|Year : 2017 | Volume
| Issue : 2 | Page : 215-222
Drug promotion in a resource-constrained Nigerian environment: A cross-sectional study of the influence of pharmaceutical sales representatives on the prescribing behaviors of medical practitioners in Abia State
Gabriel Uche Pascal Iloh, Miracle Erinma Chukwuonye
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
|Date of Web Publication||15-Dec-2017|
Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
Background: Pharmaceutical drug promotion is an important component of pharmaceutical care and is one of the factors that may lead to unethical drug prescriptions. As the impetus for rational drug use grows, emphasis should also be focused on prescribing behaviors of physicians, particularly in resource-poor settings. Aim: The study was aimed at describing the influence of drug promotion by pharmaceutical sales representatives (PSRs) on the prescribing behaviors of medical practitioners in Abia State, Nigeria. Materials and Methods: A descriptive study was carried out on a cross-section of 185 medical practitioners in Abia State, Nigeria. Data collection was done using a pretested, self-administered questionnaire that elicits information on practice and attitude to drug promotion, types of incentives, frequency of visits, drug promotion methods and information, sources of drug information, and awareness of code of regulation on drug promotion. Results: The age of the participants ranged from 28 to 71 years. There were 166 males and 19 females. The prescribing practices of 47.6% of the medical practitioners were influenced by drug promotion and 66.5% of them had positive attitude to drug promotion. One hundred and sixty-four (88.6%) were visited >12 times in the previous year. The most common incentive received was branded stationeries (100.0%); predominant drug promotional method and information were in-person clinic encounter (100.0%) and brand names of the drugs (100.0%), respectively. The most common source of drug information was calling a colleague/pharmacist (93.5%) while 84.9% of the respondents were aware of code of regulation on drug promotion. The prescribing practice (P = 0.041) and attitude (P = 0.032) to drug promotion were significantly associated with working in public hospitals. Conclusion: Drug promotion by PSRs influenced prescribing practices of medical practitioners with 66.5% of them having positive attitude to drug promotion. The most common incentive, drug promotion method, and information were branded stationeries, in-person clinic encounter, and brand names of products/drug indications, respectively. The most common source of drug information was calling a colleague/pharmacist, and awareness of code of regulation of drug promotion was inadequate.
Keywords: Abia State, drug promotion, medical practitioners, Nigeria, pharmaceutical sales representatives, prescribing behavior
|How to cite this article:|
Pascal Iloh GU, Chukwuonye ME. Drug promotion in a resource-constrained Nigerian environment: A cross-sectional study of the influence of pharmaceutical sales representatives on the prescribing behaviors of medical practitioners in Abia State. Arch Med Health Sci 2017;5:215-22
|How to cite this URL:|
Pascal Iloh GU, Chukwuonye ME. Drug promotion in a resource-constrained Nigerian environment: A cross-sectional study of the influence of pharmaceutical sales representatives on the prescribing behaviors of medical practitioners in Abia State. Arch Med Health Sci [serial online] 2017 [cited 2018 Sep 22];5:215-22. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/215/220830
| Introduction|| |
Globally, as new drugs are produced by pharmaceutical industries, pharmaceutical companies continue to influence the prescribing behaviors of medical practitioners, especially in resource-constrained environments.,,, As the trend of pharmaceutical care services is changing daily, the impetus for rational drug use is growing with focus on prescribing behaviors of medical professionals. The World Health Organization defines drug promotion as all informational and persuasive activities by manufacturers and distributors, the effect of which is to influence the prescription, supply, purchase, or use of medicinal drugs.
The magnitude of the influence of pharmaceutical sales representatives (PSRs) on prescribing habits of medical professionals has been reported within and across global medical populations in Australia, Germany, Turkey, India,, Saudi Arabia, Peru, United States of America (USA), Ethiopia, and Nigeria. However, factors that influence the prescription of pharmaceutical products worldwide have been reported in biomedical literature., Apart from scientific knowledge, other factors that influence prescription of drugs include incentivized gifts,,,, sponsorships for conferences,, and other lobbying pharmaceutical marketing practices.,, The incentives and enticements used by PSRs are variable ranging from drug samples,,, office stationeries,,,, free meals/lunch, journal advertisements,, and sponsorships for continuing professional development (CPD) and conferences.,, The incentivized relationships between medical professionals and PSRs cut across all cadres of medical practitioners such as general practitioners,, private practitioners, resident medical doctors, family physicians, emergency physicians, and other specialists.,,, Other stakeholders in healthcare profession such as nurses  and patients  affirm that medical practitioners do receive incentives and inducements from PSRs, thus raising concerns about rational drug prescription, patient safety,, and cost of medications.
