Assessing the effect of educational intervention on pharmaceutical promotion: a follow-up study among medical students from Pakistan

Abstract

Background

The promotional strategies implemented by pharmaceutical organizations lead to abnormal prescribing practices that both diminish physician-patient confidence and drive-up healthcare expenses. The motives of the pharmaceutical companies are to appeal students’ natural preferences. So, educating them represents an essential approach to combat these effects. Research provides few examples of educational programs while their long term sustained benefit has not been established over time. This research investigated how educational programs affect students in the short- and long-term after exposure to pharmaceutical promotional activities.

Methods

The study was conducted longitudinally across 7 schools within three provinces of Pakistan. Survey data collection took place from 856 medical students of the 3rd year class of term 2021–2022 and 2022–2023 for pre-post educational assessment. We performed two-year follow-up surveys which asked the same questions to these 2 cohorts to determine both the clinical rotations’ impact and various promotional methods on their responses. We measured the opinions of 819 students who completed their last year and did not take part in the educational intervention to compare with those taking it. Analysis of each individual point in all comparison sets occurred through SPSS version 23.0.

Results

Student perception along with business approach towards promotional strategies underwent significant modifications throughout the short-term period. The educational method lost its effectiveness at convincing students about avoiding financial support from pharmaceutical companies in the long-term period (median 2(1) to 2(0) p:0.049). Educated students displayed superior knowledge about how trivial gifts affect medication decisions over uneducated final year students (2 (0) to 3 (0) p < 0.001). In the group with high promotion exposure the educated students-maintained awareness about trivial gift influences (p < 0.001) but uneducated students believed they were unaffected by such promotions (p < 0.001).

Conclusion

An education program could serve as a platform to build pharmaceutical promotion awareness alongside promoting skepticism levels and developing positive perceptions about pharmaceutical promotion methods. The educational intervention faces a high risk of becoming ineffective when students interact with the informal and hidden curriculum and exposure to promotional activities. The impact of role models, organizational culture, and institutional policies could be important aspects to be addressed for sustaining the effectiveness of such education programs.

Background

Pharmaceutical promotion (PP) enclosed the range of tactics that are persuasive in nature and carries the potential of negatively modifying the behavior of the healthcare professionals (HCPs) [1,2,3]. The World Health Organization (WHO) defines PP as “all information and persuasive activities by manufacturers, the effect of which is to induce the prescription, supply, purchase and/or use of medicinal drugs” [4]. Students are the integral part of the community chain as their future decision matters and are influential [5]. Weighing the benefits of the PP to the students, pharmaceutical companies (PCs) start targeting them from the undergraduate college level [6, 7]. This in return cultivate brand locality in the minds of the students, change their perspective towards drug handling and increase irrationality of medicine including the antibiotics [8, 9].

The trend of PCs continues to shift toward PP and they dedicate their efforts to reach students [10]. Students who receive PC promotions and gifts develop stronger brand loyalty and become brand representatives [8,9,10,11,12]. Students need PP education [8, 9, 11, 12] so medical educators and mentors must defend students from false PP information through proper education [10]. Students develop their perspectives toward promotional activities through informal curriculum (IC) and hidden curricula (HC) during their clinical training and according to reports by final-year student about drug choices, it is based on their medical teacher examples [13]. Student requests for PP education become ineffective when medical authorities present it as an obligation or requirement. Medical and pharmacy schools worldwide surveyed their students for PP education and discovered most students received less than a day of instruction and only 2 h of dedicated learning time [10, 14]. The review by Norris P et al. shows that self-regulation of PI along with editor supervision, medical sales representatives (MSR) guidelines, advertising standards and post-marketing regulations fail to decrease promotional problems by PCs [15, 16]. The review demonstrated official government regulations together with research into deceptive promotional strategies and prescriber education about promotion methods as effective measures. Medical students and physicians require training about PC promotional tactics to transform their support against the negative PP impact [16]. The American Medical Student Association, Healthy Skepticism. Inc., The educational initiative regarding PP and device promotion should focus on 4 main objectives according to the recommendations of No Free Lunch and Pharm Aware, the American Medical Student Association and Healthy Skepticism Inc. All healthcare providers need explicit education about decision-making and evidence evaluation and promotion while learning about the proven absence of effective promotional methods to gain benefits without harm and their responsibility to avoid pharmaceutical and device promotion and educated explicitly about the most reliable sources of information [16, 17].

