Attitude of Physicians and Patients towards Pharmaceutical Promotion in Healthcare: A Qualitative Study from Ethical Context

Pharmaceutical marketers generally target physicians as their customers and patients as their consumers. Pharmaceutical promotion influence physicians significantly to prescribe branded medicines within limited norms. Patients are also influenced by pharmaceutical promotional activities within regulatory bindings. The purpose of this study was to determine the attitude of physicians and patients towards pharmaceutical promotion from an ethical context. The study was carried out by qualitative content analysis. Face to face interview method was applied to collect data from six physicians and six patients in the metropolitan area of Malaysia using the judgmental sampling technique. The interviews data were transcribed and analyzed systematically using Nvivo software. The findings revealed that Physicians have a positive attitude towards pharmaceutical promotion as it fulfils their need and professional knowledge. Alternatively, patients have positive as well as negative attitude and mindset towards pharmaceutical promotion. This study will help medical regulatory policymakers to better understand physicians’ ethical dilemma with pharmaceutical marketers and patients’ perception of aggressive promotional tools. It will also help the policymakers to govern further proceedings by increasing ethical practices for better healthcare. a study which on the unethical promotion of pharmaceutical products concluded that pharmaceutical companies are not compliant with their aggressive marketing activities. Such companies tactfully use their medical representatives to maximize their market share by adopting unethical ways. Merlo and Mulinari conducted a mix-mode study of pharmaceutical industry self-regulation on complaints, complainants, and rulings regarding drug promotion in the United Kingdom and Sweden from 2004 to 2012. This study revealed that self-regulatory bodies in both the UK and Sweden are required to actively monitor promotional items and impose sanctions on violating companies. The researchers found that Swedish and UK bodies regulated 536 and 597 cases, respectively, which were in breach, equating to an average of more than one case/week for each country. Adnan, Azmi and Izham (2012) have also done a study in Yemen on the Impact of pharmaceutical promotion on healthcare professional’s practices and behaviour. They have taken a qualitative approach to understand the status of pharmaceutical promotions and their influence on the use of medicine among healthcare professionals in Yemen. A total of 30 medical doctors, medical representatives and medicine dispensers were interviewed using a semi-structured questionnaire. They concluded that all of the offered promotional items were in exchange for the doctors’ prescriptions. The study also revealed that pharmaceutical companies use unfavorable promotional methods to ensure their sales target.


Introduction
Pharmaceutical companies produce medicines for patients and not like other consumer product; it is the one which needs expert advice. Physicians are the experts who play this role of advocacy for the betterment of patients. The prescriptions generated by physicians contain the name of medicines, in the form of a product name or generic name or maybe together. The decision of writing either way of medicine names depends on the physicians. In this context, pharmaceutical companies take part in marketing activities towards physicians for prescribing their branded products. In this study, the research question is how ethical it is for pharmaceutical marketing promotion in health care services from the perception of physicians and patients. The objective of the following study was (i) to determine the attitude of physicians and (ii) to determine the attitude of patients, regarding pharmaceutical promotion from an ethical perspective.
Pharmaceutical sales representatives (PSRs) are the field force of pharmaceutical companies. PSRs visit physicians in hospitals, clinics or healthcare centers where healthcare service is usually provided to patients. While visiting physicians, PSRs offer various promotional items in the form of gift (Jonathan, 2012). They also offer a sample of drugs, invitation to continuous medical education (CME) programs to visiting physicians (Jonathan, 2012). These activities of PSRs are controlled by medical regulatory acts (Wazana, 2000). There are certain compliance issues in providing gifts to physicians (Code of Medical Ethics, 2001). Pharmaceutical companies have a wide range of products in different therapeutic areas. Although pharmaceutical companies value preventive measures of infectious diseases for patients to cure (Peay and Peay, 1998), the quality aspects of their medicines cannot be equal. Therefore, physicians need to be aware of the quality of promoted medicines.
The effect of medicines on the human body can be either good or bad depends on the quality of medicine it takes. World Health Organization (WHO) monitors globally the quality of medicines, their effects, ownership and pricing (Pezzola and Sweet, 2016). In Malaysia, the local Drug Control Authority (DCA) is the medical regulatory body that controls drug administration under the supervision of the Ministry of Health (PhAMA, 2019). Globally, the pharmaceutical product's total sale was more than one thousand billion USD in 2014 and 2015 successively (Statista, 2015). Among these, the total sale of medicines in Malaysia was more than 3 billion USD in 2014 (MPM, 2014). There are 182 traditional medicine companies, 75 pharmaceutical companies and 3 animal health companies among 259 registered drug manufacturers in Malaysia (Jimmy and Cheah, 2014). These manufactures produce generic medicines for the local Malaysians, and it is categorized mostly under prescription drugs with revenue of about 4.39 billion MYR in 2012 (Jimmy and Cheah, 2014).

