Pakistan consists of the provinces of Punjab, Sindh, KPK, and Baluchistan alongside the two Independent Administrative territories of Gilgit Baltistan and Azad Jammu Kashmir and the capital region of Islamabad (Pakistan beurre of statistics. Population census, 2025). The country offers education at six distinct levels, and Pharm-D and MBBS are in graduate (bachelor’s) level degrees (Education in Pakistan, 2025). The Pharm-D degree is awarded by pharmacy colleges regulated by the Higher Education Commission (HEC), and the MBBS degree is awarded by medical colleges regulated by the Pakistan Medical Council (PMC) and HEC (Education in Pakistan, 2025). Pakistan currently operates 176 medical colleges, including 45 public and 72 private institutions, that grant MBBS degrees (Wikipedia, 2025a), and 68 pharmacy Incomplete colleges deal with the Pharm D degree (Wikipedia, 2025b). We chose Punjab as the data collection site because of its large population, extensive healthcare infrastructure, and significant contributions to public health initiatives. As the most populous province, Punjab plays a vital role in achieving national health goals and providing accessible healthcare to a large proportion of the population. It also contains the greatest number of medical and pharmacy colleges in Pakistan. We randomly selected three populous cities of Punjab: Lahore, Rawalpindi and Sialkot.

This research was conducted in two phases. In the beginning of the first phase, we tried to contact professors and students from the government and private medical and pharmacy colleges in Punjab province. As this occurred during COVID-19, a physical approach to universities and medical colleges was limited, so tried to approach the authorities and professors/assistant professors via email and the phone numbers given on the university website. We provided the basic idea and the motives of the research, and we asked to share this with a number of class representatives (CRs) in the third, fourth, and fifth years of their study. Three private and three government medical and pharmacy colleges agreed to participate in the first phase and shared the numbers or contact information for the CRs. The CRs of all three grades were asked to share the online link of the survey instrument with as many students in their classes as they could. We employed snowball sampling, and the survey was made available on Google Forms. All female and male medical undergraduates currently enrolled in the third, fourth, or final year of study in medical or pharmacy colleges were targeted. We opted for an online platform for data acquisition because it was too challenging to conduct paper-based or observational studies during partial or complete lockdown, and a large proportion of people (76 million people) frequently use the internet, with 37 million active users in Pakistan (Gillani et al., 2017) (Anjum, 2020).

In the second phase, the students who participated and completed the baseline survey were given information about the educational intervention and how to join the WhatsApp group. Willing students who then contacted the PI to be part of the interventional program were then added to the WhatsApp group. Separate groups were formed for the medical and pharmacy students. We informed the students of the 1-month window for being part of this study and that willing students should enter the group within the specified period. At the beginning of the baseline survey, every student was asked to select a code/identification number (IN) before completing the questionnaire. Those students who showed intent to be part of the post-survey were then asked to change their number or name in the group by that specific code so as to assure anonymization and identification in the pre–post survey. This IN was also used during the online class Zoom or TenCent meeting. Students who forgot their IN or those whose IN did not match the pre-survey were excluded from the pre–post evaluations. The interventions were done separately on the medical and pharmacy students at different times. The willing students were divided into small groups for the Zoom meeting, not exceeding 50 per group.

We created an educational initiative called the “Pharmaceutical Promotion Interventional Program” (PPIP) based on our comprehensive review of existing literature. The literature review revealed various PP modules and programs, yet our goal to help future physicians and pharmacists develop critical thinking skills (Mansfield, 2019) and an understanding of promotional methods led us to create modules based on national and international guidelines (Civaner, 2012; Civaner et al., 2016). We developed our program using the Understanding and Responding to Pharmaceutical Promotion manual published by Health Action International (HAI) and the World Health Organization (WHO) (Mintzes, 2010). This manual functions as an educational resource to support teachers who teach students about PP. The program utilized rules for university–industry relations from developed countries to achieve these goals (Lewis et al., 2001). We gathered all necessary materials before finalizing the educational goals for the upcoming 3-month teaching period.

The main points addressed in the course were as follows.

1) Types of interactions with the PI:

This module was categorized and accepted for all international PP standards and has been well adopted in previous studies (Shankar et al., 2012; Civaner, 2020; Mar et al., 2008). For local regulations, we gathered information from the guidelines given by the Drug Regulatory Authority of Pakistan (DRAP) in “Advertisement of therapeutic good” (Advertisement of Therapeutic Goods, 2022). These guidelines were updated in 2021. ¹

The content drafted from these rules was as follows.

