Impact of marketing mix tools on Physicians prescribing behaviour- An exploratory study

Ms. Neeti Kasliwal Assistant Professor, Faculty of Management Studies, Banasthali Vidyapith, C-62, Sarojini Marg, C-Scheme, Jaipur, Rajasthan Contact No: 9829166007 Email id: neetikasliwal@gmail.com

Dr. Ipshita Bansal Professor, Faculty of Management Studies, WISDOM, Banasthali Vidyapith, Banasthali, Rajasthan Contact No: 9414642479 Email id: ibansalindia@yahoo.co.in

Track: Strategic Marketing Initiatives

Impact of marketing mix tools on General Physicians prescribing behaviour- An exploratory study Introduction Pharmaceutical companies in India are directing their marketing efforts towards physicians as they play a pivotal role in influencing their patients pattern of selecting and administering drugs, hence making them the most important player in the pharmaceutical marketing system. Therefore the intermediary role played by the doctors cannot be ignored as they are the key decision makers who choose among array of drug alternatives but it is the patient who takes the ru n n s up p y n or t o s m y t p ys n G nul et al 2001).

Pharmaceutical companies try to influence prescription pattern of doctors in favour of their drugs by offering various kinds of product attributes, pricing considerations, distribution and logistics management and promotional inputs. The pharmaceutical companies are spending a lot of money on marketing their products to doctors. While the industry is driven by innovation, it spends an enormous amount of money on marketing. It is estimated that the promotional and marketing expenditure on an average is 2030% of sales turnover or about two or three times the average expenditure on research and development (Lancet 1993). The term promotion means those informational and marketing activities, the purpose of which is to induce prescribing, supply or administration of medical products (Walker G 1993). Hence an attempt to describe how and what doctors think while prescribing is therefore an important part of enhancing the quality of the prescription process. Thus regular, continuous study of the prescribing behaviour of doctors is essential for pharmaceutical marketer so that the companies can draft their marketing plans according to the characteristics and criterion of each physician market segment. Being able to identify prescribing p tt rns t rou mont s w t r t m l r pr s nt t v s MRs) s v ry pow r ul tool for the companies. If a n xt w ks or o tor s wr tt n n w pr s r pt ons or t ru . I t o tor o snt, t n certain doctor is given free samples of a drug, t s MRs t n tr k ov r t

they go in and try to modify their behaviour. If they know a doctor has recently switched and is prescribing more of a rival drug, then they go in and say something negative about the rival drug and persuade the doctors to switch to their company drug (Hopper et al 1997). Review of Literature Past studies have shown that the physicians prescribing behaviour can be influenced and mult pl tors r nvolv n p ys ns s on to n t r pr s r n ts

(Hartzema et al 1983, Armstrong et al 1996, Waheed Abdul Kareem et al 2007, Rahmer et al 2008, Crowe et al 2009, Suggs et al 2009, Theodorou et al 2009, Kotwani et al 2010, Karayanni et al 2010, Neyaz et al 2011). Various studies have shown that doctors get influenced in their prescription behaviour due to factors like trust, or the quality image of the pharmaceutical manufacturer (Moss et al 2011), prioritize safety and efficacy over cost aspects while prescribing (Rahmner et al 2008). A good number of studies have concluded that the physicians have a positive attitude towards the pharmaceutical sales representatives (PSR) and they have an impact on the prescribing of the physicians (Caudill et 1996, Wazana 2000, Prosser T et al 2003, Watkins et al 2003, Chimonas et 2007, Lieb et al 2010, Saito et al 2010). The past studies have also investigated that the promotional activities by the drug companies are ethical and appropriate and also the doctors perceive that these interactions would affect the prescribing behaviour of their colleagues more than their prescribing behaviour (Bhat AD 1993, Gonul et al 2001, Brett et al 2003, Verma SK 2004, Sierles F et al 2005, Saito et al 2010). The studies done to explore the impact of gifts on prescribing behaviour have concluded that the gifts given by pharmaceutical companies are considered gesture of interaction (Madhavan et al 1997, Gibbons et al 1998, Pinto et al 2007) and GPs considered them as appropriate if these gifts are of relatively lower costs and are benefitting the patients (Sharma et al 2010). Waheed Abdul Kareem et al 2007 concluded that the tangible rewards to the physicians by the pharmaceutical companies lead to prescription loyalty. The studies investigating the effect of marketing tools and prescription behaviour have linked a positive correlation between the two (Girdharwal 2007, Jayakumar 2008, Stros et al 2009). Karande et al 2005, Kotwani et al 2010 identified through their study that there was lot of scope to improve rational drug use in India as over prescriptions of antibiotics and poly pharmacy is the norm of the day. Mirza et al 2009 in their study also found that the average medicines prescribed per patient in India was much higher as compared to economically developed western countries. . Duerden Martin et al 2010 concluded in their study that generic substitution would result in cost savings if generic and therapeutic substitution would be adopted as a standard practice in secondary care by the prescribers.

