The pharmaceutical industry (PI) uses numerous tactics for promoting its products to physicians such as offering gifts, free meals, and advertisements (King et al., 2013). Although, pharmaceutical manufacturers claim that drug promotional activities are intended for the education of the physician, the accelerated promotion of medicinal products is possibly linked to the prescription behavior (Epstein et al., 2013; King et al., 2013). In high-income countries such as the U.S., all payments used to promote pharmaceutical products must be disclosed under the Sunshine Act. In addition, to maintain the transparency of the interaction between the PI and physician, an open payment database has also been created through which all industry payments to physicians and teaching hospitals can be retrieved (Greenway and Ross, 2017).

The previous literature has highlighted that in a Pakistani health care system, physicians prefer to prescribe selected brand medications over generics, which are usually more costly than their generic counterparts (Sharif et al., 2016). In 2019, a study was conducted to document the interaction between physicians and medical sales representatives in Pakistan. The study found that according to perceptions of medical sale representatives 33% of physicians were indulged in unethical prescribing and 42% never made an inquiry or sought evidence for promoting medicines, whereas 70% of the physicians claimed that medical sales representatives ignored patient’s well-being to achieve their sales objectives (Naqvi et al., 2019).

It is noticeable that the impact of drug promotional activities is not only limited to physicians, but also it has put patient’s health and safety on stake as well. These interactions can also have implications for patient’s safety and care. The irrational prescription based on the promotion of specific brands can bring negative clinical and humanistic outcomes for patients, subsequently lowering general public’s trust toward a health care system (Ammous et al., 2017). In Pakistan, most health care expenditure is out of pocket, and usually poor patients bear the burden of these expensive medicines. Moreover, doubts and lack of trust on health care professionals may reduce levels of patient satisfaction, poor adherence to screening recommendation, and treatment (Safran et al., 1998). In total, patients get lower quality of care, whenever unethical promotional activities take place.

Considering its potential impact on patient’s well-being, many studies have been performed in other countries to determine perceptions of patients toward this relationship (Semin et al., 2006; Green et al., 2012; Ammous et al., 2017). Based on a systematic review of 20 studies, it is already clear that patients have limited knowledge about interactions between physicians and drug companies (Fadlallah et al., 2016). As far as we know, no study has yet been conducted in Pakistan to investigate the perception and knowledge of the general public regarding the physician–pharmaceutical company interaction. Therefore, this is the first study aimed to evaluate the awareness and attitudes of the Pakistani population about the interactions between physicians and pharmaceutical companies.

This study explored the awareness and attitudes of the Pakistani general population regarding physician–pharmaceutical company interactions. In this study, most were aware of the presence (or absence) of pharmaceutical companies in physician clinics, with a smaller proportion aware of physician gift practices. Half of the population thought that accepting small gifts or meals by physicians affected the prescribing practices of the doctor, and almost two-thirds of the respondents said drug representatives were affecting physicians to prescribe the antibiotics for those diseases in which it is not required and who received gifts prescribed more antibiotics than others. These results were in line with the previously conducted study in Lebanon, where participants were generally more aware of PI presence (or absence) in physicians’ offices and accepting meals affects the prescribing practices (Ammous et al., 2017).

Some interesting facts highlighted in our study are that level of awareness was high in relation to pharmaceutical company presence (or absence) in doctors’ clinics and that of gift-related practices of physicians, it is somewhat similar with the study in the Lebanon (Ammous et al., 2017). Similar outcomes were observed in developed countries. A study conducted in 2008 in the United States found that 82% of the respondents were aware of the presence of small gifts (pens or notepads) in physicians’ clinics, as compared with 56.6% in our study (Green et al., 2012). The participants who were aware of physicians accepting gifts >15,000 PKR, gifts <15,000 PKR, and trip invitations were, respectively, 12, 16, and 34% in the United States, 29, 31, and 30% in Lebanon, and 33.5, 50.0, and 43.3% in our study. One of the most probable explanations is that the drug company presence in the office is typically noticeable (e.g., drug company advertisements, items, and education material with drug company logos on them), whereas most of other interactions of physicians with drug companies are not. This highlights the need for transparency and disclosure by physicians.