Literature Review
Unethical marketing practices have become an integral part of the pharmaceutical industry all over the world. In Bangladesh, Health Watch conducted a study (Masud, 2012) on the sales promotion of pharmaceutical products and found that medical representatives do many unethical things to achieve the sales target which contradicts the ethical promotion of the drug sales act of the country. They work on visiting the doctors and try different demurral ways to convince the doctors to prescribe their drugs. On the other hand, doctors share their likings, requirements with the PSRs and in that way, committing to fulfil the PSRs' request. Mohiuddin et al. (2015) conducted a study in Bangladesh in 2009 which has been published in 2015 on the unethical promotion of pharmaceutical products concluded that pharmaceutical companies are not compliant with their aggressive marketing activities. Such companies tactfully use their medical representatives to maximize their market share by adopting unethical ways. Zetterqvist, Merlo and Mulinari (2015) conducted a mix-mode study of pharmaceutical industry self-regulation on complaints, complainants, and rulings regarding drug promotion in the United Kingdom and Sweden from 2004 to 2012. This study revealed that self-regulatory bodies in both the UK and Sweden are required to actively monitor promotional items and impose sanctions on violating companies. The researchers found that Swedish and UK bodies regulated 536 and 597 cases, respectively, which were in breach, equating to an average of more than one case/week for each country. Adnan, Azmi and Izham (2012) have also done a study in Yemen on the Impact of pharmaceutical promotion on healthcare professional's practices and behaviour. They have taken a qualitative approach to understand the status of pharmaceutical promotions and their influence on the use of medicine among healthcare professionals in Yemen. A total of 30 medical doctors, medical representatives and medicine dispensers were interviewed using a semi-structured questionnaire. They concluded that all of the offered promotional items were in exchange for the doctors' prescriptions. The study also revealed that pharmaceutical companies use unfavorable promotional methods to ensure their sales target.
Patient's perception of their doctor's advice through pharmaceutical marketing activities has been studied by Wei and Delbaere (2015). They described two common distinctions about pharmaceutical marketing communication in their study, one is direct-toconsumer (DTC) advertising and another is promotional activities directed toward health care providers. DTC advertising includes mass media (TV, Radio, Newspaper) and web channel. Promotional activities for doctors include drug sample, gift and detailing/e-detailing through professional medical journals. According to Cegedim Strategic Data (2013), the pharmaceutical industry spent $3.1 billion on DTC advertising and $15 billion on detailing in 2012. Wei and Delbaere indicated that the prescribing behaviour of doctors can be influenced by pharmaceutical marketing communications in the form of non-informational gifts like complimentary pens and sponsored lunches. However, the question remains as to whether and how patients might then, in turn, perceive their doctors as having been influenced by pharmaceutical marketing. A patient view survey by Baum (2013) asked patient groups (~80% from Europe, with the rest from North America) their opinions on the reputation of the pharmaceutical industry as a whole and of its leading companies. It is found that only 30% believed that multinational drug companies have a good reputation (a 7% decline from the prior year). Those results from the survey pointed to several industry shortcomings, a failure to assist patients in securing medications in a difficult economic environment and offering drugs with only short-term health benefits, not serving the needs of neglected patient groups, inappropriate marketing of drugs, a lack of fair pricing policies, making drugs unaffordable to many poor patients, a lack of transparency in corporate and social activities, adverse news about products, not having a patient-centric strategy, and not acting with integrity.
The pharmaceutical industry in Malaysia is unique (Zin, 2013). Many research-based multinational pharmaceutical companies are known as "Big Pharma", have established their offices in the country, employed their sales and marketing staffs with full International Journal of Innovative Research and Publications www.ijirp.com technical/medical/drug regulatory and administrative organization; while leaving their appointed sole distributors to the physical activities of importing raw materials, order processing, delivery and bill collection. There are pharmacists and even doctors employed under these principles and distributors to ensure the health care service. The most unethical practice can be summarized by what has been read and communicated among pharmacistmembers of the Malaysian Pharmaceutical Society: "The promotional practice driven by salestarget-commission has perhaps fostered a "runner-network" driven by greed, made possible by the medical representatives working in cahoots with some members of the healthcare professions themselves. The artificially inflated price conjures a disorderly retail environment that draws unfair negativity with the accusation of price hiking by pharmacies and marring their image and also reflects poorly on ethical practice within the industry" (Zin, 2013). Noordin et al. (2015) conducted a comparative study between Malaysia and Australia to understand the quality of claims by pharmaceutical representatives from a medical doctor's view. It said, the majority of doctors in Australia and Malaysia likely to change their prescribing habits from the interactions of pharmaceutical representatives. About one-third of the claims were undetermined. It concluded that doctors need to be more aware of the consequences of the quality use of medicines. A qualitative study (Rohit et al., 2014) on the perceptions of medical doctors from private medical centers in Malaysia about the usage of generic medicine while they prescribe has been conducted by another group of researchers. They have interviewed 18 medical professionals from different medical fields. They found that majority of the doctors were positive about generic substitution instead of brand names but requested more clinical information by the generic manufacturers. Pharmaceutical marketing depends on physicians. In the health care industry, physicians are defined by medical professionals who generate huge prescriptions. The strategy of pharmaceutical sales representatives heavily relies upon these prescriptions. Patients are the key to the health care system. Keeping these two main stakeholders in mind, the above framework has been conceptualised ( Figure 1).

