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Table 1 Characteristics and methodological features of the included studies

From: Knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interacting with pharmaceutical companies: a systematic review

Study ID
Study design
Participants and setting Type of interaction studied Sampling and response rate Validity of tool; pilot testing Results
Al Areefi 2013 Study 1 [15]
• Semi-structured interview
Study 2 [14]
• In-depth interview
Study 1 & 2
• Physicians from private and public hospitals (N = 32)
• Sana’a, Yemen
• May-July 2009
Study 1
• Relationship with PCR
• Frequency of PCR visits
• PCR marketing activity
Study 2
• Interaction between PCRs and physicians
• Physicians’ attitudes toward these interactions and the PCRs
• Reasons for accepting the PCRs’ visits
• Sample size calculation (both studies): not reported
• Sampling frame (both studies): bot reported
• Sampling method (both studies): purposeful sampling
• Response rate (both studies): 100 %
Both studies
• Interview guide developed through a literature review, then pilot tested with 3 physicians
Study 1
• Percentage of participants reporting the following as important factors in prescribing a specific drug: relationship with PCR (9 %), frequency of PCR visits (34 %), PCR marketing activity (13 %).
Study 2
• Most physicians thought they were immune from being influenced by their interactions with PCRs.
• Physicians accept a PCR’s visit because of the beneficial patronage or the financial support provided by the PCRs.
• Physicians recognize the professional authority of PCRs as information providers.
• Physicians considered accepting the PCR’s visit was their moral duty.
• Participants still doubt the role of representatives, with some accusing them of creating problems, harming the ethical reputation of the profession and harming the patients’ welfare
Alssageer 2013 [16]
• Self-administered anonymous questionnaire
• Doctors from selected public and private practice settings (N = 608)
• Libya
• August-October 2010
• Gifts received from PCRs (e.g., printed materials, simple gifts or drug samples • Sample size calculation: not reported
• Sampling frame: not reported
• Sampling method: convenience sampling
• Response rate: 61 %
• Questionnaire developed based on previous published studies • Perceived benefits from interactions with PCRs: receiving new information about products (95 % approved), invitations to conferences (35 % approved) and receipt of gifts (22 % approved). Attitudes towards accepting PCR gifts: 25 % totally disapproved; 25 % clearly approved; 50 % would accept gifts in some cases.
• Acceptance of gifts according to educational value: of respondents who did not disapprove of gift provision, 82 % considered educational gifts as appropriate; 49 % considered non-educational gifts as appropriate. Belief that pharmaceutical promotional activity decreased rational drug prescribing: 42 % disagreed; 32 % agreed; and 27 % were neutral.
• Perceived impact of pharmaceutical promotion on prescribing decisions of physicians: minor (62 %); major (38 %). Perceived impact of pharmaceutical promotion on own prescribing decisions: minor (80 %); major (20 %). Perceived need to develop national policies to restrict PCR interactions with doctors: 57 %.
• Awareness of guidelines regarding PCR interaction: 99 % had never read any guidelines.
Guldal 2007
• Interview
• Specialists and general practitioners in government posts (N = 446: 24 % GPs, 42 % specialists and 35 % residents)
• Turkey
• Visits by PCR (frequency, duration)
• Promotional Program
• Provision of drug information
• Sample size calculation: not reported
• Sampling frame: list of physicians from the Ministry of Health and from the 1992 Izmir telephone directory
• Sampling method: stratified random sampling
• Response rate: 91 %
• Questionnaire pretested with 25 subjects • Physicians’ expectations about promotional programs: reliable educational publications (82 %); medical equipment (57 %); free drug samples (54 %); financial support for training courses (43 %); social events (e.g., dinners, trips) (34 %); and gifts of up to $50 for private use (27 %).
• Support for the prohibition of PCR visits to physicians: 54 %
• Attitudes towards promotional programs: not ethical (33 %); not ethical in some aspects (36 %); ethical (20 %).
• Perceived effect of advertising gifts on prescriptions: high (18 %); medium (12 %); low (44 %); no effect (27 %)
• 68 % thought the information was unreliable.
• 94 % pointed out the necessity for a reliable source of information other than drug companies.
