INTRODUCTION
The USA has always allowed mass media advertising of prescription drugs, but the US Food and Drug Administration FDA has set various restrictions over the years. The most recent guidelines came into force on 1st January, 2006, but they are not binding and it is up to the individual company to choose whether or not to follow them. So far, 23 companies have agreed to adopt and follow the new guidelines, confirming the industry's support for the regulation of direct-to-consumer advertising (DTC-A).1 In New Zealand, DTC-A was allowed by chance in 1991, but its future may be short-lived. In their report to the Minister for Health, Toop et al.2 argue for an immediate ban on all types of marketing of prescription drugs. Despite earlier scepticism, DTC-A is still permitted in these two countries. In recent years various attempts have been made to determine whether DTC-A has a positive or negative influence on the consumer, but because these studies have been conducted in countries whose healthcare sectors differ greatly from Denmark's, it can be difficult to adapt their results to this well-regulated Scandinavian society. The USA is a consumer society, and consumers presumably expect the best possible information about the products to which they have access. In New Zealand drugs are considered consumer goods on par with all others, which means that they can be advertised under the same set of regulations.2
In Denmark, drugs are considered to be in a different category from consumables purchased in the supermarket. Drugs are products prescribed to patients by doctors in connection with treatment, and can occasionally cause more harm than good. This viewpoint may be one of the reasons for the decision to protect the public by keeping drugs in a regulated environment. Treating illness is, however, meant to improve the health of the population, for which it should be in everyone's interest to learn about various treatment options. In Denmark, doctors and pharmacists are still the sole source of this information, but the increasing demand from patient groups for more information cannot continue to be ignored.
In previous debates on the subject, it has primarily been healthcare professionals, politicians, consumer organisations, industry and other opinion makers who have expressed an opinion. In a society where patient autonomy and putting patients first are high priorities for the health sector, it is thought provoking that the patient's perspective is so seldom offered. Therefore, this survey attempts to shed light on the awareness of and attitude towards the DTC-A of prescription medicine that can be identified in the Danish population.
METHOD
A quantitative internet-based questionnaire survey was used to collect the empirical data.
Data were collected in the period 19–27th April, 2005, based on the market analysis company Zapera's data panel, which has 80,000 members in the Nordic countries, of which 40,000 are Danish. Members of Zapera's panels are recruited through various media. Recruitment methods include advertising in daily newspapers and magazines, direct telephone recruitment followed by e-mail confirmation, local radio spots, recruitment from existing databases, banner advertising on the internet, and recruitment through recommendations from current members. The survey was conducted on a representative population from ages 18 to 70. A total of 6,100 e-mail invitations were sent out. A total of 3,255 interviews were conducted, of which 3,001 respondents matched the target group. Background criteria were gender and age.
The internet as a data collection medium
Today most Danes have access to the internet. On 21st June, 2006, Statistics Denmark reported that 89 per cent of the Danish population had access to the internet either at home or at work, a significant 6 per cent increase in only two years.
The difference between east and west Denmark is almost negligible, as the internet access ratio is 90:88 per cent for this parameter. The gender difference is not significant, although difference in age groups is a negative factor. While 90+ per cent of people aged 16–59 have access to the internet, only 65 per cent of seniors aged 60–74 do.3
Participation in an internet-based questionnaire survey requires the respondent to have access to the internet as well as an e-mail address. This could be considered a disadvantage since not all Danes have internet access. There could also be wide differences between the share of the population that uses the internet and the share that does not, in that perhaps internet users are more open to innovation. This factor could lead to selection bias and needs to be taken into consideration when reporting the results.
As to the question of whether they are representative of the population, respondents were weighted to compensate for possible distortions due to demographic and socio-economic conditions. The advantage of an internet-based survey is clearly the large sample available compared to traditional methods. The method is also cheaper and data collection is simplified since it is in electronic form.
Data processing
The data collected were stored in an Excel file that could quickly and easily be converted for the statistical program SAS JMP. A bivariate data analysis was conducted on the responses on the basis of the research questions. Responses were crosschecked to see if they correlated with response options. The variations were evaluated on the basis of a chi-squared test with a significance level of p<0.05.
