. The self-rated effect of pharmaceutical promotion on prescribing decisions was lower for experienced GPs. Total year of practice was found to be another factor to have an influence on the pathway of prescribing decision.
Similar to our study, many previous studies also determined that GPs were affected by promotions of pharmaceutical companies [13–19]. According to several primary care physicians, detachment within the health care system, especially in the traditional primary care model, is exploited by pharmaceutical companies to create personal links with the physicians [20]. This may have an effect on a more positive perception of the quality of the information provided by sales representatives while affecting the physician's prescribing behavior. In a 2001 survey of random sample of U.S physicians, 92% of the physicians received free drug samples from companies; 61% received meals, tickets to entertainment events, or free travel; 13% received financial or other in-kind benefits [21]. These incentives may be dominant for GPs who prescribed high number of drugs. In this study, we noticed that the frequency of the visits to GPs performed by SRs was higher for the GPs with high number of patients per day (Figure 1). This may suggest the presence of the effect of pharmaceutical promotion on GPs.
Of the GPs, 77.0% received education on prescribing. Whereas 53.0% of these only participated in training courses of pharmaceutical companies, the remaining 47.0% received education from both the drug companies and other sources (in-service training, course of universities). It was found that there was a lack of postgraduate medical education provided by public sector (in-service training) in GPs in Eastern Turkey. Thus, participating in educational courses of pharmaceutical companies was common among the GPs. All of the GPs, who had been involved in any pharmaceutical education activity, had received at least one suchlike training programme from drug companies. Patient per day ratio per GP was also significant, indicating the involvement of GPs in training programmes of pharmaceutical companies. This is possibly due to the higher frequent visit of SRs to GPs with higher number of patients per day. Previous studies also determined that most physicians allocate more hours to receiving SRs than to attending updating courses [20, 22]. According to various authors, commercial information makes up for the lack of training in health care services, and this is even more common in developing countries where the drug industry influence is greater[23, 24]. However, postgraduate medical education should not be completely dependent on the initiative of pharmaceutical companies, a well-known issue worldwide [25]. For example, the pharmaceutical industry is also the main provider of information to physicians in Spain [23]. The quality and content of formal pharmacology education during medical faculties is another factor that can directly affect the formation of prescribing decision and the attitudes of GPs towards the relations between doctors and pharmaceutical companies. Critics argue that basic pharmacology rather than problem solving and practical application or audit is overemphasized during medical training in developing countries, and largely responsible for establishing poor prescription habits that subsequently prove difficult to change [26–28].
In our study, drug guides of pharmaceutical companies, medical books, and the documents of pharmaceutical companies other than drug guides were the most commonly used reference resources in case of any problems in prescribing. The most common reference source used by 73.7% of the GPs in this study was drug guides of pharmaceutical companies. It has been reported that 86% of the GPs in Tunisia mainly use drug guides when any prescribing problems arise, and nearly 30.0% do not refer to any medical publications [29]. Drug guides prepared by pharmaceutical companies may have a negative effect on rational prescribing behavior of GPs. Nevertheless, various studies determined the great extent of the effect by the pharmaceutical industry on prescribing behavior of GPs [30, 31]. In our study GPs reported that self-reading after graduation and pharmaceutical promotion were the leading factors that affected their prescribing decisions. As mentioned above, this finding also indicates the lack of in-service training provided by public sector. In addition to this, consultation between GPs and other specialists was quite inadequate. (Table 3). Heavy patient burden might play a role in these inadequate interpersonal consultations. Pharmaceutical companies may fulfill the gaps occurring because of limited communication between physicians.
The findings of this descriptive study were based on self-report of GPs about the effect of pharmaceutical promotion on their prescribing decision. The reliance of self-report is one of the main issues of the studies similar to ours. Blumenthal et al. noted that in a study of residents, it was found that 61% believed that they were not influenced by the marketing efforts of pharmaceutical companies, although only 16% were equally confident about their colleagues [21]. Carthy et al stated that GPs considered themselves as cautious and conservative prescribers. In this study, GPs also stated that they were not unduly influenced by the drug representatives [32]. Like Prosser and Avorn et al. and based on the findings of other studies above, there might be an underestimation of the effect of pharmaceutical promotion on the prescribing decision of the GPs in our study.
As this was a descriptive and exploratory study in a single province of Eastern Turkey, we aimed the enrollment of all the GPs in the area; therefore, we did not use any sampling method. The participation rate was relatively high (96.8%), and this was one of the strengths of our study. This might be due to the support of local health directorate in the enrollment and willingness of the GPs to participate. The official regulations governing the pharmaceutical promotion was arranged by law in Turkey in 2003 and since then it has been in effect. This law provided restrictive mandatory regulations to pharmaceutical promotion. However, the implementation of the regulation was not adequately monitored by Ministry of Health.
