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Effect of Promotional Strategies of Pharmaceutical Companies on Doctors'

Prescription Pattern in South East Nigeria

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 TAF Preventive Medicine Bulletin, 2010: 9(1)

Araştırma/Research Article TAF Prev Med Bull 2010; 9(1):1-6

Effect of Promotional Strategies of Pharmaceutical

Companies on Doctors’ Prescription Pattern in South East
Nigeria
[Güneybatı Nijerya’da İlaç Şirketlerinin Reklâm Politikalarının Doktor
Reçetelerine Etkisi]
SUMMARY Uchenna Ijoma1,
AIM: Drug promotions use multifaceted approaches incorporating hospital and office detailing by Ikenna Onwuekwe ,
1
marketing representatives. Very few studies exist on their influence on doctors’ prescription pattern in Obinna Onodugo ,1
Nigeria. We examined the scope and effects of marketing strategies on the prescription habits of doctors 2
Emmanuel Aguwa ,
in Enugu, South East Nigeria. 1
METHOD: This was a cross-sectional study; 210 self-administered structured questionnaires were Emmanuel Ejim ,
1
distributed among doctors in six major hospitals in Enugu. Ethical approval was obtained from the Cajetan Onyedum ,
3
University of Nigeria Teaching Hospital Ethics Committee, Enugu. Linus Onah ,
3
RESULTS: There was 88% response rate, with more males than females (M:F= 2.2: 1). Most were Emecheta Okwudire ,
residents-in-training/ house officers (69%) while consultants were 7.1% of the group. Stickers, drug Geraldine Ugwuonah4
presentations/ launches and personal souvenirs were most commonly employed marketing strategies.
Most doctors (60%) attending a drug presentation felt influenced. While 87.5% appreciated the benefits 1
of marketing strategies, about 70% would consider patients’ socioeconomic status before prescribing. Department of Medicine,
2
Continuing medical education and stiff competition were reasons adduced for the marketing strategies. Department of Community
CONCLUSION: Pharmaceutical companies in Nigeria adopt varied strategies to influence doctors’ Medicine, University of
prescriptions. Often this aim is achieved. The practice is accepted by most who nevertheless will consider Nigeria Teaching Hospital,
other factors when deciding on what to prescribe. Enugu, Nigeria,
3
College of Medicine,
4
ÖZET Department of Marketing,
AMAÇ: İlaç promosyonları, ayrıntıları pazarlama temsilcileri tarafından belirlenen, çok yönlü hastane ve University of Nigeria Enugu
ofis yaklaşımlarını birleştirilerek gerçekleşmektedir. Nijerya’da konunun doktor reçetelerine etkisini Campus, Nigeria.
araştıran sınırlı sayıda çalışma mevcuttur. Bu çalışma, güney batı Nijerya’nın Enugu eyaletinde
pazarlama politikalarının doktor reçetelerine etkisini saptamak amacıyla gerçekleştirilmiştir. Key Words: Doctors,
YÖNTEM: Kesitsel tipteki bu çalışma, araştırmacılar tarafından hazırlanan 210 soru formunun Enugu Prescriptions, Marketing,
eyaletinde bulunan altı büyük hastanenin doktorlarına dağıtılması yoluyla gerçekleştirilmiştir. Nigeria.
Araştırmanın etik izinleri Enugu’da bulunan Nijerya Üniversitesi eğitim Hastanesi Etik komitesi’nden
alınmıştır. Anahtar Kelimeler:
BULGULAR: Soru formlarını cevaplama oranı %88’dir, erkeklerin cevaplama oran kadınlarınkinin 2,2 Doktorlar, Reçeteler,
katıdır (E:K=2,2:1). Cevaplayanların çoğunun uzmanlık öğrencisi doktorlar olup (%69), uzman Pazarlama, Nijerya.
doktorlarda bu oran %7’de kalmıştır. Çıkartmalar, ilaç promo0syonları ve hediyelik eşyalar pazarlama
politikasında en sık kullanılan reklâm aracı olarak tespit edilmiştir. Doktorların çoğu (%60) ilaç Sorumlu yazar/
promosyonlarının etkileyici olduğuna katılmaktadır. Doktorların %87,5’i pazarlama politikalarının Corresponding author:
yararlarını takdir ettiklerini, %70’i reçete yazmadan önce hastaların sosyo-ekonomik durumlarını göz Ikenna Onwuekwe,
önünde bulundurduklarını ifade etmişlerdir. Doktorların medikal eğitiminin devam ediyor olması ve sıkı Department of Medicine,
rekabet bu pazarlama politikalarına sebep olarak gösterilmektedir. University of Nigeria
SONUÇ: Nijerya’da bulunan ilaç firmaları doktorların reçetelerini etkilemek için çeşitli politikalar Teaching Hospital, P.M.B.
geliştirmişlerdir. Bu politikalar, sıklıkla başarıya ulaşmaktadır. En çok Reçete yazarken diğer faktörleri de 01129 Enugu, Nigeria.
dikkate alanlar söz konusu politikalardan etkilenmektedir. onwuekweio@yahoo.com

This study was supported by a grant from the Consortium for Advocacy and Research (CADRE) Enugu,
Nigeria.