Various methods of medicinal products promotion have been documented in biomedical literature such as face-to-face talks, conference presentations, exhibitions and materials, continuing medical education/CPD, drug launch, journal advertisements, pharmaceutical detailing, and academic drug detailing,,,, Activities once considered independent of promotional intent like medical research have currently been used as a new marketing strategy for medicinal drugs including paying to publish articles on promoted drug products.,, In the USA, emergence of new media and technologies is quickly changing the landscape of pharmaceutical marketing tactics with increasing reliance on internet (social media) as a source of drug information since PSRs are finding it difficult for in-person face-to-face drug detailing. The e-detailing is widely used to reach “no see physicians” as a primary method of drug promotion. The emerging e-promotional activities include live video detailing, online events, and electronic drug sampling. Research studies have also shown that PSRs provide incomplete medical information to influence the prescribing habits of medical practitioners,,,, with implications for patient-centered pharmaceutical care. The drug information provided by PSRs, particularly in developing countries, is predominantly skewed toward brand names and drug indications with less emphasis on adverse effects, precautions, drug interactions, contra-indications, adverse drug reactions, and boxed warnings.,,,
At present, the expenditure on drug promotion and marketing is more than the expenditure on pharmaceutical development and research with billions of dollars spent on drug sales representatives visits, distribution of gift items, and funding of physicians training, education, and development.,,, The good, bad, and ugly aspects of physicians–PSRs interactions have been documented with implications for the best and evidence-based medical practice.,,,,,,,,,,,,,, The intricacies of the associations between medical professionals and pharmaceutical industries may hinder rational prescription and could engender unethical professional practices,,,, conflicts of interest,, and dysfunctional relationships. There are also arguments that medical practitioners–PSRs interactions can add values to pharmaceutical care and are beneficial for patients management, particularly keeping busy physicians abreast of cutting-edge information in pharmaceutical industries.,
In Nigeria-African medical practice environment, pharmaceutical industries are relentlessly being approached by medical professionals for assistance in their intentions to hosting of association and professional annual general meetings and scientific conferences and seminars, CPD, and attendance to national and international conferences. In some cases, the PSRs of drug firms who do not comply with the physician's demand are threatened with nonprescription of the products as well as boycott of other products by the drug company. However, these solicited sponsorships are often promotional and can undermine the ethics of professional practice as well as jeopardize therapeutic objectives and scientific legitimacy. In Nigeria, there is a paucity of research on the influence of PSRs on the prescribing behaviors of medical practitioners. However, anecdotal and current information in Nigeria suggests that prescribing practices of physicians are influenced by drug promotional and persuasive activities of PSRs. It is based on this background that the authors were motivated to study the influence of drug promotion by PSRs on the prescribing attitudes and practices of medical practitioners in Abia State, Nigeria.
| Materials and Methods|| |
This was a descriptive, cross-sectional study carried out on 185 private and public medical practitioners who participated in CPD program organized by the Directorate of Postgraduate Studies of Federal Medical Centre Umuahia, Nigeria, for medical practitioners in Abia State, on May 3 and 4, 2017, as well as during the General Meeting of Nigerian Medical Association, Abia State Branch, held on May 7, 2017.
The study was carried out in Abia State, Southeastern Nigeria. Abia State is endowed with luxuriant agricultural and mineral resources with a supply of professional, skilled, semi-skilled, and unskilled workforce. Until recently, the capital city has witnessed upsurge in the number of hotels, junk food restaurants and eateries, banks, markets, schools, and industries, in addition to the changing demographic geographical, nutritional, and social lifestyles. The formal sector healthcare delivery system in Nigeria and every Nigerian States is organized at three levels of care, namely, primary, secondary, and tertiary care with health facilities owned by federal and state governments, religious organizations, medical and nonmedical private individuals. The public health facilities are owned by either federal or state government with public servants as their workforce. The private hospitals are individually owned by medical and nonmedical proprietors, while other private hospitals belong to religious bodies such as Roman Catholic Hospitals, Seventh Day Adventist Hospitals, and Anglican Hospitals. Healthcare is provided by medical officers of health, resident medical doctors, and consultants, physicians, and surgeons depending on the level of health delivery system. The tertiary hospitals provide highly specialized care, undergraduate and postgraduate medical education. The medical workforces of tertiary hospitals are predominantly made of consultants and resident doctors in various specialties of medicine and surgery. Abia State has one federal tertiary hospital, one state-owned tertiary hospital, and several religiously-owned and privately-owned hospitals.