Pakistan’s National Code of Pharmaceutical Marketing Practices exists but lacks enforcement. Unqualified “doctors” receive drug promotions, and transparency mechanisms are absent [18]. There is none from Pakistan and very few studies around the globe estimated the effectiveness of educational intervention on how to cope with PP strategize of PCs [10, 16, 19,20,21,22,23,24,25,26,27]. There was one study reviewing the impact of these education programs concludes, “It is not entirely clear from these studies that the changes in attitudes and/or behavior are sustainable over the long run [28]. More research is needed to determine the long-term impact of these educational interventions” [28]. Most of these interventions were in format of short lectures and seminars that lasted from hour to day, and were evaluated by pre-post estimations without follow up studies. Another systematic review dated back to 2017 concluded that there are no data available on the sustainability of the effects of such courses on participants’ behavior [29]. So, we undertaken a follow up evaluation of effectiveness of the educational program by WHO/HAI on PP strategies. The specific focus was estimation of the durability of program where students encounter the full force of promotional influence and in the institutes where there is no specific regulation for preventing exposure to PP. In order to do that we conducted research among the 3rd year students and gathered data right after the intervention (short term) and 2 years after the intervention (long term).

Methods

Study Area

Pakistan is the territory of the 4 provinces namely Punjab, Sindh, KPK and Baluchistan, 2 Independent Administrative states (Gilgit Baltistan and Azad Jammu Kashmir) and a Capital region (Islamabad) [30]. Pakistani education system is divided in to 6 piers, Pharm-D and MBBS are categorized bachelors’ degrees and are in the high education domain [31]. The higher education system in terms of universities is governed by the Higher education commission (HEC) and in terms of medical colleges it is dealt by HEC and Pakistan Medical Council (PMC) [31]. Pakistan by far have 176 medical colleges, including 45 public sector and 72 private sector medical colleges. In addition, there are 17 public sector and 42 private sector dental colleges [32].

The intervention

We designed an educational program [Physician-Pharma Industry Interaction (PPII)] through comprehensive review of available literature [10, 16, 33,34,35,36]. The literature revealed the existence of various modules and programs in the PP yet our objective to help future-physicians develop awareness and skepticism and dissatisfaction towards PC promotional methods led us to create a module focused on international and national guidelines. The program development incorporated analysis of PC promotional methods together with PC application strategies, potential negative prescription impacts, physician arguments about pharmaceutical relationships and prevention strategies for promotional effects [33,34,35]. We designed our program through the integration of material from Health Action International (HAI) and WHO ‘Understanding and responding to pharmaceutical promotion’ manual [36]. The manual can act as an educational tool which supports teachers when teaching students about PP. This module covered a range of domains that include promotion of medicine and patient health, techniques that have influence on the medicine use, how to analyze the promotion in medical journal, who are MSRs and their duties, response to patients request on the advertised medicine, what are conflict of interest and how students get aware of such things, regulation of PP and its need and impact, how to use unbiased information source and impact of promotion on professional practice and patients trust. The main objectives of the program focused on helping medical students develop critical thinking abilities regarding promotional methods and promotion advantages and disadvantages and providing individual coping strategies against promotion effects and understanding the limitations of these individual strategies. The module uses rules for university-industry relations and guidelines from developed countries to support these goals [37]. We selected the teaching motives that would be implemented throughout the next 3-month period after gathering the necessary material.

The main points addressed in the course were.

1. 1)

The types of interactions with the healthcare industry

*

Rights and responsibilities of different parties

*

Related legal regulations and professional codes

2. 2)

The nature and motives of a PC as an entity.

3. 3)

The influential effects of promotional methods on clinical decisions.

4. 4)

Soundness of the arguments for and against physician-PCs interactions.

5. 5)

Protection from negative impacts of PC promotion methods.

1. 6)

Individual measures.

*

Rational prescribing/dispensing.

*

Reaching out to independent scientific information source.

*

Avoiding promotional influence.

The above module was categorized and accepted for all the international standards regarding the PP and was well adopted in the previous studies [10, 16, 20]. While for the local regulations we gathered information from the guidelines given by Drug Regulatory Authority of Pakistan (DRAP) in “Advertisement of therapeutic good” [38]. These guidelines were updated in 2021 [39].

The content drafted from these rules was as follow.

1. 1)

Local conditions for advertisement.

2. 2)

Probihitions.

3. 3)

Penalties.