• 54 % approved that doctors who receive expensive advertising gifts tend to prescribe that company’s products
• Public knowledge that physicians were receiving gifts and awards from drug companies did not matter for 64 %
Loh 2007 [20]
• Self-administered questionnaire
• Registered practitioners (N = 172)
• Penang, Malaysia
• March to May 2005
• Pharmaceutical- sponsored continuous medical education (CME) • Sample size calculation: not reported
• Sampling frame: databases of Penang Medical Practitioners’ Society and Malaysian Medical Association (Penang branch)
• Sampling method: exhaustive (all registered doctors)
• Response rate: 19.5 %
• Self-developed tool: content first approved by the Committee of The Penang Medical Practitioners’ Society, reviewed by 5 clinicians in active medical service to ensure clarity and appropriateness
• Pilot testing not reported
• Rated impact on clinical practice by descending order, as it relates to medical conferences: local conferences, pharmaceutical talks, internet-based medical education, conferences organized by pharmaceutical firms and overseas conferences
• Rated impact on clinical practice by descending order, as it relates to pharmaceutical firms: reputation of the firm, pharmaceutical company representatives, and advertisement or announcement.
Mikhael 2014 [21]
• Self-administered questionnaire
• Specialist physicians in different areas of Baghdad governorate (N = 22)
• Iraq
• March to October 2013
• Quality of promotional information that is given by MRs to physicians • Sample size calculation: not reported
• Sampling frame: not reported
• Sampling method: not reported
• Response rate: 63 %
• Self-developed tool; validation not reported. Pilot testing not reported • Information from PCRs about drug indication was perceived as good and information about drug contraindications and side effects was perceived as weak.
• Academic physicians have a significantly more negative opinion than hospital physicians regarding PCRs information on drug contraindication
• Only hospital physicians found that PCRs’ information are useful for them
Oshikoya 2011 [17]
• Self-administered questionnaire
• Doctors in University College Hospital teaching hospital (N = 163)
• Nigeria
• Provision of drug information • Sample size calculation: not reported
• Sampling frame: not reported
• Sampling method: convenience sampling
• Response rate: 41 %
• Questionnaire developed from previous studies in developed and developing countries, then piloted among 10 doctors • Drug information was sourced from colleagues (99 %), drug reference books (97 %), PCRs (93 %), materials from drug companies (93 %), scientific papers/journals/internet (91 %), and drug promotion forum/product launches (88 %).
• Perception of importance of PCR as drug information source: efficient (70 %), reliable and accurate (66 %), influences prescription behavior (72 %), useful and readily used when prescribing (69 %)
• Perception of the effect of detailing by a PCR of a promoted drug: increases awareness (82 %), increases preference for prescription (60 %).
Rajan 2008 [18]
• Self administered survey questionnaire
• General practitioners and specialists from an urban town (N = 57)
• India
• Provision of drug information • Sample size calculation: not reported
• Sampling frame: not reported
• Sampling method: convenience sampling
• Response rate: 95 %
• Questionnaire based on theoretical model, no validation reported • Perception that product information provided by medical representatives is biased and insufficient: 79 %
Scheffer 2014 [22]
• Structured Interview
• Physicians in Sao Paolo, Brazil (N = 300)
• October 2007 to May 2009
• Informative materials about ARVs
• Visits by sales promoters and sales representatives
• Inexpensive objects for the doctor’s office
• Invitations to take part in continuing education courses and events Scientific journals sponsored by the laboratories
• Sample size calculation: described in detail
• Sampling frame: Logistics Control System (SICLOM) of the STD, AIDS and Viral Hepatitis Department of the Ministry of Health in Sao Paolo
• Sampling method: stratified random sampling
• Response rate: not reported
• Validation not reported; pilot testing not reported • Pharmaceutical companies’ actions were considered to have a strong influence (10 %), slight influence (50 %) or no influence (40 %) on physicians’ prescribing of antiretroviral.
Siddiqi 2011 [19]
• Self administered questionnaire
• General practitioners and consultants (N = 200)
• Various districts of Rawalpindi division, Pakistan
• January –June 2010
• Sponsorships
• Scientific promotional tools
• Personal touch promotional tools
Common promotional tools.
• Sample size calculation: not reported
• Sampling frame: not reported
• Sampling method: “Judgmental sampling”
• Response rate: 75 %
• Questionnaire was adapted from existing one • General practitioners perceived common promotional gifts as most effective tool for changing the prescribing behavior; while sponsorship and personal touch promotional tools are considered neutral and relatively least important.
• Consultants perceived scientific promotional tools as most influencing in changing prescribing behaviors in comparison with other promotional tools; while sponsorships are least important