The inclusion criteria were private and public medical practitioners in Abia State who participated in the CPD program and General Meeting of Nigerian Medical Association, Abia State Branch.
Sample size estimation was determined using the formula for estimating minimum sample size for descriptive studies  using the formula: n = Z2pq/d2 and nf = n/1 + n/N, where n = Desired sample size when population is >10,000; nf = Desired sample size when population is <10,000; Z = Standard normal deviate set at 1.96 which corresponds to 95% confidence limit; p = Since prescribing attitude and practice are multivariate concepts, authors assumed that 50% (0.50) of the participants would have positive attitude and their practice influenced by drug promotional activities of PSRs; d = Desired level of precision set at 0.05. Using finite population correction formula when studying population <10,000 with an estimated population size of 200 medical practitioners based on the previous medical practitioners continuing professional development records at the Directorate of Postgraduate Studies, Federal Medical Centre, Umuahia. This gave a sample size estimate of 132 patients. However, a sample size of 185 medical practitioners was used to improve the precision of the study.
The eligible medical practitioners for the study were consecutively recruited for the study based on the inclusion criteria until the sample size of 185 was achieved.
The study instrument consisted of sections on sociodemographic data, information on practice and attitude to drug promotion, frequency of visits by PSRs in the previous 12 months, types of incentives received, drug promotion methods, drug promotion information, sources of drug information, and awareness of code of regulation on drug promotion.
The questionnaire was designed by the researchers through robust review of literature on previous studies on the influence of PSRs on the prescribing behaviors and habits of medical professionals.,,,,,,,,,,,,,,,,,,,,,,,, The questionnaire consisted of dichotomous, matrix, and open-ended questions which were structured in such a way that could elicit immediate answers from the respondents. The questionnaire was pretested using 10 postgraduate resident medical doctors in Federal Medical Centre, Umuahia. The pretesting was done to find out the understanding of the questions by the respondents and ensure that there were no ambiguities. However, no change was necessary after the pretesting as the questions were interpreted with the same meaning as intended. The questionnaire was self-administered since the participants are health literate.
Operationally, prescribing practice referred to prescribing habits and response to practice-based question on the influence of drug promotion by PSRs on the prescribing practice of the medical practitioner in the previous 12 months. Attitude to drug promotion referred to the state of mind of the medical practitioner toward drug promotion by PSRs in the previous 12 months.
The ethical clearance was obtained from the Ethics Committee of the Federal Medical Centre, Umuahia, Nigeria. Informed written consent was also obtained from the respondents.
The data generated were analyzed using software International Business Machines Corporation, Statistical Package for the Social Sciences (IBM SPSS) version 21, New York, USA. Categorical variables were described by frequencies and percentages. Bivariate analysis involving Chi-square test was used to test for significance of association between categorical variables.
| Results|| |
Of the 185 medical practitioners who participated in the study, 131 (70.8%) were middle-aged adults (40–59 years), 46 (24.9%) were young adults (18–39 years), and 8 (4.3%) were aged 60 years and above. The age of the participants ranged from 28 to 71 years with a mean age of 34 ± 5.4 years. There were 166 males (89.7%) with 19 females (10.3%) with female-male ratio of 1:8.7 [Table 1].