4. 4)

Limitation and obligations regarding the PP in the regional context.

5. 5)

Basic definitions i.e. MSRs, Therapeutic goods etc.

6. 6)

Type and control of advertisement

7. 7)

Ethical and principal for the conformance of the contents of promotion.

Study population and design

The primary objective was to implement this module in the course of the medical education around the country. But before the implementation of the interventional program the provision was to select and invite the medical schools. As there are large number of medical schools operating in the 4 provinces of Pakistan, we invite most assessable ones to be the part of this interventional study. We proposed the invitation to the both private and public sector medical schools with the brief introduction of our objectives, module, line of action and their participation and funding for the whole study. As the primary objective was to enroll the 3rd year students, principal investigator visited the colleges by self in the duration of Sept-Oct 2021. In the face-to-face encounter we debrief the Dean/Principal of respective college and class teacher or senior teacher of 3rd academic year. We introduced our research group, research objectives, proposed our study plan, duration, protocol and assessed their feasibility to be part of and help conducting the study. We also assured them that the name, location or any information related to the university/medical school will not be revealed and only being used for the research purpose only. We further assured that this is just a longitudinal survey that does not include any intrusive or harmful procedure and participation of the students is voluntary and their anonymity will be kept. We also assured that the institution anonymity will be kept. Afterwards, we left our contact details and asked them to get back to us with 1 week time regarding their willingness or rejection. Those who did not respond in the time frame were given another reminder and then consider them as drop off institution. After their agreement each university provided an associate/assistant professor (AP) as a goalkeeper to the research and requested to provide the class room or a hall for the training purposes. We afterwards made the schedule and informed each institution about the days of interventional program.

This follow up study was conducted among the 3rd year students in the grade of 2021–2022 and 2022–2023. This research was an elective program and we announced in the 3rd year classes and also mention about this program on notice boards as pamphlets. These pamphlets include the basic detail about the research and the procedures to get enrolled in the research. Those who showed willingness to take part in the study were asked to get the details from the AP who was designated as the recruiter in their particular institute. The students who were willing to enroll were given the consent form and after filling the consent form, they were assigned with the identification code number (ICN) that we used for data collection and evaluation. This code number was of the great value as it served as identity of the students after 2 years. Students were then asked to remind it or keep it safe for the purpose of the identification in future. Those who forgot it and took part in the pre studies were excluded from the study. This method also served to identify the particular respondent and prohibited the inclusion of those students in post survey who were not participated in pre surveys. We analyzed or calculated the responses on the basis of this ICN at the end of 2-year period i.e. those who provided the data after the 2-year period were then back checked and if they provided data in pre-educational survey, they were included in it. The post 2-year survey was conducted after announcing in the final year class and asked the students to ensure their attendance at the particular day but to ensure that all wiling participants fill it we announced it twice in the subsequent days so if anyone is absent in the first time may fill it the second or third time. This course was fully self-voluntary and no incentive in the form of any favor, or monetary vales were given to the students. This research was not conducted in the controlled environment and there are no such restrictive policies in the institution to avoid the contact with MSRs or alleviation of PP. In the meanwhile, no further restriction was there for PP and MSRs and PCs continued to perform what they were doing in the past i.e. providing financial support to organize seminars or conferences in the universities or colleges or to organize the expos in the vicinity of students.

The above literature was organized in the form of 12-hour course that has been divided in 3 lectures spanning over 4 h once in 2 weeks. Before the start of this course each class were given a lecture by the professional from multinational company who was specialist in marketing education. The course was delivered by the principal investigator himself to all the willing students to ensure the same level of training to all the individuals. We employed both classical methods i.e. lectures and interactive group sessions. We also focused on the interactive activities such that critical appraisal of promotional materials for the validity of claims and students were given assignment to evaluate them according to the standards and write reports, look for covert drug advertisement in newspapers and or on the media and social media, using case scenarios to analyze arguments for and against physician-PCs relationships and their views to improve the situations and policies. We further enhanced their understanding by showing a short video “Side Effect” [40] about the professional life of a MSR and asked to spot the promotion methods; the ways of implementing those methods. After completing the teaching, we engaged students in the role play with true MSR followed by detailed explanations about how certain strategies are used to promote pharmaceutical products. A total of 7 medical institutions were agreed to be the part of this study. In the 2021–2022 batch, 251 of the medical students from 4 private medical colleges and 233 students from 3 government medical colleges were initially agreed to participate in the study However, 223 from private and 211 from the government institutes completed the pre-post data in 2024. Similarly in 2022–2023 batch a total of 199 medical students from government and 223 from private institutions were agreed to be the part of the study and completed the pre-post survey.