In our study, the number of respondents who believed that gifts and pharmaceutical interactions between physicians and PI affect the physicians’ prescribing pattern was 50.4%, which is slightly higher than in the United States (41%) and Lebanon (44%) (Jastifer and Roberts, 2009; Ammous et al., 2017). Our study also highlighted that 60.8% of the population said that it is unethical for the doctors to accept the gifts from companies; these are in line with results in Turkey, where 71% patients admitted to primary health care centers in 2004 agreed that accepting gifts from the drug companies is not ethical (Semin et al., 2006) and same is in the United States (Blake and Early, 1995). But, these results were much higher than the previous results from Pakistan (9%) (Qidwai et al., 2003). It is evident in our results that some individuals would be opposed to this unethical practice (physicians’ pharmaceutical interaction) and believe it affects physicians’ prescribing behavior (43.8%). Interestingly, the question that demonstrates the ethicality of similar practices (accepting small gifts and meals) with other professions indicated that the respondents might have different standards or expectations across professions. The number of respondents who thought that it is wrong and unethical for doctors to accept was low as compared to referees, judges, and politicians.

In our study, the minority of respondents reported (6.6%) lower trust in response to accepting gifts by the physicians and suggests that relatively few of them made a connection between physicians’ practices and their behaviors. As in other studies, it has been indicated that patients’ lack of trust is associated with the possibility that physicians chose drugs that are more expensive, less efficacious, and cause higher side effects (Jastifer and Roberts, 2009). Notably, a substantial proportion of the participants reported that they had more trust in their physician if he/she had a relationship with PI; it was also observed in Lebanon (Ammous et al., 2017). It is therefore hypothesized that there is a belief that close interaction between the two leads to enhanced physician’s awareness of the newest pharmaceutical innovations, whereas participants of the study conducted in the United States indicated a greater decrease in their level of trust on knowing that their physicians were accepting monetary gifts and enjoying trips paid by drug companies. We also illustrated examining the change in the level of trust when PI offers paid trips to physicians, 66.6% of our population said no change which is quite higher than in the Lebanese population (55%), while 30% reported lower trust. Conversely in the American study sample which showed that 58% reported a decrease in the level of trust in doctors’ accepting paid trips by PI, while 38% had no change in their level of trust (Green et al., 2012). It is a clear-cut indication of the fact that our population is less aware of the potential harm of these interactions than the Lebanese and the American population. As for the comparison, the percentages of people stating lower trust in physicians related to their acceptance of gifts >15,000 PKR [90.3 USD] and to trips paid by the PI were, respectively, 50% and 58% (2008) in the US survey, 45 and 30% in the Lebanese survey, and 33.3 and 16.7% in our sample.

We aimed to target the larger population in the wider area of Punjab. Though the sample is large, our sample is not representative of the general Pakistani population. However, representativeness was enhanced by inclusion of patients (from primary health care clinics) and pharmacy outlets. From a policy perspective, there is a definite need to raise awareness among the Pakistani population about the potential negative impacts of interaction between physician and industry on the cost and quality of their health care. On a broader level, there is a need for system-level interventions to regulate physician–industry interactions (Alkhaled et al., 2014). These interventions should focus governmental and self-regulation (e.g., voluntary codes of practice). The ultimate aim would be to minimize any negative effects of the physician–pharmaceutical company interactions on patients and eventually improve patient care.

The study has some limitations too such as we assessed the knowledge by close-ended questions; respondents may have selected the most favorable answers rather than accurate ones, and therefore a qualitative approach might be more suitable to reveal misconceptions. Also, we selected the districts randomly and targeted the cities and participants from the cities conveniently. In addition, the questionnaire has not been validated. The private clinics with higher patient flows were selected in order to obtain a large sample. It, however, creates the biasness. We recruited patients from the pharmacy sites as well.

Survey respondents were well aware of the interactions between pharmaceutical companies and doctors. Participants were more knowledgeable regarding the pharmaceutical company presence (or absence) in physicians’ offices than about gift-related practices of physicians. Pharmaceutical interactions were widely believed to affect the way physicians prescribe drugs. Accepting gifts from pharmaceutical companies for doctors is considered less bad/unethical than judges accepting gifts from lawyers and referees from athletes. The trust level was not affected for various types of physician–pharmaceutical company interactions except for receiving large gifts.