Of the 185 respondents who participated in the study, 123 (66.5%) of them had positive attitude to drug promotion with 88 (47.6%) admitting that their prescription practices were influenced by drug promotion by PSRs. All the respondents 185 (100%) were visited by PSRs in the previous 12 months with 164 (88.6%) visited 12 times and above while 21 (11.4%) were visited 12 times and less in the previous 12 months [Tables 2].
|Table 2: Distribution of the study participants by their attitude; influence of drug promotion on prescribing practices; visits and frequency of visits by pharmaceutical sales representatives in the previous 12 months|
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[Table 3] summarizes that the most common incentive received by the medical practitioners was branded office stationeries (pens, jotters, diaries, calendars) with all of the respondents 185 (100%) accepted the gifts; the most common drug promotion method used by PSRs was clinic in-person encounter (face-to-face); and the predominant drug information provided by PSRs was both brand name of the drugs and drug indications [Table 3].
|Table 3: Type of gifts/incentives; drug promotion methods and drug information provided by pharmaceutical sales represen|
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[Table 4] shows that most common source of drug information used by the respondents during clinical consultation was asking or calling a colleague or pharmacist with 173 (93.5%) of them employing this method when they have problems with drug information. One hundred and fifty-seven (84.9%) of the respondents were aware of the code of conduct regulating drug promotion by PSRs.
|Table 4: Sources of drug information during clinic consultations and awareness of code of regulations of drug promotion among the study participants|
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Bivariate Chi-square analysis of the sociodemographic characteristics of the study participants as related to attitude and prescribing practice showed that working in public health facilities was statistically significant for attitude (χ2 = 2.75; P = 0.032) and prescribing practice (χ2 = 3.22; P = 0.041) while other demographic characteristics were not statistically significant [Table 5] and [Table 6].
|Table 5: Association between demographic variables and attitude to drug promotion|
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|Table 6: Association between demographic factors and the prescribing practices of study participants|
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| Discussion|| |
Eighty-eight (47.6%) of the study participants agreed that their prescribing practices were influenced by the drug promotional activities of PSRs. This finding is in consonance with high incentive-induced prescription rates reported in other studies from the USA,, Germany, India, Iraq, Turkey, Ethiopia, and Nigeria. The high level of drug promotion-induced prescription practice among the study participants could be a reflection of the frequency of unsolicited visits and enthusiastic gifts by the PSRs to the medical practitioners in Nigeria. Although medical professionals in Nigeria  and other parts of the world ,, mostly deny that their prescribing practice is influenced by the activities of PSRs, anecdotal and current information in Nigeria  and other parts of the world ,,,,, has demonstrated that prescribing practices of medical professionals are influenced by the drug promotional strategies of PSRs. Admittedly, medical professionals are privileged with the right and responsibilities of recognizing the medication needs of their patients and prescribe appropriate medications for their well-being devoid of persuasive activities by drug manufacturers, distributors, and PSRs, but the physician–patient relationships can be threatened by the persuasive influence of PSRs on the prescribing practices of medical practitioners, especially in resource-limited environments where there are poverty of appropriate resources for standard pharmaceutical care., To the pharmaceutical industries, drug promotion is designed to enthuse the physicians, allay fears about safety profile, and encourage maximum use of medications, while to the medical practitioner, drug promotion is meant to provide succinct and sufficient information to make appropriate therapeutic choices and shared decisions to prevent attendant adverse consequences. However, it is only a balance between pharmaceutical industry perception and expectation and physicians perception and expectation that will enable rational patient-centered therapeutic decisions to be made., It is therefore quintessential for medical practitioners and pharmaceutical industries to develop mutually and ethically acceptable limits of drug marketing and promotional activities. The internationally and nationally available codes of practice for drug promotion should be embraced for appropriate prescriptions and pharmaceutical care.,
One hundred and twenty-three (66.5%) of the study participants had positive attitude to drug promotion by PSRs. Research studies ,,,, have demonstrated that whenever a medical practitioner accepts a gift, there is an unalloyed disposition to reciprocate the gesture by prescribing the medical products even less expensive gifts can create a feeling of obligation.,, Although medical practitioners have the referent power to prescribe medicinal drugs which are available on prescriptions, the drug promotion activities by PSRs have been largely blamed for attitudinal change in pharmaceutical care, resulting in medication errors and its attendant challenges., The consequences of such inappropriate prescriptions are treatment failures from use of wrong medications, exposure of patients to unnecessary adverse effects of the drug, and waste of patients monetary resources.,, Medical professionals should therefore be required to change their prescribing attitude by writing only generic names of drug during prescription order  as well as disclosure of interest in the medical products and the drug companies., These will invariably help to promote healthy and ethical relationships between the medical practice, the patients, and the pharmaceutical companies.