RESULTS
Respondents
As described in the methods section, respondents were men (49 per cent) and women (51 per cent) aged 18–70 (Table 1) and were residents of Denmark. Gender, age and geography were weighted to make responses representative of the Danish population.
Education and occupation
The majority of respondents have an education that corresponds to the bachelor's level (39.59 per cent). A total of 18.13 per cent have an education corresponding to a master's degree. About 13.70 per cent have the equivalent of an associate's degree, while 17.16 per cent have graduation from high school as their highest level of education, 10.00 per cent finished 10th grade and 1.43 per cent fall into the category of 'other'. In terms of occupation, 45.28 per cent are white-collar employees, 4.00 per cent are unemployed and 10.13 per cent are students. The remaining respondents have blue-collar jobs (15.10 per cent), or are retired (14 per cent) or self-employed (6 per cent).
Awareness of drug advertising
This section deals with respondents' awareness of drug-related advertisements. About 35.53 per cent of respondents state that they have seen or heard a drug-related advertisement within the past 14 days, while only 7.48 per cent say that they have never seen or heard an advertisement for a drug. The awareness factor is almost evenly divided between genders, with 18.32 per cent of women and 17.21 per cent of men responding yes to having seen an advertisement for a drug within the past 14 days.
The yes respondents are dominated by the 30–44 and 45–59 age groups, which responded 11.57 and 9.89 per cent, respectively, out of the total 35.53 per cent. No significant correlations between age groups were found, however. Nor does there appear to be a significant correlation between household income and awareness of drug advertising.
In contrast, there was a significant difference between the respondents' geographic place of residence and their awareness of drug-related advertising. Our results showed that urban residents in large towns or cities are more aware of drug-related advertisements than people living in provincial towns.
Attitude towards drug-related advertising
Here focus is on the extent to which respondents found the information from campaigns to promote health and prevent disease useful. About 60.12 per cent found the information useful, 23.80 per cent found it very useful and only 6 per cent found it less or not at all useful. Thus more than 80 per cent of respondents are positive towards the usefulness of information in health campaigns.
Attitude towards the types of drugs for which advertising should be allowed
A total of 18.84 per cent of respondents (58.31 per cent male and 41.69 per cent female) have indicated that advertising prescription drugs is acceptable. About 61.24 per cent of respondents find it acceptable to advertise for over-the-counter (OTC) drugs, and here the gender split is quite even: 51.45 per cent male and 48.55 per cent female.
With respect to natural medicines, 55.45 per cent of respondents were positive towards advertising, while 44.55 per cent had no opinion. About 51.32 per cent of the positive respondents were male and 48.68 per cent female.
Only 10.90 per cent of respondents (47.17 per cent male and 52.83 per cent female) thought that advertising should not be allowed for some of the types of drugs mentioned above.
The above responses show a generally positive attitude to the use of drug-related advertising, particularly for OTC products. Men tend to be more positive than women with regard to advertising for all types of medicine. We can also see that almost 60 per cent of women found it difficult to decide whether or not drug-related advertising should be allowed.
Attitude to the role of the drug industry in health campaigns
To what extent are respondents clear about the role of drug companies in connection with various internet pages focusing on specific diseases? A total of 58.18 per cent of respondents answered that they were familiar with the role of drug companies and only 3.25 per cent responded 'do not know'. About 53.36 per cent of the respondents who knew about the role of drug companies were male.
We also surveyed the general attitude to the role of the drug industry in health campaigns. A total of 42.57 per cent of respondents said that they were 'indifferent' about the role of the drug industry, that is, neither positive nor negative. About 33.37 per cent were negative, 10.17 per cent were very negative, while 10.73 per cent were positive and only 1.11 per cent were very positive about the drug industry's initiatives. A negative attitude to the role of drug companies can be seen generally, although almost half of respondents do not have a standpoint, which could mean that they need more information on the subject. Again, men were more positive than women.
About 55 per cent of respondents indicate that they were not influenced to buy the product from the drug company behind a website providing information about a specific disease. This is confirmed by the fact that 50 per cent of respondents say they can imagine buying the drug produced by the company responsible for an internet page about a specific disease.