Tool development and validation

A survey form was developed on the basis of the previous literature [10, 16, 33,34,35,36]. It served to evaluate participant perception about the influence of the module on knowledge, attitude and skills pre and post intervention. The statements to be included in the questionnaire were developed based on points covered during the module and highlighted in the manual after discussion. It consisting of 8 background questions and 26 statements. This was divided into 5 parts: Sect. 1) The background questions established were gender, nature of the school, whether they took the elective course and any other education about physicians-healthcare industry relationships, opinions about the program, and exposure to direct and indirect promotion methods. Section 2) This section claims about the nature and necessity of PCs and asked students to agree, or disagree, including factual errors and faulty inferences gathered from various sources [10, 16, 35, 42,43,44]. 5 questions were asked (agree, not sure and disagree and was scored 1, 2 and 3 respectively). It also contains 6 items on knowledge about the influence of PP which were characterized by ‘No idea’ was 1, for ‘Have a vague idea’ 2, and 3 for ‘Clear idea’. 11 areas were explored under the heading ‘knowledge’, giving a total score of 33 and minimum of 11. Section 3) The 3rd section includes the statements, to reflect the optimal professional mindset that maintains a healthy skepticism about PP to which students responded with their opinions and attitudes. It contained 10 items regarding the opinion and attitudes about PP (i.e. agree, no opinion and disagree numbered as 3, 2,1 respectively). The scores for 10 statements were added to obtain the total ‘Attitude’ score. The minimum possible score was 10 and maximum was 30. Section 4) It contained 5 sets of ‘Skills’ regarding PP. For each skill the respondent was given the following choices: ‘he/she was not confident’, ‘somewhat confident’, ‘very confident’ in performing the skill and ‘will be able to do independently in future’. These were given the scores 1, 2, 3 and 4 respectively. The total skills score was calculated adding the scores of the 5 skills. The score range was 5–20. Section 5) in addition to the perceptions we also evaluated the proposed practices in influence of PP regarding the use of PP. It contains 3 items the answer of which was gathered as, 1 Yes I would like to, 2 maybe, 3 maybe not, and 4 Not at all. The scoring is reversed for question 2 which was negative question.

Validation of the concept and content of the questionnaire was accomplished by a comprehensive assessment of the related literature. The tool was used and validated in multiple studies [10, 16] but we did face validity of the data collection instrument by the contributions of professional researchers who assessed the items contained within the instrument. Expert panel of 5 faculty members who have prior experience in the field of pharmacy practice conducted a review and evaluated the questionnaire. Both content validity index and content validity ratio was calculated and their results have been given in supplementary file. Before beginning the research, the instrument was put through a pilot testing (among 33 students) to see how easily the items on the instrument could be understood and how clear they were. During the pilot a subset of pilot participants (13) were asked to verbalize their understanding of key items and provide feedback on wording. They were further asked if they have any confusion in understanding any term. Through the use of pre-testing, we were also able to ascertain whether or not the respondents were willing to take part in the research and provide the requires information. The phrasing and scale were both clarified by the making some small adjustments based on their suggestions. Internal consistency of questionnaire was measured by Cronbach’s alpha which was 0.623.

(Moderate range).

Evaluating the effectiveness

We measured the effectiveness of the educational intervention in a two-phases, i.e. short term (after the class), and the long term (2 years later at the end of 5th year of education). In 1 st phase, we concluded a pre post analysis and the survey was applied to medical students who were willing to attend the course in 2 consecutive terms, 2021–2022, 2022–2023 to determine the pre-educational status of students’ opinions and any post-educational changes in students’ opinions. This survey was conducted at the spot after completing the intervention.

The Phase II evaluation aimed to evaluate the effectiveness of the program in the 5th year of medical studies, hypothesizing that the HC and different kinds of promotion activities might have a negative impact on students’ approach to interactions with the industry even after having a special training in their preclinical years. Therefore, a follow-up study 2 years later asked those to fill out the same survey for comparison in 2023–2024 and 2024–2025, terms when they became 5th year students. In addition, 819 final year students who had not taken the PPII class in their 3rd year of education in the same terms were also enrolled into the Phase II study in the terms of 2023–2024 and 2024–2025 as the control group and asked to complete the same survey. Their opinions were compared to the students who had attended the program as the intervention group to evaluate the program’s effectiveness via assessment of outcomes in the intervention and control groups.