All the participants have been visited by PSRs in the previous year with 88.6% of the respondents being visited > 12 times. The finding of this study has shown that medical practitioners in Nigeria allow a free and unrestricted access of PSRs to the medical doctors during clinical consultations with the patients. The doctors consulting clinics have become a booming market arena for physician–PSRs interactions for persuasive prescription of drugs. Due to widespread and extensive competition and unethical drug promotion activities among PSRs, it is ethically imperative to restrict visits of PSRs to medical doctors individually. PSRs can present and promote their pharmaceutical products to group of medical doctors during a fixed time period with adequate drug detailing., Although the borderline between genuine drug detailing and profit-oriented persuasion is narrow but marketing of branded medical products is not the only aim of drug detailing. Drug detailing is also meant to provide busy medical practitioners with up-to-date information on the promoted drugs and keep them abreast with cutting-edge advances in pharmaceutical industries., While legitimate prescription is useful to patient care, profit-oriented incentives create an opportunity for misuse and violation of medical ethics and code of marketing of pharmaceutical products. Closer cooperation between the national medical association and pharmaceutical regulatory authorities is a necessity in ensuring internationally accepted ethical drug promotional practices., This will help in improving patient-related pharmaceutical outcomes and limit the negative effects of drug promotion activities on patients, healthcare profession, and the public.,
This study has shown that various incentivized items were accepted by the medical practitioners with the most common incentives being branded office stationeries. This finding is in tandem with reports from Ethiopia, India, Iraq, and Germany., Although this apparently innocuous practice is generally accepted as a norm, many medical practitioners feel uncomfortable about its ethical implications.,,,,,,, Of great interest is that gift items whether small or big cost money to the pharmaceutical companies and the cost is ultimately passed on to the patients without their overt knowledge.,, It is admitted by most physicians that whenever a medical doctor accepts a gift, an implicit relationship is established between the medical doctor and the PSRs with obligation to reciprocate for the gifts.,,,, The gifts embossed with the branded drug information also remind the medical practitioner about the brand name of the medicinal drugs which could result in product prescriptions. Regrettably, accepting gifts from PSRs can generate potential conflicts of interest , and dysfunctional relationships, with ethical and financial quandary for standard patient care. This finding therefore calls for caveat emptor on physician–PSRs relationships. In addition, there is a professional call to considering whether the association between medical practitioners and PSRs is a dangerous liaison, beneficial or bait, or follow-up scripts. The intricacies of physicians–PSRs relationships raise concerns on whether a gift is ever a gift, how free is the free lunch, and a gift has a return on investment. These incentives invariably increase the cost of medications with no added value to patient care. In all gift items accepted by the medical professionals in the ecology of medical care, the medical practitioners, PSRs, and pharmaceutical companies are smiling while the consumers (patients) are overtly or covertly crying, thus necessitating the need for medical practitioners to open their eyes to the complexity of the relationships  and act ethically  and timely  to safeguard the interest of the patients who bear the financial burden of drug promotional materials. It is therefore pertinent in Nigeria to define the acceptable norms for gifts particularly if the gift items are relevant to the clinical practice with substantial benefit for standard patient care. The implementation of approved code of conduct for pharmaceutical promotional activities  needs to be enforced in Nigeria for patient-centered pharmaceutical care.
The most common drug information provided by the PSRs was the brand name of the pharmaceutical products. These findings are in consonance with the reports from Ethiopia, Iraq, India, and Libya. This is in contrast to the reports from Germany  and the USA  where PSRs provide all types of pharmaceutical product information. These disparities could be due to the differences in the strength of regulatory and legislative control of the activities of drug promoters among different countries., More so, PSRs have negative perception and attitude to other competitors brand products, thus occasioning overemphasis on their companies brand products with less emphasis on adverse effects and black box warnings which signify that the medicinal drug carries a significant risk of serious or even life-threatening adverse effects., Even though the World Health Organization has provided specifications on drug promotional practices, most pharmaceutical firms and their marketers fail to provide the essential information for medical practitioners during their encounter with tendency to providing incomplete information ,,,, and manipulation of drug information., It is therefore pertinent that PSRs in Nigeria should have a high standard of ethical conduct in the discharge of their duties, especially providing product information that must be accurate and scientifically sound. The marketing message should be educative based on approved drug use,, and black box warnings should also be emphasized when indicated., None of the respondents was informed on the boxed warnings for specific medications which are available in Nigeria. Admittedly, there is a risk and benefit associated with taking medications, but the black box warning is to alert the physician of the potential harm in prescribing the medical products. Of great concern during physician–PSRs interactions in Nigeria is that physicians are often not informed about the risks included in boxed warnings for drugs such as rosiglitazone  which is the strictest labeling required for certain prescription drugs.