Health status
The results show that respondents generally were in good health with 55.54 per cent saying that they are almost never ill and 31.49 per cent only ill a couple times a year, while 2.83 per cent were often ill and 9.63 per cent were chronically ill. The results do not show a significant correlation between health status and awareness of drug-related advertising, nor is there a correlation between awareness of drug-related advertising and use of medicine. Health status has no influence on the respondents' perception of the usefulness of the advertising. No correlations were seen between health status and attitude to drug companies providing information about health and disease on the internet. Furthermore, no significant correlations were seen between health status and the types of medicine respondents find reasonable to advertise.
Use of medicine
A total of 28.12 per cent of respondents took medicine daily while 14.18 per cent had taken medicine within 14 days of the start of the survey. About 7.10 per cent of respondents last took medicine 15–30 days before the start of the survey, while 12.64 per cent had taken medicine more than six months ago. About 20.90 per cent said it had been more than a year since they last took medicine. Women showed a slight tendency to take medicine more often than men. No correlation was seen between medicine consumption and awareness of drug-related advertisements, nor between medicine consumption and the respondents' attitude to the usefulness of health campaigns.
Steps taken after exposure to advertising
A total of 2,563 of respondents had seen drug-related advertisements within the past 14 days. These respondents were asked if they had taken any steps after being exposed to the advertisements, and of this number about 2 per cent responded that they had gone to the pharmacy, about 1 per cent saw their doctor, about 4 per cent sought further information on the Internet, while less than 1 per cent contacted a drug company direct and about 1 per cent took an entirely different action. About 68 per cent of the approximately 48 respondents who visited the pharmacy ended up buying the product in question. Of the total, 37 per cent of the respondents who visited their own doctor were prescribed the same drug as the one advertised.
DISCUSSION
Similarity of the respondents to the Danish population generally
As mentioned in the methods section, the respondent group was selected as representative of the Danish population in the age group 18–70. Therefore it is expected that the respondents can be compared to the population generally.
In the following section, we measure the respondents against various parameters in order to evaluate the extent to which they make up a representative segment of the Danish population.
Socio-economic factors
If we consider the distribution of respondents relative to education, we find quite a deviation compared with the Danish population generally. No less than 40 per cent of respondents have an education corresponding to a bachelor's degree, twice as many as the Danish population generally. The same is true for people with the equivalent of a master's degree: 18 per cent of respondents have studied for this many years, while the real figure for the population is only 9 per cent. About 10 per cent of respondents said that their education stopped after lower secondary school or 10th grade, which is only a fifth of the figure for the population generally. Thus respondents were better educated than the general population. The respondent group also deviates with regard to household income.
The group of respondents with an annual income of more than 500,000 DKK were over-represented relative to the lower income groups. This distortion might influence the results to the same extent as the education parameter.
Medicine consumption
It is also relevant to compare the respondents' health status and medicine consumption with the Danish population generally, as that could influence the approach to DTC-A. We compared our results with the Health and Morbidity Survey 2000 (SUSY2000) conducted by the National Institute of Public Health among 17,000 Danes. When we compare pharmaceutical consumption of our respondents to SUSY2000, we can see that 28.12 per cent of respondents in our survey take medicine daily compared to 34.1 per cent in the SUSY2000 survey.4
The results of our survey show that women tend to consume more medicine daily than do men. Of the 28.12 per cent respondents who take medicine daily, women make up 53 per cent, which corresponds very well to the findings in SUSY2000, where women make up 60.4 per cent of daily medicine consumers. In general, the respondents match the population fairly well measured in terms of medicine consumption.
What is characteristic of Danes' awareness of drug advertising?
It turns out that almost 36 per cent of respondents had seen a drug-related advertisement within the previous 14 days, which seems like a rather small number. More interesting is, however, that almost 80 per cent of respondents had seen drug-related advertising either within the previous 14 days. Thus it was possible to determine that respondents were generally broadly aware of drug-related advertising. The gender split was very even, but awareness was greater in age groups 30–44 and 45–59. The results do not tell us what this dominance is due to, but one could assume that these age groups are generally better informed than others. A correlation was found between seeing drug-related advertising and living in densely populated urban areas. The reason here must be greater access to electronic media in large towns and cities, although there is no evidence for this claim.
No correlation was found between household income and awareness of drugs, nor between education and awareness of drugs. The results show generally broad awareness of drug-related advertising spread over a wide age group. Age appears to influence awareness, since respondents under 30 years of age have less insight into drug-related advertising than do people who are older.