This research checked for protection from promotional methods deterioration among medical students as studies show direct links between promotional tactics exposure to immunity belief [17, 44,45,46,47]. All 5th year students had to specify their encounters with 15 promotional tactics they observed during their clinical rotations. Students had experienced 11 promotional techniques that involved physician-given gifts and representative-detailing observation while also encountering four methods applied directly to them. The possible scoring for promotional activities reached 15 points. 316 5th year students scored at least 8 points on the exposure tool thus qualifying them as highly-exposed to promotional methods. Then, in this sub-group of highly exposed 5th year students, results from the survey were used to compare the opinions of 436 students who attended the class to 378 students who had not.

Statistical analysis

The descriptive statistics were used to analyze the 1 st section whereas to analyze the scores of each subsequent section we 1 st conducted the test for linearity (Kolmogorov-Smirnov test). After evaluating the data that is nonlinear, we evaluated the difference in the mean rank by using The Kruskal Wallis test for each item to analyze the possible significant differences between pre and post educated groups. Wilcoxon signed-rank test was used for comparing median scores before and after the educational intervention. Mann-Whitney U test was used for comparing median scores of the cohorts in 3rd and 5th year, educated and uneducated students both in the 5th year and in the highly-exposed group. All statistical comparisons with a p-value below 0.05 were assumed statistically significant. Statistical analyses were performed with IBM SPSS statistics version 23.0.

Ethical approval

This longitudinal study was carried out in accordance with the Declaration of Helsinki and was approved by Medical Ethics Committees of Xi’an Jiaotong University China (PP-2021-05), and the Ethical Review Board of The Superior University, Lahore and Baqai Medical University, Karachi. We selected the colleges on the basis of their approval to be part of the study. A pre-approval consent from each student was also obtained in written. All participants had to sign the consent form and agree. None of the personal information (name, address phone number etc) was asked purposefully and participant were assured that the data would only be used for research purposes and treated with confidentiality. We encouraged the students to complete the whole research but as the participation was voluntary and is free of any incentive or penalty so the students can back off from the research at any time.

Results

Among the respondents 434 students from the 2021–2022 batch completed the pre-post study and among them 61.8% were males and 51.4% were from the private organizations. Similarly, in 2022–2023 batch the males were dominant and accounted for the 63.5% of the total and 47.2% were from the government institutes. Among the 856 participants from both academic years, mostly agreed that the taking class was useful for them (81.2%) and almost similar (82.3%) said that it was helpful to improve the decision-making power and tend to help making the objective and unbiased decisions.

After completing the course, it had been observed that there were considerable changes in the behavior attitudes, skills and proposed practice of the medical students. Post education the students were moved from not sure to agree for “It is normal that,similar to other sectors, pharmaceutical companies give priority to increasing their profits or they cannot afford to develop new drugs” (p < 0.001) and disagree to agree for the term “Pharmaceutical promotion should be conducted within certain limits” (p < 0.001). It was also noted that the respondents were being significantly clearer about the “Promotion of medicines to consumers” and “Medical student & the pharma industry relationship” (p < 0.001). Post-intervention, the participants became neutral from disagreeing that accepting the pens from the companies is not ok (p < 0.019) they were also not sure about getting financial support from PCs for organizing and participating in scientific activities (p < 0.001).

When we compared the antibiotic handling behavior for the students, we came to know that the behavior changed from maybe to maybe not in terms of “Would you prefer to prescribe antibiotics in future due to PP pressure by PCs” (< 0.001) and “Will you be prescribing antibiotics so as to just please the PC for better relationship and incentives in future”(p < 0.001).Details are mentioned in Table 1.