Methods
This study determines the attitude of physicians and patients toward pharmaceutical promotion in healthcare service from an ethical perspective. There are four main stakeholders in the healthcare service, namely physicians, patients, pharmaceutical companies and pharmacies. Physicians and patients have been taken into account as primary respondents in this research as they are the main caregivers and care receivers respectively. A judgmental sampling technique has been used for selecting respondents. Face to face interviews with twelve respondents including six medical professionals and six patients from a healthcare center located in the Klang Valley area of Malaysia has been conducted with a semi-structured openended questionnaire. Total interviews conducted with an average of thirty minutes per interviewee during May 2017. The information collected from interviews were of sensitive nature which includes the patient's medical history. Therefore, written consent from all respondents has been taken. A comprehensive, systematic analysis of contents from the data has been done through the Nvivo ver. 11 computer program. All data coded independently and unbiased by the author.

Data Analysis
The interview verbatims have been transcribed and organized according to qualitative data analysis with Nvivo (Bazeley and Jackson, 2013). The coding of the transcripts has been done systematically one by one upon selecting as many codes are possible. The word frequency count shows the highest word spoken in the interviews was "yes" means maximum interviewees responded affirmatively. "Word" counts of highest 40 to 10 covers one third (33.36%) of the total interviews. Table 1 represents the analysis results derived from Nvivo software. The maximum spoken words (yes, medical, doctors, patients, treatment and so on) are being identified. The mapping among most used words in the interviews was built upon the words found in word frequency count and it shows medical doctors have a positive relation with pharmaceutical sales representatives and patients. Here, codes are recoded and categorized in 5 and 3 themes respectively for each group and represented by different color schemes. These 8 themes are then labelled and put on a hierarchy model depending on the number of sources and number of references from high to low (Figure 2).