Objectives of the study In the light of the above review of literature and the issues raised the objectives of the present study are to identify factors influencing General Physicians (GPs) prescribing behaviour with respect to marketing mix tools used by the pharmaceutical companies. To fulfill the above objective following hypothesis are proposed:

H1: Product Mix variables will have a significant influence on prescribing behaviour of GPs of Rajasthan. H2: Price Mix variables will have a significant influence on prescribing behaviour of GPs of Rajasthan. H3: Place Mix variables will have a significant influence on prescribing behaviour of GPs of Rajasthan. H4: Promotion Mix variables will have a significant influence on prescribing behaviour of GPs of Rajasthan.

Research Methodology For the purpose of the study, questionnaire was formulated and pretested among 10 GPs and was revised to remove ambiguities in the process and then revised questionnaire was tested for reliability and validated using Split Half Method and Reliability Coefficient Method which was used to calculate the correlation coefficient among 2 split halves from reliability coefficient, difficulty index, validity index and variance. The reliability coefficient was found to be 0.7648, for product mix, 0.7229 for price mix and 0.7811 for promotion mix. The place mix reliability coefficient was not performed as there were only two questions devoted for this P. This standardized questionnaire was then m n st r to 300 G n r l P ys ns o R j st n.

The respondents (GPs) were selected from Rajasthan Medical Directory using convenience sampling. They were first contacted through telephone and permission was taken to send them the postal questionnaire. Then questionnaires were either emailed or posted to the doctors as desired by them after the telephonic conversation. A covering letter explaining the purpose of the study and reassuring that the responses given by them would be kept confidential and would be used only for research work was sent along with a self stamped envelope which was also included with each questionnaire. Respondents had the option of replying anonymously. The total of 209 questionnaires were returned but 11 questionnaires were found to be incomplete in their responses and were therefore rejected. Remaining questionnaires i.e. 198 were selected for analysis, making a response rate of 66%. Descriptive statistics were used for examining the perception of GPs across all demographic groups. The data was checked for normality and then ANOVA and Z test were applied to examine the significance of difference between the mean scores of different groups.

Findings and Analysis Table 1: Demographic Profile of the Sample Respondents Characteristic Employment status of the doctors Government Sector Doctor Private Sector Doctor Self Employed Doctor Years of experience of the doctors 1-5 years of exp 6-10 years of exp 11-20 years of exp 21-30 years of exp 31-40 years of exp 41 & above years of exp Age of the doctors 25-35years of age 36-40 years of age 41-45 years of age 46-50 years of age 51-60 years of age 61 & above years City of doctors City 1(pop>1 million) City 2(pop within 0 .5 million -1 million) City3(pop within 0.1 -0.5 million) City4(pop < 0.1 million) 90 38 60 10 45% 19% 30% 5% 9 16 21 29 68 55 5% 8% 11% 15% 34% 28% 10 12 47 63 35 31 5% 6% 24% 32% 18% 16% 71 63 64 36% 32% 32% N Percentage