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There were significant changes in the behavior of the pre and post 3rd year students for the short term, but the longitudinal effect of the intervention demonstrated variable effects. In the final year cohort, the response changed from agree to neutral in terms of promotion should be conducted in controlled way (p < 0.007) and from maybe not to maybe in terms of prescribing antibiotics so as to just please the PC for better relationship and incentives in future (p 0.001). Students were also less inclined toward statements “The industry’s primary objective is to sell their medicines” (p < 0.045) and preferring to prescribe antibiotics in future due to PP pressure by PCs (p < 0.043). Details are available in Table 2. Most of the elements in the knowledge attitude and skills domains showed no significant difference after the 2-year period of the same cohort. So, it showed a good retainability of the intervention program in long term

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As for the comparison of the group who took class with those who did not take class it was observed that p value of the most of items in nature and necessity of PCs, opinions and attitudes about promotion of PCs methods showed significant different values between the 2 groups. Whereas, all the items in the skills and practices sections (p < 0.001). However, there was no changes in scores observed but the educated groups were showing more affinity towards most of the items. Details given in Table 3

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In terms of the views of the final year students who took the class and who did not take the class in the high exposed promotion group, we saw that there was significant improvement in the knowledge and other parameters of the promotion. As there were significant high number of the students who agreed to the term that “It is normal that, similar to other sectors, PCs give priority to increasing their profits or they cannot afford to develop new drugs” (p 0.007) and on limiting the PP (p < 0.001). The educated students in the 5th year, and also in the highly-exposed group, were against PC-sponsored research; while the uneducated students agreed more with them when they were highly exposed to promotion (p < 0.001) There was insignificant change in the checking of literature for the antibiotics claims and by MSRs but there was significant change in the prescribing behavior of the students in the educated groups and they had less tendency to prescribe antibiotics for the reason of promotion and making PCs happy (p < 0.001) (Table 4)

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Discussion

The healthcare system (HCS) has a lethal bug called PP that makes HCPs choose irrationally. PP influences medical practitioners’ choices of antibiotics and their antibiotic prescription decisions [4, 5, 8, 9]. Medical students demanded an appropriate level of teaching about PP and educating them seems to be one of few approaches to control the deteriorating impact of counteract PP [15]. Research on educational interventions about PP remains scarce throughout the literature without any studies emerging from Pakistan. We created an educational program for 3rd year medical students before their clinical rounds at both private and government medical institutes across 3 Pakistani provinces. Our study demonstrated that pre-post educational programming combined with long-term knowledge retention proved more effective than the control group who did not participate in the class. Our cohort demonstrated a positive intervention effect immediately following the program which is typical because participants showed reduced ratings about seeing the MSR before and after training. Organizations allocate more than 25% of their marketing budgets to establish relationships between MSR and physicians [48]. MSR serve as a resource for physicians to obtain relevant information about treatments while also providing free medication samples to patients who cannot afford them [10]. Research indicates that MSRs both raise public awareness about untreated medical conditions and contribute positively to society yet their frequent misleading activities tend to increase irrational behavior [2, 3]. Many HCPs in South Asia are in private practice and it is an unfortunate fact that MSRs may be their only source of information about medicines. Banning MSRs may deprive them of this source. Exposing students to misleading presentation, fostering false beliefs, debunking these beliefs, and explaining the misleading techniques is an effective approach to teach critical evaluation of medicinal drug promotion [49,50,51]. The medical authority maintains that doctors must avoid seeing MSRs because it breaches professional ethics while also wasting valuable time [52]. There is strong evidence in the previous literature that there were positive changes knowledge, attitudes and perceptions among participants in the pre-post assessments [10, 16, 19,20,21,22,23,24,25,26,27, 48, 53,54,55,56,57] The immediate behavioral modifications do not accurately demonstrate the program’s effectiveness nor evaluate its results during clinical years when students deeply engage with HCS while observing patient-provider interactions in real healthcare settings and developing their understanding of comprehensive healthcare delivery. A longitudinal study was conducted at the start of 3rd academic year to measure the program’s sustainability through 2 consecutive terms in 2021 and 2022 from the 3rd academic year to the 5th academic year (2 academic years and 3 years of clinical exposure to MSRs and promotional strategies). The educational program demonstrates enduring qualities regarding student knowledge about PP influences and their opinions and attitudes toward PC promotional strategies and their ability to handle PP and MSRs. It was also observed in previous literature [10, 16]. Students demonstrate stronger agreement that pharmaceuticals should be treated like regular market products while PP activities should maintain specific boundaries. The students who completed the class and those who did not show similar levels of knowledge and skills in multiple areas according to the research findings. The students may have already displayed positive attitudes toward PP and PCs before their medical rotations began. The students may have become familiar with PC-sponsored activities through their exposure to newly graduated doctors and experienced physicians. In Pakistan a widespread belief exists that small activities funded by PCs remain harmless because they do not influence prescribing choices [1, 8, 18]. Medical students during their clinical years tend to develop doubts about the essential nature of PCs for scientific progress and the business values that sacrifice human needs for profits. The resulting consciousness seems to affect pharmaceutical markets by elevating branding practices above other considerations. The result in increased healthcare costs. The development of critical thinking through early education on PP techniques would support future-physicians to adopt a patient-centered perspective [58]. The educational intervention failed to maintain its positive impact on final year students’ opinions about accepting financial support from PCs for research activities and scientific activities. This negative outcome can be attributed to both promotional activities and IC and HC [16] The research included final-year students who did not take part in the program to function as a control group for assessing long-term program effectiveness. The education program consistently yielded positive results when comparing the influence of trivial gifts and PC sponsored research between groups. Students with formal education maintained elevated awareness levels in both the 5th year and within the highly-exposed group regarding trivial gifts affecting medical prescriptions whereas students without education believed the opposite. The results match earlier research which demonstrated that higher exposure levels led students to make positive assessments about their relationships with PCs and believe doctors were impervious to promotional techniques [44,45,46,47,48]. The observed data demonstrates that participants in this program demonstrate resistance to developing inflated beliefs about physician immunity to PP despite their increased exposure to promotional methods. Students showed increased willingness to accept pharmaceutical financial support for scientific activities and reduced opposition to pharmaceutical representative meetings when they experienced the clinical environment. The effectiveness of the education program diminished when faced with influential promotional methods because students failed to understand that no proven method exists to gain more benefits than harms from promotion according to program recommendations [17]. The development of medical students’ professional identity occurs through formal educational programs and their interactions with the healthcare setting [59]. The attitudes of students are influenced by value atmospheres and organizational cultures as well as the behavioral patterns of their role models [60, 61] because students absorb both structural principles and behavioral models and attitudes that exist within clinical environments [62].