INTRODUCTION made clear and appreciated by the target customers.

Promotional strategies are communication
strategies through which a company passes across the
benefits of its product and services to its target
customers. No matter how successfully developed a
product may be, it is worthless except its benefits are
A company’s promotional strategies comprise
basically of message and media strategy, consisting
of the appropriate use of branding, logo or slogan.
The World Health Organisation defines drug
promotion strategies as "all informational and
persuasive activities by manufacturers and

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TAF Preventive Medicine Bulletin, 2010: 9(1)

distributors, the effect of which is to induce the RESULTS

prescription, supply, purchase and/or use of medicinal
drugs."(1). Drug promotion has an important bearing A total of 185 questionnaires were returned duly
on the rational use of drugs; on drug price-control completed and analysed (response rate 88%). One
mechanisms, the manufacture, availability and use of hundred and twenty eight respondents (69%) were
essential drugs, on equity of drug distribution and the males while females were 57 (31%). The male:
cost of health care. It thus becomes a public health female ratio was 2.2:1. There were 97 doctors in
issue of concern. residency training, 13 consultants, 49 recently
Pharmaceutical companies invest large sums of qualified doctors (house officers) and 26 medical
money promoting their products. They use a officers constituting 52.4%, 7.1%, 26.2% and 14.3%
multifaceted approach to drug promotion, respectively of the study population. These findings
incorporating techniques such as hospital and office are shown in figure 1.
detailing by pharmaceutical representatives. Although
these practices are commonly used, little has been
published about the attitude of physicians concerning
their interaction with the pharmaceutical industry. In
Nigeria, pharmaceutical companies, especially those
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 in order to gain and maintain a
reasonable share of the market. This paper examined Fig 1. Distribution of respondents by their cadre.
the strategies of the companies with particular
Of the physicians interviewed, 85 (45.9%) agreed
emphasis on the ones targeted at the doctors to
that the most targeted group were the consultants
ascertain their effect on the prescription habits of the
while 87 (47%) believed that doctors in the various
doctors.
residency programmes were the group most targeted
by marketing representatives of pharmaceutical
companies. Only 13 (7.1%) felt other cadres of
MATERIALS AND METHODS
doctors were targeted (figure 2).
South East Nigeria is principally a rain forest
region with the population mainly engaged in
agriculture, public/civil service and
commerce/trading activities. Enugu is the major city
in the region and is home to several public and
privately owned hospitals of different levels. The city
has one of the largest concentrations of medical
doctors in Nigeria. Ethical approval was obtained
from the Ethical Committee of the University of
Nigeria Teaching Hospital, Enugu, Nigeria. Then
following verbal consent from participants, two
hundred and ten (210) self-administered structured
questionnaires were distributed among medical Fig 2. Most targeted cadre of doctors by drug
doctors, randomly selected using a table of numbers companies
from a population of 620 doctors in six major
hospitals in Enugu. Statistical analysis was done It was noted that 60% of doctors who attended drug
using SPSS version 16.0. Normally distributed presentations/ product launches were influenced to
variables were expressed as simple frequencies and prescribe the drugs. Ninety eight doctors (53%)
percentages. Tests of significance for the discreet believed that drug presentations should not occur
variables were done using chi square. more than once a month while 4 doctors (2.2%) did
not approve of drug presentations.

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 TAF Preventive Medicine Bulletin, 2010: 9(1)

A group of one hundred and thirty eight doctors

(74.6%), of different cadres, believed that drugs
should be advertised to different degrees while
another group of 25 (13.5%) felt it was inappropriate
to advertise drugs (Table 1). The difference between
the two groups was statistically significant (p<0.05).
Use of stickers (40%) was the most common
promotional strategy employed by pharmaceutical
companies followed by drug presentations / product
launch and then gift items given as souvenirs to the
doctors (see figure 3).

Fig 3. Most commonly used promotional material.

Table 1. Distribution of respondents’ views on need for drug advertisement.