As depicted in Table 1, out of total of 198 GPs, 71 (36%) GPs were practicing in Government Sector; 63(32%) in private sector and 64 (32%) were self employed. The GPs age in the study was categorized into six categories and 9 (5%) GPs were found to be in 25 -35 years of age, 16 (8%) GPs were in age group of 36-40 years, 21 (11%) in 41-45 years, 29 (15%) of GPs in 46-50 years, 68 (34%) in 51-60 years and 55 (28%) in 61 &above years of age. Also the work experience of the doctors was categorized in six categories and 10 (5%) GPs had 1-5 years of

experience followed by 12 (6%) GPs with 6-10 years of experience, then 47 (24%) GPs had 1120 years of experience, 63 (32%) had 21-30 years of experience, 35 (18%) GPs had 31-40 years of experience and 31 (16%) GPs had 41 &above years of experience. The total number of GPs who were practicing in cities having a population more than 1 million was 90 accounting to 45% while 38 (19%) GPs were practicing in cities having a population within 0.5 1.0 million, 60 (30%) GPs were practicing in cities where the population was within 0.5-0.5 million and 10 (5%) doctors were practicing from cities having a population of less than 0.1 million accounting to .9% of the total sample. Table 2, 3 4 5 depicts the results of ANOVA and Table 6,7,8,9 showing the results of Z-test used for hypothesis testing.

ANOVA results: Table 2a: ANOVAs for Product Mix as City as a factor Source of variations Sharing of research feedback by company Between Groups Within Groups Total **p<=0.01 The results of one way ANOVA shows that all the General Physicians with different demographic profiles demonstrated different responses for the product attributes, price attributes, place attributes and promotional attributes of the drug. As shown in Table 2a, the difference in importance given to sharing of feedback of research by the company and research and development status of the company was found to be significant among GPs of different cities. The difference was found to be statistically highly significant (p<=.01). The GPs of Rajasthan practicing in different cities showed their preference towards that omp nys ru w s r s t r s r k w th the general physicians. The Sum of Squares 6.515 107.828 114.343 df 3 194 197 Mean Square 2.172 .556 F 3.907 Sig. .010**

importance attached to this factor pertaining to the product mix suggests that the companies should focus their attention by giving the appropriate and timely research feedback to the GPs to get the mind share of the GPs practicing in different cities of Rajasthan state. The other factors like efficacy of the dug, drug delivery mode, recommended daily schedule, safety profile, palatability, US FDA approval status, previous experience with the drug, peer group//colleagues advice and trust on the company medicine were the other factors where the variations in the prescribing was found to be insignificant.

Table 2b: ANOVAs for Product Mix as Year of experience as a factor Source of variations Between Groups Packaging quality and shelf life *p<.05 The above Table 2b, depicts the variation in factor of packaging quality and shelf life of the drug was also found to be significant (p<.05) among different years of experience of GPs. This means that different years of experience of GPs considered packaging quality and shelf life of the drug as the variations was found to be statistically significant factor while prescribing a drug to their patients as compared to other GPs who did not show much variance in packaging quality and shelf life of the drug while prescribing. Table 3a: ANOVAs for Price mix as age as a factor Source of variations Financial status of patient Sum of Squares Between Groups Within Groups Total 9.327 146.128 155.455 df 5 192 197 Mean Square 1.865 .761 F 2.451 Sig. .035* Within Groups Total Sum of Squares 7.547 97.327 104.874 df 5 192 197 Mean Square 1.509 .507 F 2.978 Sig. .013*

*p<0.05 Table 3a, shows that in the study, the variation in influence of price attributes of the drug particularly affordability (financial status of the patient) was found to be significantly different (p<.05) among GPs in different age groups. Different age groups of GPs considered cost to the patient which is price of the drug as the prime criteria of variations in behaviour thereby influencing the choice of the drug. Table 3b: ANOVAs for Price mix as Years of experience as a factor Source of variations Insurance status of the patient Sum of Squares Between Groups Within Groups Total 11.379 193.677 205.056 df 5 192 197 Mean Square 2.276 1.009 F 2.256 Sig. .050*

*p<=0.05 Further, variation of influence of insurance status of the patient was found to significantly different (p<=.05) among GPs with different numbers of years of practice depicted in Table 3b.