What is characteristic of Danes' attitude to advertisements for drugs?
The results show that more than 80 per cent of respondents were positive about campaigns to promote health and treat disease. Male respondents appear to find the information slightly more useful than do female respondents. About 20 per cent of respondents think it is acceptable to advertise prescription drugs, and here male respondents are generally more positive than female. Advertising OTC products is found acceptable by 60 per cent of respondents, male and female alike.
Surprisingly, 55 per cent of respondents find it acceptable to advertise for natural medicines, which is probably due to awareness of this type of medicine. Unfortunately, the various types of medicines are not defined in the survey, which might have been an advantage in characterising respondents' knowledge.
What is characteristic of Danes' attitude to the role of the drug industry in health campaigns?
As mentioned in the results section, almost 60 per cent of respondents were familiar with the fact that the drug industry runs websites focusing on specific diseases.
The results also show that 43 per cent of respondents do not take a position on the extent to which it is acceptable for the drug industry to take on this role. Even though the response basis is fairly small, respondents do show a tendency to be relatively negative about the role of the drug industry. About 40 per cent of respondents have thus indicated a negative attitude to the drug industry's efforts to provide information about disease and health. About 55 per cent of respondents, however, say that a company's sponsorship of a health campaign does not influence their desire to buy medicine from the company in question.
This is confirmed by the fact that 50 per cent of respondents say they can well imagine buying the drug produced by a company sponsoring an internet page on a specific disease. In general, the results are slightly contradictory, since the respondents have a negative attitude to the role of the drug industry, yet half of them will still buy their medicine. Again it must be said that the questionnaire should have been structured differently to create clarity about the meaning of the responses.
How do drug-related advertisements influence Danish behaviour?
The results showed no correlation between health status and awareness of drug-related advertising, nor between medicine consumption and awareness of drug-related advertising. Generally we could not find a correlation between attitude, perception, health status and medicine consumption. The extent to which exposure to advertising led respondents to alter their behaviour must be said to be relatively limited with regard to my expectations. Of the approximately 80 per cent of respondents who saw drug-related advertisements, only 2 per cent then went to the pharmacy, 1 per cent saw their own doctor, 4 per cent sought further information, 1 per cent contacted the drug company direct and 1 per cent took some other step.
CONCLUSION
The results of the questionnaire survey showed that about 80 per cent of Danes find information from campaigns to promote health and treat disease useful. The results also showed that Danes are generally negative about the drug industry's role in health- and disease-related campaigns, but are not influenced negatively by it. The population is divided about the extent to which drug-related advertising should be allowed. Generally, Danes found it acceptable to advertise OTC products, while only one-fifth are positive about advertising prescription drugs.
According to the results, exposure to drug-related advertising does not lead the public to change their behaviour. This conclusion, however, rests on an uncertain data platform, for which reason more targeted research should be conducted on the subject.
In general, it was possible to identify both opportunities and obstacles to DTC-A of prescription drugs seen from a layman's perspective. The population found campaigns to promote health and treat disease useful, and people are not influenced negatively when they discovered the drug industry is behind such campaigns. We must, however, stress that the conclusion is based on secondary research results, and thus it is only an estimate.
References
References and Notes
- Kaiser, H. J. (2005). 23 drug companies agree to new guidelines on advertising. Kaiser Daily Health Policy Report, 3rd August, 2005.
- Toop, L., Richards, D. & Saunders, B. (2003). New Zealand deserves better. Direct-to-consumer advertising (DTC-A) of prescription medicines in New Zealand: for health or for profit? New Zealand Med. J. 116(1180), U556; discussion U. | PubMed |
- Befolkningens adgang til Internettet I 2006. Danmarks Statistik. [The public's access to the Internet in 2006. Statistics Denmark. In Danish].Quoted 4th November, 2006 via: http://www.dst.dk/upload/bef2006e_001.pdf.
- Sundheds- og Sygelighedsundersøgelsen 2000 (SUSY2000), udført af Statens Institut for Folkesundhed. [Health and Morbidity Survey 2000 (SUSY2000), conducted by the National Institute of Public Health. In Danish]. Quoted 10th October, 2006 via: URL: http://www.si-folkesundhed.dk/susy/.