The most drug promotion method employed by the PSRs in this study was in-person face-to-face encounter in the clinic. Globally, launching of new drugs and advertising a medicinal drug product have been among the earliest promotional strategies used by pharmaceutical firms with consequential effects reported in both developed and developing countries.,, However, today drug product advertisement is under scrutiny particularly in advanced nations.,, In Nigeria-Africa, the aggressiveness with which drug promotion activities by the PSRs occur in the clinics in Nigeria is better imagined than witnessed. This is attributed to the fact that increment in the salaries of PSRs, sponsorships for foreign tours, and other companies' incentives depend on the achievement of sales targets set by their managers and chief executive officers. It is therefore imperative to employ measures to improve the quality of promotional information on drug products. Every promotional material must have clear and complete information. Besides, the product should have canons of good manufacturing practice for the provision of cutting-edge care to the patients. Personal or anecdotal testimonies on the use of the drug product should be discouraged.
The most common prescribing resource used by medical practitioners in this study was calling or asking a colleague/pharmacist. This is particularly phenomenal in Nigerian environment where pharmaceutical companies do not provide printed package information (leaflets) for medical practitioners and the patients on every drug packet. Furthermore, in most drug products leaflets and other package inserts and embossments do not provide sufficient information for safe, effective, and efficient use of the medical products. The advertisement of drug products in lay press such as religious bulletins and newspapers in Nigeria could lead to omission of important contra-indications, warnings and precaution for the use of the medicinal drug products. With the wider availability of prescription-only-medicines without prescription in Nigeria, the unwary and uninformed patients can buy the drug products for inappropriate use and may suffer undesirable consequences from the medications.
This study has shown that 84.9% of the study participants were aware of the regulation on drug promotion. While there is need to increase the awareness of regulation on drug promotion among the study participants, this awareness should be translated to appropriate prescribing practice and positive attitude towards drug promotion. This will enable medical professionals to conduct their interactions with PSRs in a responsible, professional, and ethical manner devoid of unhealthy marketing tactics. Medical practitioners should not wait for the government to legislate morality, pervasive inducement, and medical ethics.
On bivariate Chi-square analyses, working in public health facilities was significantly associated with attitude and prescribing practices of the study participants. This could be a reflection of accessibility and frequency of visits by PSRs to medical practitioners working in public health facilities among other epidemiological variables. Public health facilities in Abia State are easily accessible to PSRs and the medical practitioners working in public health facilities are more likely to be exposed to the persuasive and lobbying activities of PSRs. The finding of this study signals the need more than ever before for increased awareness of code of regulation on drug promotion, especially for medical practitioners in public health facilities in Nigeria. This appears to be one of the ways Nigerian patients will benefit from satisfaction with patient-centered pharmaceutical care that is comparable to what is obtained in advanced countries.
The limitations of this study are recognized by the researchers. First and foremost, the study was carried out in Abia State, and the findings may not be generalized to other parts of Nigeria. Second, the attitudes to drug promotion by PSRs were based on respondents' subjective experience and were not verified. However, there is a tendency to under-reporting the outcome of the interactions and relationships with PSRs. Finally, the details of specialties of the respondents and specific incentives received were not considered, and these are important areas that require further study.
| Conclusion|| |
This study has shown the influence of drug promotion on prescribing practices of medical practitioners with majority of the respondents having positive attitude to drug promotional activities of PSRs. The most common incentivized gift, drug promotion method, and drug information were branded office stationeries, in-person face-to-face encounter in the clinics, and brand names of the medicinal products respectively. The most common source of drug information was calling a colleague/pharmacist, and the awareness of code of regulation of drug promotion was inadequate.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]