Opinion of staff on the Cadre of doctor

need for drug Resident House Medical Total
presentations Consultant
doctor Officer Officer
Strongly agree 2(15.3) 12(12.4) 13(26.5) 11(42.3) 38(20.5)
Agree 6(46.2) 64(66.0) 23(46.9) 7(26.9) 100(54.1)
Indifferent 3(23.1) 10(10.3) 6(12.2) 3(11.6) 22(11.9)
Disagree 1(7.7) 2(2.1) 4(8.3) 4(15.4) 11(5.9))
Strongly disagree 1(7.7) 9(9.2) 3(6.1) 1(3.8) 14(7.6)
Total 13(100.0) 97(100.0) 49(100.0) 26(100.0) 185(100.0)
χ2=26.270, P=0.010 (Significant)

Table 2. Factor that account most for choice of drug prescribed

Cadre of doctor
Factor that account most for
Resident House Medical Total
choice of drug prescribed Consultant
doctor Officer Officer
Patient’s status 8(61.5) 85 (87.6) 29(59.2) 8(30.8) 130(70.3)
Drug availability 4 (30.8) 9 (9.3) 13(26.5) 9(34.6) 35(18.9)
Others 1 (7.7) 3 (3.1) 7 (14.3) 9(34.6) 20(10.8)
Total 13 (100.0) 97 (100.0) 49 (100.0) 26 (100.0) 185 (100.0)
χ2=41.185, P<0.001 (Significant)

Table 3. Cadre of doctor and the opinion on the benefit of attending drug presentations

Cadre of doctor
Opinion of staff on the benefit of
Resident House Medical Total
attending drug presentations Consultant
doctor Officer Officer
Broaden scope of knowledge 1 (7.7) 30 (30.9) 32(65.3) 16(61.5) 79(42.7)
Makes it easy to remember 2 (15.4) 22 (22.7) 10 (20.4) 8 (30.9) 42(22.7)
Direct prescription 1 (7.7) 30 (30.9) 6(12.2) 1 (3.8) 38(20.5)
Little or no benefit 9 (69.2) 15 (15.5) 1 (2.1) 1(3.8) 26(14.1)
Total 13 (100.0) 97 (100.0) 49 (100.0) 26 (100.0) 185(100.0)
χ2=62.637, P<0.001 (Significant)

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TAF Preventive Medicine Bulletin, 2010: 9(1)
On factors that accounted for choice of drugs
prescribed, 130 respondents (70.7%) considered the
patient’s economic status the most important factor
while 35 (18.6%) believed drug availability was more
important (Table 2). The difference between the two
groups was statistically significant (p<0.05). One
hundred and seventy five doctors (94.5%) knew that
drug presentation is a promotional strategy, 142
(76.7%) knew about posters as promotional materials
while stickers, drug samples, souvenirs and leaflet are
known as promotional materials by 127(68.6%), 116
(62.7%), 109 (58.9%) and 135 (73%) respondents
respectively.
About 42.7% of respondents believed that
promotional strategies were useful to broaden their
knowledge concerning a particular medication while
22.7% were of the opinion that these strategies made
drugs names and doses easier to remember. About
20.3% thought they were primarily to direct
prescriptions and 14.3% felt such strategies had little
or no impact on their prescription habits (Table 3).
The difference between those who saw a benefit and
those who didn’t was statistically significant
(p<0.05).
The major reasons adduced for hospital marketing
were to educate hospital management (129
respondents) and to outwit other competitors (127
respondents).
DISCUSSION
The pharmaceutical industry in Nigeria depends
heavily on prescription from doctors because the
typical hospital patients do not make a choice but
depends on the opinion of the doctor and as such, the
key to drug sales lies on influencing the physician. To
convince the doctors, strategies such as research
funding, sponsorship to local and international
conferences and training programmes, drug lunch/
dinner meetings are employed. There are other less
expensive methods such as use of stickers, free drug
samples and gift items to the doctors. There is a wide
range of evidence suggesting that drug promotion
affects attitude and behaviour of doctors. (2,3,4)
The influence of drug promotion on doctors has
been noted as one of the most difficult research areas
because most of the doctors are not aware of how far
reaching the effects of drug promotion on them is or
downplay these effects (5). It has become
increasingly important to understand the effects that
drug promotion have on prescriptions and the use of
medication. Many descriptive studies clearly show
that a significant proportion of promotional materials
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contain inaccuracies, or at least present very selective
accounts of the evidence about the drug presented.
(6,7).
Our study showed that the use of stickers was the
most common promotional strategy used. These
stickers are stuck to walls, doors and even on the
consulting table. This finding corresponds to other
studies done in other parts of sub-Saharan Africa and
poor resource management areas. Osiobe documented
about two decades ago that there was a low utilization
of commercial drug information by doctors and
physicians in Port Harcourt, Nigeria (8). Contrary to
his findings, other studies in developing countries
reported heavy reliance on drug information from
sales representatives especially regarding new drugs
(9,10). Drug samples are commonly used strategies to
get doctors to prescribe those drugs. Studies have
shown extensively that the use of drug samples by
pharmaceutical companies resulted in higher
prescription for those drugs (2,11,12,13).
A study by Sergeant et al in Canada showed that
34% of family physicians agreed that interaction with
sales representatives influenced their prescribing
habits (14). Keirn and co-workers found that 49% of
resident doctors believed that marketing techniques
affect prescribing practices (15). In the United States
56% of doctors in family practice residency
programmes felt that information and resources
provided by sales representatives affected the
prescribing pattern of practicing doctors 16).
Banisnath et al reported that 56% of Indian
cardiologists agreed that sales representatives had
played a role in their decision to prescribe brand or
generic drugs 17). In our study, we were able to show
that a significant proportion of respondents (60%)
admitted that their prescription of drugs was
influenced by contact with drug sales representatives.
Contrary to our findings, 63% of doctors in a Turkish
city surveyed by Guldal and Semin felt that
information from sales representatives did not
influence their prescribing pattern. (18).
American general medical practitioners surveyed
by Pitt and Neil rated sales representatives as the
third most important influence on their prescribing
decisions while advertisements and gifts (souvenirs)
ranked fifth and sixth respectively 19). This study
however had a low response rate and excluded
journal articles as list of influencing material. In
another study by Hodges et al, 55% of trainee
psychiatry doctors surveyed felt that accepting gifts
did not affect their pattern of prescriptions 20). The
effects of use of drug samples were noted in a study
by Boltri et al where prescription of first line
antihypertensive drugs rose from 38% to 61%