As the insurance status of patient is one of the factor showing differences in prescribing behaviour among GPs with different work experience this means that the GPs they tend to affected by price variable of the drug when it comes to prescribing the drugs for their patients for which the third party is bearing the cost of the medical treatment. Table 3c: ANOVAs for Price mix as Employment Status as a factor Source of variations Education status of patient Sum of Squares Between Groups Within Groups Total 9.779 193.110 202.889 df 2 195 197 Mean Square 4.889 .990 F 4.937 Sig. .008**

**p<0.01 Further it was also observed that the variation in education level of the patient was found to be highly significant factor (p<.01) influencing the GPs with different employment status as depicted in Table 3c. Since the clientele significantly varies when it comes to the government sector doctors as compared to private and self employed and the education status of the patient was given the maximum weight age by the private sector GPs (Mean =3.7) Table 4a: ANOVAs for Promotion Mix as Age as a factor Source of variations MR Product Knowledge Sum of Squares Between Groups Within Groups Total Between Groups Within Groups Total *p<0.5 As shown in Table 4a, interestingly the perception of promotion attributes relating the medical representatives product knowledge and frequency of prescribing OTC (over the counter) drug were found to be significantly different across specific categories of age of the GPs with age as an important profile getting influenced by the above factors. Also shown in Table 4b the effect of samples provided by MRs and frequency of prescribing OTC drug were found to be statistically significant among GPs with different years of experience thereby showing variations in preference towards samples and OTC drug, but it was only single factor which is frequency of prescribing of OTC drug which was found to be significant factor influencing among GPs with different city of practice as shown in Table 4c. 17.302 280.421 297.722 14.018 180.189 194.207 df 5 192 197 5 192 197 Mean Square 3.460 1.461 F 2.369 Sig. .041*

Frequency of prescribing OTC drug

2.804 .938

2.987

.013*

Table 4b: ANOVAs for Promotion Mix as years of experience as a factor Source of variations Samples provided by MR Sum of Squares Between Groups Within Groups Total Between Groups Within Groups Total *p<0.05 Table 4c: ANOVAs for Promotion Mix as City as a factor Source of variations Frequency of prescribing OTC drug Sum of Squares Between Groups Within Groups Total *p<0.05 Table 5a: ANOVAs for Place Mix as years of experience as a factor Source of variations Availability of drug in the vicinity of the patient Between Groups Within Groups Total *p<0.05 Moreover the study also revealed that the influence of place attributes which corresponds to the availability of the drug in the vicinity of the patient was also found to be significantly different among GPs with different years of experience thereby affecting their prescribing decisions. Z-results: Table 6: PRODUCT MIX Sample criteria 36-40 years of age Others 6-10 years of exp N 16 182 12 Mean 51.75 49.24 51.50 SD 3.316 4.941 2.812 2.46 <.05 Z 2.77 p-value <.05 Sum of Squares 4.437 65.927 70.364 df 5 192 197 Mean Square .887 .343 F 2.584 Sig. .027* 8.982 185.225 194.207 df 3 194 197 Mean Square 2.994 .955 F 3.136 Sig. .027* 15.871 213.584 229.455 11.586 182.621 194.207 df 5 192 197 5 192 197 Mean Square 3.174 1.112 F 2.853 Sig. .016*