1) Local conditions for the advertisement

The above literature was organized as a 6-hour course divided into two 3-hour lectures over 2 weeks. Those who became part of the pre–post evaluations were requested to take both lectures so as to complete the course. Those who took a class on day 1 and missed the other were given another chance to complete the course a few days later. Attendance was taken by monitoring the code numbers in the Zoom meeting groups and engaging with them during the course by calling their IN and asking frequent questions. As the number of students was large, we divided the students into batches and then gave the educational classes. Any students who did not complete the course in the two terms were not considered for the post evaluations. The course was delivered by the principal investigator to all willing students to ensure the same level of training for all individuals. During the course, each class was given a lecture by a professional from a multinational company who was a specialist in marketing education. We employed both classical methods of lectures and interactive group sessions. We also enhanced the understanding of students by showing a short video called “Side Effect” (Slattery-Moschka, 2005) about the professional life of a MR and asked them to spot the promotion methods; ways of implementing those methods were then discussed.

Two different tools were used to evaluate the perceptions: the attitudes and practices of medical and pharmacy students.

For the medical students, an amalgam of previous studies acted as sources for tool development (Ball and Al-Menea, 2018; Siddiqui et al., 2014; Soyk et al., 2010; Sarikaya et al., 2009; Sandberg et al., 1997; Vainiomaki et al., 2004; Fitz et al., 2007; Wilkes and Hoffman, 2001). A comprehensive 45-item instrument was used which was developed based on the above literature. The questionnaire sought information in four main sections: Section 1: demographics of medical students (4 items); Section 2: perception of medical undergrads about PP (10 items); Section 3: attitudes/behaviors of medical students toward PP (29 items); Section 4: further investigation of the two questions regarding their future practice in terms of the antibiotic prescribing. As there were no legal rules and regulations in our medical setting regarding interactions between PCs and medical students, AMSA guidelines were followed. The detail, content and validation process is given in the baseline studies (Gillani et al., 2024a). In order to make comparisons, the pre-data were evaluated as all items in parts 2 (Perception) and 3 (Attitude) on 5-point Likert scales (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree). Cumulative scores were calculated for the perception and attitudes section to describe medical students. Some questions have negative consequences, so the answers “strongly disagree” give the highest score: “strongly disagree” = 5 and “strongly agree” = 1. The collective score of each student was then measured. The cumulative score for attitude ranges 10–50, for perception 29–145, and 2–10 for practices.

The research tool for pharmacy students combined 47 items obtained from various studies involving pharmacy and medical students (Ball and Al-Menea, 2018; Mandiracioglu and Kiran, 2014; Mintzes, 2005; Ashker and Burkiewicz, 2007; Rogers et al., 2004; Bellin et al., 2004). The questionnaire divided its inquiries into four sections: demographic information about pharmacy students (4 items), pharmacy students’ understanding of PP (19 items), their promotional attitudes and behaviors (22 items), and questions about antibiotic practices (2 items). Complete details about the tool, pilot evaluation, and validation study are provided in Gillani et al. (2024b) and Mandiracioglu and Kiran (2014). An overall representation of pharmacy students’ perceptions and attitudes toward PP and PCs was generated by calculating the scores from all perception, attitude, and practice sections. The same above innovative scoring method was also adopted for pharmacy students. The “Perception” section’s scoring spans 19–95 points, “Attitude” scored 22–110 points, and “Practice” 2–10 points. Student scores correlate with their level of affinity toward PP and gifts and PCs but not toward practice where lower scores indicate reduced PC influence on antibiotic prescribing/dispensing.

The data were analyzed using SPSS version 23.0 for Windows. One sample Kolmogorov–Smirnov test was used to determine the normality of the variables. Most variables were found to not follow a normal distribution, and hence non-parametric tests were used. Median scores were compared according to gender, nature of institution, monthly parental income, and years of schooling before and after the module, using a Mann–Whitney test. Median scores before and after the module were compared using the Wilcoxon signed ranks test. A p value less than 0.05 was taken as statistically significant.

This interventional study was approved by the Medical Ethics Committees of Xi’an Jiaotong University China and the Ethical Review Board of the University of Lahore. Online pre-approval consent from each student was obtained by clicking “Agree” at the beginning of the online questionnaire. The questionnaire could not commence without agreement with the ethical statement. As the intervention was online and the students had to join WhatsApp groups, their numbers were shown in the groups; this was relayed to them before the commencement of the study; if they agreed, they could be part of the study. Participants were assured that the data would only be used for research purposes and would be treated with confidentiality. We encouraged them to complete the whole study, but participation was voluntary and free of any incentive or penalty, so students could leave the study at any time.

