Healthy Skepticism Library item: 1604

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Publication type: Journal Article

Suryawati S, Santoso B.
Drug advertisements: A critical lesson for Indonesian students
Essential Drugs Monitor 1997; 23:23
http://www.who.int/medicines/library/monitor/edm_23_e.pdf

Notes:

HAIWHO

Full text:

Drug advertisements: a critical lesson for Indonesian students
SRI SURYAWATI*,BUDIONO SANTOSO**

INFORMATION on drugs and therapeutics is undoubtedly of paramount importance in keeping doctors updated about the most recent medical advances and in maintaining their standard of practice. Unfortunately in many parts of the world objective and unbiased information is a luxury which is difficult for most practitioners to access. In contrast, pharmaceutical information from commercial sources is far more readily available, although often biased and with a tendency to promote the use of specific brand name drugs<1>. Yet during their formal training doctors are rarely equipped with the requisite knowledge and skills to critically assess drug information and advertisements. Faced with the huge volume of materials produced by pharmaceutical companies, this weakness in their education may contribute to irrational prescribing by doctors<2>.

To rectify this situation the University of Gadjah Mada, Indonesia, has designed and introduced a teaching module to improve medical students’ ability to assess information and advertisements critically. This report of a field test on the module’s effect shows that such training sessions achieve their goal of sensitising medical students’ assessment skills, and that they have a long-term impact. As a result the module has been incorporated as an
assessed element into the clinical pharmacology course in the University’s Medical School.

A PROBLEM-ORIENTED APPROACH
Teaching consists of two sessions, the first lasting an hour and the second, two hours.

The first session involves a brief lecture about: commercial and non commercial sources of drug and therapeutic information and the characteristics of each source, type and form of such information; how to search and choose the appropriate information in a certain situation; how to select and use the information; and the main elements required to critically assess commercial drug information. WHO’s Ethical Criteria for Medicinal Drug Promotion<3> are then introduced and intensively discussed. The Criteria contain a list suggesting the type of information which advertisements to health professionals should include. The list is based on a sample drug information sheet found in the second report of the WHO Expert Committee on the Use of Essential Drugs<4>. The list in the Criteria is adapted and condensed into four components – appropriateness of:

• indication(s)/clinical efficacy;
• pharmacological (kinetic and dynamic) information;
• information on dosages and administration;
• and information on clinical safety, including side effects with common and rare evidence, warnings, precautions and contraindications.

Apart from the four components of information, students are also exposed to examples of misleading messages in drug advertisements from Indonesia and from other countries, to illustrate the extent of the problem. These messages include exaggerated claims or the extension of indications without substantial scientific support; misinformation on adverse effects to minimise potential hazards; inappropriate recommendations for drug use and dosage schedules; incorrect information on pharmacokinetic and pharmacodynamic profiles; and insufficient warning and precautions information.

In the second session students are asked to critically assess selected drug advertisements
from local medical journals, using the four components of information, and decide if misleading information is included. Students work on their own and are given worksheets and standard scientific textbooks or handbooks on drugs and therapeutics as references. Group
discussions on their findings follow.

SUCCESSFUL EVALUATION
Twenty-three medical students who were about to start their clinical internships took part in the field test. Recruited from volunteers, their selection was based on two criteria: that the student should have some knowledge about clinical problems; and ideally should not have been influenced by the prescribing behaviour of their clinical tutors. After 12 months, another 13 volunteers at the same stage in their medical training were used as an additional control group.

The field test used a pre- and post-test randomised controlled group design. Students were randomly assigned into two groups: Group A (n=11) underwent training, and Group B (n=12) served as controls. Two weeks before and two weeks after the training sessions, Group
A and Group B underwent pre- and post-testing respectively, with a final test 12 months after the intervention. Another group of students, Group C (n=13), who were never involved in the training, were recruited for this final test. Ten drug advertisements selected from leading
Indonesian medical journals were used as test materials. Students had to critically assess the advertisements, to evaluate the appropriateness of information on indications, safety and efficacy, dosage and use, pharmacokinetics, and other relevant information. Their ability to critically assess drug advertisements was assumed to be reflected by the number of examples of misleading or incorrect information identified. The change in the number of examples found before and after the intervention between groups was tested using analysis of variance followed by t-test.

Long-term impact of the intervention was measured by comparing the number of items of misleading/incorrect information identified by the three groups at the final test, 12
months later. A peer group of experts cross-checked the students’ objective evaluation of
the advertisements.

The students’ subjective responses were substantiated by the findings during the pre-test,
2-week, and the 12-month posttests, when they again had to evaluate published drug advertisements (see table). The students who underwent training (Group A) could correctly
identify more examples of misleading information two weeks after the intervention than before it (15.0 ± SEM 1.7 vs. 5.8 ± SEM 0.6). This difference was statistically significant (t-test,
P<0.02). In contrast, the control group (Group B) did not demonstrate any difference
in the number of items of misleading or incorrect information that they could identify during the pre-test and the two week post-test (6.7 ± SEM 0.7 and 5.9 ± SEM 0.6 respectively). After 12 months Group A still demonstrated their ability to critically assess drug advertisements (15.8 ± 1.2). The score obtained by Group B increased at the final test, probably due to cross-contamination, while Group C’s score was only 7.9 ± 0.9.

AN EXAMPLE TO BE FOLLOWED
The difference in the number of examples of misleading information identified by the intervention group as compared to control groups suggests that the intervention succeeded in improving knowledge and skills to critically assess drug advertisements. Misleading or incorrect information identified by the students included: paracetamol as a cure for all headaches; multivitamins promoted for the prevention of physical and mental exhaustion and tiredness; vitamins as adjunctive therapy to antibiotic treatment; and assertions that as a drug is new it must be the most powerful.

All the students who received training recognised its importance. They felt that they were better able to understand how to critically assess drug advertisements, and how to search and to use drug information appropriately. They also expressed the view that similar training should be introduced for all medical students.

Our experience indicates that this training module can be implemented effectively in existing medical curricula, after adaptation to local circumstances. In most developing countries the flood of drug advertisements received by physicians cannot be controlled or avoided. It is therefore imperative that practitioners should be properly equipped with the knowledge and skills to evaluate them.

• Sri Suryawati is Director of the Graduate Programme for Pharmaceutical Management and Policy, Gadjah Mada University.
  • Budiono Santoso is Director of the Centre for Clinical Pharmacology and Drug Policy Studies, and of the WHO Collaborating Centre for Research and Training on Rational Drug Use, Gadjah Mada University, Yogyakarta, Indonesia.

References
1. Herxheimer A, Stalsby Lundborg C, Westerholm B. Advertisements for medicines in leading medical journals in 18 countries: a 12-month survey of information content and standards. International Journal of Health Services 1993; 23(1): 161–172.
2. Raisch, DW. A model of methods for influencing prescribing: Part I. A Review of prescribing models, persuasion theories and administrative and educational methods. Annals of Pharmacotherapy 1990; 24: 417–421.
3. World Health Organization. Ethical criteria for medicinal drug promotion. Geneva: WHO; 1988.
4. World Health Organization. The Use of Essential Drugs. Technical Report Series, No. 722, Geneva: WHO; 1985.

Number of examples of misleading/incorrect information in 10 selected drug advertisements identified by the intervention and control groups (mean + SEM)

• Significantly different compared to controls, Student’s paired t-test, P<0.02