Frequency of prescribing OTC drug

2.317 .951

2.436

.036*

Others 31-40 years of exp Others City4(pop < 0.1 million) Others

186 63 135 4 194

49.31 48.27 49.90 45.00 49.53

4.951 5.903 4.223 2.582 4.869 -3.38 <.01 -2.07 <.05

As seen in Table 6, we can see that GPs with age group of 36-40 years of age considered product attribute of the drug more important (mean =51.75) as compared to other GPs as in starting of their career, the drug attributes have to play a significant role in prescribing it as we can see that GPs with a work experience of 6- 10 years also gave more importance to product attributes of the drug while prescribing as compared to other GPs. We can see from the above table that GPs with an experience of 31-40 years were negatively influenced by the product mix attributes of the drug. This means that as the work experience increases the importance attached to the product attributes decreases. While not only work experience but also the practicing city of the GPs i.e. GPs who are practicing in cities having a population of less than 0.1 million were also found to be negatively influenced with the product attributes of the drug. This means that there are some other factors which are considered more important by these GPs other than product attributes. Hence H1 is accepted. Table 7: PRICE MIX Sample criteria 25-35 years of age Others 1-5 years of exp Others 21-30 years of exp Others Private Sector Others N 9 189 10 188 35 163 63 135 Mean 16.44 14.96 16.55 14.95 13.89 15.27 15.56 14.78 SD 1.878 2.647 2.223 2.634 3.141 2.452 2.168 2.795 2.13 <.05 -2.45 <.05 2.13 <.05 Z 2.26 p-value <.05

As depicted in Table 7, the effect of price mix on 25-35 years of age of the GPs and 1-5 years of experience among the GPs were found to be statistically significant and this segment of GPs were more influenced by the price factor of the drug while prescribing. Similarly, the price mix of the drug was found to be affecting the private sector GPs more than the others as they considered their

patients financial and insurance status before prescribing. It was also observed that the GPs from 21-30 years of experience were negatively influenced by the price attribute of the drug and this negative influence was statistically significant. This means that these practitioners were less price sensitive as compared to their colleagues. Therefore H2 is accepted. Table 8: PROMOTION MIX Sample criteria 25-35 years of age Others N 9 189 Mean 16.44 14.96 24.11 26.84 SD 1.878 2.647 6.110 6.138 -2.39 <.05 Z 2.26 p-value <.05

31-40 years of experience 35 Others 163

Table 8 shows the influence of promotion mix on the prescription behaviour of the GPs of Rajasthan and contrary to the perception that it was only the GPs of 25-35 years of age were strongly influenced by the promotional tactics done by the pharmaceutical industry. This could be because at this age the GPs are young and are more receptive to pharmaceutical promotions and get easily influenced by the promotional tactics of the companies. The table also shows the negative influence of drug promotions (Z=-2.39) on GPs with 31-40 years of work experience as compared to others GPs. One of the reason can be that the because of such vast and rich experience in the industry they consider these activities as unethical having a latent desire to sell t omp nys pro u t r t r t n n tt n t p t nt n t lt r n ustry. So H3 is

accepted. Table 9: PLACE MIX Sample criteria 61 & above years of age Others 41 &above years of exp Others N 55 143 31 167 Mean 5.44 5.07 5.58 5.10 SD .957 1.208 .958 1.173 2.49 <.05 Z 2.23 p-value <.05

Table 9 depicts a significant influence of place mix on the prescribing behaviour of senior GPs of age group of 61 &above years with an experience of 41& above years of practicing. The readily available drug in the market within the vicinity of the patient was considered an important factor by the senior most doctors of the study as they know through their experience that convenience and urgency are the two most important criteria patient considers before buying

the prescription drug otherwise they rate the doctors as not the competent enough to solve their problem. Henceforth H4 is accepted.

