WHO/HAI Drug Promotion Project

Medicines are used to treat an increasingly wide range of health problems and represent a considerable potential benefit to patients’ health and to health care services. However, when used inappropriately, their harmful effects and costs may outweigh benefits. Pharmaceutical companies must compete for product sales and market share, and this has led to an increasing amount of spending on drug promotion aimed at health professionals and the public. Drug promotion has been found to influence behaviour, with most research pointing to a negative effect on the appropriateness of drug prescribing and use.

Reasons why unethical drug promotion occurs include:

• Lack of awareness. Health personnel have insufficient training to see promotion for what it is and to critically appraise it. Consumers also lack access to reliable and objective product information, and information and education to critically evaluate drug advertising and basic principles of rational drug use.
• Low priority. In some countries, particularly those lacking access to essential drugs and with limited resources, drug promotion issues are given little attention.
• Reactive enforcement. In most countries, pre-approval of drug promotion material is not mandatory. As enforcement is reactive and occurs after a promotional event, unethical drug promotion can go unchecked for a significant period of time.
  

Background

In 1999, members of the WHO/public interest NGO Roundtable on Pharmaceuticals agreed that efforts need to be made to empower health care professionals and others to critically assess drug promotion.

As a first step, a web-based database was developed on publicly accessible material that described, analyzed, reported on or commented on any aspect of pharmaceutical promotion (http://www.drugpromo.info). Currently the database contains approximately 2700 entries. Updating the database with new material on drug promotion is ongoing.

In mid-2003, four reviews of database material (written by Pauline Norris, Andrew Herxheimer, Joel Lexchin and Peter Mansfield) were published on the web site:

• what attitudes do professional and lay people have to promotion?
• what impact does pharmaceutical promotion have on attitudes and knowledge?
• what impact does pharmaceutical promotion have on behaviour?
• what interventions have been tried to counter promotional activities, and with what results?

WHO and HAI have published the reviews as a report entitled Drug Promotion – what we know, what we have yet to learn. You can order a paper copy free-of-charge from the WHO EDM documentation centre (email edmdoccentre@who.int and ask for a copy of the report).

The fourth review on interventions to control or counter promotion, and the effects of such interventions, revealed that only a few papers have been published describing programmes to teach health professionals or students to critically assess drug promotion. Most assessed attitudes to promotion; one assessed skills. Only one undertook an evaluation of the intervention using a randomised controlled trial. Overall it appears that education about promotion appears to change attitudes and can improve skills. The impact of education about promotion on prescribing has not yet been tested.

The need to develop a manual on educational interventions to critically appraise drug promotion, targeted at health professionals and students, was confirmed by participants at the 2001 WHO/public interest NGO Roundtable on Pharmaceuticals. The review on interventions to counter or control promotion showed that few educational interventions exist or have been published. Of those that have been published, very few have been adequately evaluated.

Outcomes

In 2004 HAI and WHO commenced a project to ascertain what is being taught to medical and pharmacy students about drug promotion. The project initially attempted to contact all medical and pharmacy schools around the world (using contact information from a number of online databases and various listservs) to ascertain the presence and extent of curricula that teach students about drug promotion, and the contact details of the educators.

In the first half of 2005 a detailed questionnaire was sent to the educators asking about the structure, objectives, content and effectiveness of the courses they provided. Two hundred and sixty-two educators completed and returned the questionnaire, 34 were excluded for various reasons (e.g. they were not teaching about drug promotion, were double-ups etc). Data from 228 respondents from 64 countries was analyzed (137 from medical schools and 91 from pharmacy schools).

The survey report Educational initiatives for medical and pharmacy students about drug promotion: an international cross-sectional survey was written by Barbara Mintzes. Copies (free of charge) can be ordered from WHO by emailing edmdoccentre@who.int

Key findings include:

• 72% of respondents included education about drug promotion in the curriculum, however, about one-third of medical students and one-fifth of pharmacy students devote only 1-2 hours to this topic during their training.
• The content of the coursework was similar by health profession - primarily critical appraisal skills followed by sales representatives. Other topics included sponsored conferences and seminars, promotional 'research', gifts, industry funded journals, and the regulation and/or ethics of drug promotion
• Few covered how to respond to patient requests for advertised drugs although direct-to-consumer advertising of prescription drugs and other promotional techniques aimed at the public are becoming increasingly common
• Lack of integration and inadequate time allocation were frequently mentioned as barriers to success