In the baseline study, 1,227 medical students agreed and completed the questionnaire, and 902 students initially agreed to be part of the second phase, although 36 failed to complete the course or were not willing to take part in the post-survey. Therefore, a total of 866 medical students completed the whole study and completed the post-survey (so the target population is 866 medical students). Male students were dominant at 55.7% of the study population, and a large number of students were from government institutions (63.5%) and were from the final year of study (57.0%).

In the case of pharmacy students, 1,195 students initially filled out the baseline data, but only 816 agreed to be part of the post-survey. Among these 816 students, 772 filled and completed the pre–post study and 44 failed to complete the course. The pharmacy student population was also dominated by male students (60.8%). A large proportion were from private institutions (63.3%) and from the final years (55.2%) (Table 1).

After comparing the median of each individual item, we saw significant changes in affinity toward PP, tactics by PCs, and gift adoption behavior of the medical students. Student views changed from “disagree” to “strongly disagree” in terms of delivering information obtained in PP to patients and that PP gives doctors confidence to counsel patients (median score 2 to 1 p < 0.001). Similarly in terms of the attitude items, a significantly high number of medical students reported that medical information should not be permitted on the website of companies (median 3 to 4 P < 0.001) and that government should mandate preapproval of all PP for prescription drugs (median 2 to 4 p < 0.001). We also saw changes in future practices and students’ behavior change from “neutral” to “disagree” in terms of prescribing antibiotics under the influence of promotional activity and prescribing antibiotics due to the influence of gifts by PCs (P < 0.001). See Table 2 for details.

A Wilcoxon signed-rank test was used to investigate the knowledge, attitude, and practice scores between baseline and post-intervention for the group of medical students. There was a statistically significant decrease in the median (IQR) knowledge score of two points between baseline and post-data (P < 0.001). Similarly, the attitude and practice scores were also significantly reduced at P < 0.001. Details are given in Table 3. The demographic association of medical students with total perception attitude and practice score has been given in Table 4.

After evaluating the pre and post knowledge, attitude, and practice scores of pharmacy students, we saw a significant change in them. There is a significant change from “neutral” response to “disagree” (median 3 to 2) in terms of “It is acceptable to participate in the social activities such as dinners arranged by companies” and from “agree” to “disagree” in terms of “accepting gifts for educational purposes distributed by companies, accepting drug samples given by the companies, accepting books, journals and other educational material distributed by companies” (median 4 to 2 p < 0.001). Similarly, in terms of attitude, most items got changed answers, such as from “agree” to “neutral” in terms of “Government should mandate preapproval of all PP for drugs if they are permitted” and from “disagree” to “neutral” in terms of “it is unacceptable for a pharmacist to receive a gift from a drug company in any form” (p < 0.001). Similarly, most of the students said that they would not dispense antibiotics under the pressure of gifts or any promotional influence in future. The results are mentioned in Table 5.

Table 6 demonstrates the results of the Wilcoxon signed-rank test to investigate the knowledge, attitude, and practice scores pre- and post-intervention for the group of pharmacy students. There was a statistically significant decrease in the median (IQR) knowledge score of 12 points between baseline and post data (P < 0.001). Similarly, the attitude score plunged by 11, and the practices score decreased 2 points, which was a significant reduction (P < 0.001). The demographic association between the pharmacy students and total perception, attitude and practice score has been mentioned in the Table 7.

By transforming evidence into policy—curriculum mandates and enhanced regulatory vigilance—our study can provide a blueprint for protecting future doctors and pharmacists from industry influence. These recommendations can be disseminated via workshops with DRAP, PPC, and pharmacy deans. Further implications follow.

This is the first study to evaluate the effect of educational intervention on medical and pharmacy student behavior regarding PP after an online module. The strength of our study was the high response rate and a large sample size. The study also had limitations. First, we used pre and then post evaluations which may have pre-test sensitivity and response shift bias (Lewis et al., 2001; Shankar et al., 2010). However, following the multiple studies and protocols, we confirmed the plausibility of our study. Second, the scoring system was developed by the authors. The nature of the questionnaire may have influenced student responses. Third, this study explores students’ involvement in PP based on questionnaire data from the students. There was no attempt to validate or verify the information provided to them, and it was not possible to inquire into the elements of the informal and hidden curriculum (HC) and how they interact with the process of changing or stabilizing students’ opinions. There is a risk that the results may under- or over-report the extent of perception and attitude toward PP. Fourth, the survey we administered looks at promotion in general and not specifically the promotion of antibiotics, but we evaluated the impact of promotion on the prescription of antibiotics. It is unlikely that promotion will affect the prescription of different classes of drugs differently. Finally, it should be noted that these findings may not be readily comparable to those of students in other countries as there may be contextual variations such as the absence of universal health insurance for all individuals.