Discussion
One of the major findings of the study is that the GPs prescribing behaviour can be influenced and there are major factors involved in influencing the behaviour. Mor ov r t p ys ns

characteristics also have a major role to play in identifying the stimuli from the external variables which results in changing in prescribing pattern. The result of the study goes in line with the past studies done by Hartzema Abraham et al., 1983 where it was identified that several non medical factors are important predictors of total prescribing volume among the physicians in the study. The study done by Armstrong et al., 1996 identified factors like reading and advice from professional colleagues were involved in GPs decision to change their prescribing habits. Wun et al., 2002 also ons r mo r p l v r l s l k physicians practicing status,

gender, higher qualifications, years in primary care

as global characterises influencing

prescribing. In our study also we found that demographic variables like age of the doctor, employment of the doctor, years of practice of the doctor and city of the doctor were responding differently to the marketing stimuli of product, price, place and promotional variables of the pharmaceutical marketing system which led to variations in the prescribing behaviour of the GPs of Rajasthan. The physicians prescribing behaviour in our study was more effected by the product , price, promotion, and place attribute of the drug which goes in line with the studies done by Girdharwal,2007 where similar factors were found to be influencing the physicians prescribing behaviour. Similar to the studies of Chew LD et al., 2000, Morgan et al., 2006, Warrier et al., 2010 where drug samples led the prescribers to prescribe them even if they were not their preferred choice, our study also shows that the years of practice of the GPs showed a significant difference in importance attached to free samples given by the MRs of the companies. But demographic profile pertaining to city of the GPs, age of GPs and employment status of GPs did not show any significant difference with reference to samples provided by the companies. But distribution of leaflets and brochures, academic sponsorships by the companies, source of information of new drugs received through colleagues were found to be non significant factors among GPs of Rajasthan which equates to past studies results where the information presented in brochures and materials distributed to the doctors by the companies were found to be untrue and claims were found to be unsubstantiated and did not comply with FDA regulations (Stryer et a.,1994, Gitanjali et al., 1997, Cardarelli et al., 2006, Othman et al., 2009) while study results are contrary to the study done by Saito et al., 2010 where doctors meet with MRs and

value information they receive from them, Oshikoya et al., 2011 where majority of the doctors relied on the information from pharmaceutical companies in the form of drug promotion forums n l un s lt ou t v l ty o su k n o n orm t on w s qu st on n t o tors

mind. The drug promotion has a significant effect on the prescribing behaviour of the GPs in our study which has a mixed bag of results pertaining to literature review. The medical representatives product knowledge were found to be significantly different across specific age categories of GPs in our study which can be linked with the past studies of Caudill et al., 1996, Lagerlov Per et al., 2000 where a positive correlation was found prescribing behaviour and information provided by the PSR (pharmaceutical sales representatives) and were considered preferable promotional tool by doctors as compared to free camps and samples (Arora et al., 2006). Further the study showed that the influence of price attributes of the drug particularly affordability (financial status of the patient) was found to be significantly different (p<.05) among GPs in different age groups. Moreover the study also revealed that the influence of place attributes which corresponds to the availability of the drug was also found to be significantly different among GPs with different years of practice thereby affecting their prescribing decisions was in line with the study done by Ijaoma et al., 2010 where doctors admitted that despite the promotional strategies employed by the companies the most influencing factor was the economic status of the patient followed by drug availability. Conclusion GPs with different demographic profiles in our study have exhibited a significant effect of product mix, price mix, place mix and promotion mix parameters on their prescribing behaviour thereby giving an input to the pharmaceutical marketers to focus their marketing efforts to a segment of doctors with the appropriate marketing mix. Marketing of pharmaceuticals is of crucial importance from an economic and social welfare perspective. The relationship between doctors and drug companies have come under intense scrutiny in recent years as there is a widespread scepticism about the intent of industry and concern for the vulnerability of doctors in the relationship. This study provides a framework for marketers so that wasteful expenditure on the marketing of drugs should be cured thereby increasing the overall quality of healthcare profession.

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