following prohibition of drug sample distribution 11).
Symm and co-workers concluded in their study that
family physicians prescribed a large proportion of
prescription drug which were available freely and less
of preferred brand names 12). Other studies have
shown that availability of free drug samples caused
them to be prescribed over other generic brands
21,22).
About 43% of our respondents believed that the
consultants who are the highest level of medical
manpower in their chosen specialty areas were the
most targeted group by the pharmaceutical
companies. With the advantage of age and experience
on their side, these key opinion leaders (KOL) are
seen as respected individuals, prominent medical
scholars and professors who are able to influence
their colleagues through their professional status.
Pharmaceutical industries identify KOLs early in any
setting and aim to target the population through their
influence and recommendations. Doctors in residency
training are a major group targeted by pharmaceutical
companies because of their number, and if put
together may see more patients when compared to the
consultants. On the other hand, it is known that
resident doctors will follow in the footsteps of their
supervisors/consultants and tailor their prescriptions
to that of their consultants to get the approval of their
direct superiors.
Despite the use of promotional strategies to
influence a doctor’s prescription, 70.7% of the
respondents admitted that the most important factor
influencing drug prescription was the economic status
of the patient. Drug availability was also a strong
consideration. This is because most patients pay
directly for the medications. The National Health
Insurance Scheme (NHIS) set up by the Federal
Government of Nigeria and managed by Health
Management Organizations (HMO) to cater for
medication, procedures and investigations still has a
narrow coverage, and as a result, out-of-pocket
payment is still practiced by many patients. In
developed countries, however, the efficiency of the
health insurance scheme reduces or removes the
effect of cost on medication and as such, drug
availability assumes a more important role.
To preserve rational use of drugs and integrity,
some physician networks in the USA have adopted
new guidelines prohibiting physicians and researchers
from accepting gifts from pharmaceutical
manufactures 23). Drug samples left by these
companies are to be distributed through a centralized
system while educational programmes and
fellowships will be centrally reviewed and approved.
This has become imperative since it is recognized that
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TAF Preventive Medicine Bulletin, 2010: 9(1)
doctors are not aware of the extent of influence these
promotional strategies have on them. Most training
facilities in developed countries have policies
regulating interaction with the pharmaceutical
industries and their sales representatives and teach
critical appraisal of industry products and claims in
their curriculum. There may be need for such
regulatory policies and guidelines in Nigerian
hospitals to protect the population and offer the best
treatment options to patients without mortgaging
consciences in any form. There is need to educate
doctors about drug promotion and its influences on
prescribing attitude aiming at improving the doctors
skill in dealing in dealing with these promotional
strategies.
CONCLUSION
This study has demonstrated the most commonly
employed promotional strategies by pharmaceutical
companies in South East Nigerian medical doctors.
As much as 60% of doctors admit to being influenced
by promotional strategies. Nevertheless, despite all
forms of marketing and drug promotion, the socio-
economic status of the patient remained a key
consideration in the prescription of medication. There
is a still a need for more large scale prospective
studies to further ascertain the impact factor of such
marketing practices.
ACKNOWLEDGEMENT
The authors wish to acknowledge the contribution
of members of the Medical Research and
Humanitarian Society of the College of Medicine,
University of Nigeria Enugu Campus towards the
success of this study.
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