Results
From Table 2, it was found that the majority of the physicians interviewed were of very experienced level with good professional backgrounds. They were with the role of serving their patients with full responsibility. Their attitude towards pharmaceutical sales promotion was very positive. The interaction with pharmaceutical sales representatives (PSRs) is highly demanded in the form of scientific knowledge and sample of medicines. It proves that professional knowledge and pharmaceutical promotion are in exchange. All respondents were positive about prescribing generic names instead of brand names for medicines. Among the six International Journal of Innovative Research and Publications www.ijirp.com physicians, the respondent from the moderate age group (31-40) provided more information than others during the interview time. They were also using more technology (i.e. Mobile Apps) than others. All of the physicians were not aware of any regulatory bindings for meeting PSRs. The six patients interviewed were all male, between the age of 21 to 57, mostly students and academicians with various health issues (allergy, ulcer, constipation, hypertension, etc.). The majority of their attitudes toward pharmaceutical sales promotion were negative. Two third of the respondent were confused about the physician's relationship with pharmaceutical companies. Their prescription ideas about generic and brand names were also been crosschecked with the physician's answers and found relevant. Figure 3 represents the relationship among the themes which are being identified during analysis. Treatment provided by physicians for the patients being the top theme that has an impact on the perception of the patient's attitude and mindset. Physicians having social responsibility have clear communication with patients. In the process of updating the professional knowledge of physicians and fulfilling their needs, the pharmaceutical company promotes drug with minimum regulatory bindings.

Discussion
Pharmaceutical sales promotion directed towards medical professionals for getting prescription of their medicines as much as possible. They interact with the doctors with their offers. From this study, it is found that these offers are in the form of sample of drugs, product literature, invitations of CME programs. The doctors positively accept their offers and thus enhance professional knowledge by receiving product information, disease information, clinical trial information, new drugs information. So, this fair trade can lead to possible favoritism for the doctors as there are 75 pharmaceutical companies (Jimmy and Cheah, 2014) in Malaysia and not all companies will visit the doctors in a certain period. As one physician said in this study, medical representatives visit her once a week. It may vary for different health centers. The prescribing pattern also defines the attitude of medical professionals regarding pharmaceutical promotion. The study conducted by Rohit et al. (2014) on medical doctors in Malaysia concluded that the majority of the medical professionals in Malaysia agreed upon using generic medicine. Prescriptions written with generic names of medicines prove ethical and unbiased behaviour of medical professionals. Although, it sometimes depends on the situation of the patient was said by one physician in this study.
Interviewer: Do you prescribe medicines with generic names or brand names? Interviewee: It depends. Depends on the problem or issue having by the patient.
Pharmaceutical companies promote their products for all human beings as patients are the care receivers from care providers. This complex phenomenon indicates complains from patients regarding the treatment they receive from caregivers. Medical professionals can't attend to the patients equally which impacts the satisfaction level of patients (Haque et al., 2019). In this study, it is being found such behavioral patterns from different attitude and mindset of patients regarding treatment and pharmaceutical promotion. As one patient said, Patients are concerned about medicines naming on prescriptions as they have to consume them after available sourcing. As one patient said, Interviewer: Do you see the prescriptions given by doctor; is it prescribed through generic names or product names? Interviewee: I think it was product names, not generic names. I know generic names are bigger than product names.
Regarding pharmaceutical promotion, patients do not have transparent information. They have different opinions which reflect the reputation of pharmaceutical companies as described also by Baum (2013). As one patient in this study said, Interviewer: Do you think doctors are biased by pharmaceutical companies? Interviewee: In Malaysia, the doctors do not rely on the pharmaceutical companies. I never found the doctors prescribing specific medicine of pharmaceutical companies.
From the above statements and findings in this study, it is proved that physicians have a social responsibility for patients to provide treatment. Physicians have a positive attitude towards pharmaceutical promotion as it fulfils their needs and professional knowledge. But, they are not aware of any regulatory bindings which raise the question of unethical practices unknowingly. Patients have positive as well as negative attitude and mindset towards pharmaceutical promotion, although they are the center of healthcare as a global agenda stated by pharmaceutical companies (Guy et al., 2017).

Conclusion
Malaysia is a culturally diverse nation with different race and different religions of people who "believe in God" being the national principle (Rukunegara). Many core values are having in the ethical beliefs of the country, which are creditable. Organizations adopt these core values for their business and employees. The difference between health care services with other service is, both buyers and sellers can be a patient; both can be seeking for medical attention under the same umbrella. Pharmaceutical companies operate their business depending upon drug promotion strategies towards physician in-exchange for enhancing the professional knowledge of the physician. Ethical beliefs besides regulatory bindings should be aware and kept in mind by everyone in this trade. Patients-centric healthcare service needs to be prioritized by the pharmaceutical companies.