Strength and limitations

Study holds strengths such as robust methodology, effectiveness of the educational intervention was evaluated longitudinally for the first time by following cohorts and comparing them to a control group after they had been exposed to the clinical environment. Study was conducted in 3 provinces with the large data sample and enclosed both private and government institutions but despite of this, as we selected the institutes based on their willingness, the results cannot be generalized. One of the limitations of study was that ‘effectiveness’ was evaluated by survey based on the opinions and attitudes of students, rather than by observing the true behaviors towards PP and evaluating the actual audits of their prescriptions after graduation. Secondly, not investigating the 3rd year students who had not taken the class posed another limitation for evaluating their opinions when they become final year students. Thirdly, the quantitative nature of the study is another limitation since it was not possible to inquire into the elements of the IC&HC and how they interact with the process of changing or stabilizing students’ opinions. Fourthly, we did panel views on the suitability of questionnaire, we provided space for qualitative discussion between them and asked them to provide the modifications according to them. Fifthly, a small pilot size was approached due to the financial constraints, this sample size matches the universal absolute sample size for pilot study (> 30). But according to the AMEE guide no 87, 5–10 students should be focused on each item so our sample is smaller as compared to that. This limitation is covered by the fact that we calculated CVI and CVR which showed high relevance and essentiality. We also evaluated the factorial analysis and mentioned the rotated matrix for each component. Finally, our Cronbach Alpha lies in questionable range (0.60–0.70) and raise question for the reliability. However, we did a comprehensive tool evaluation by taking the expert opinion and calculating two parameters CVI and CVR which stated the high acceptability.

Further studies

Our study left some unanswered phenomenon which can be responded by qualitative researches which may explain unexpected results. It is known that preclinical and clinical students were less likely to feel sufficiently educated on the topic of physician–pharmaceutical industry interactions [12]. Since one of the aims of the education program was to create an awareness that one could never be totally immune to the influence of promotion, the reasons for this transformation of confidence needs further research to determine whether this transformation is a positive effect of the education or a failure that could be connected to the interactions in clinics.

Conclusion

The study revealed an essential deficiency exists in current medical education programs for teaching future doctors to work with the PI. Our intervention program shows promise to defend against promotional strategies while raising PP awareness and fostering negative perceptions about promotional activities. The educational program achieves notable success yet it faces the risk of losing its sustainability in actual clinical settings. The curriculum should address role-models and organizational culture and practical experiences as key elements while simultaneously reducing student exposure to PP in order to create significant interventions. All institutions should ban promotional effects through policy changes while students and physicians need open access to unbiased information resources that stay updated Data Availability statement The data will be available upon proper request from corresponding author.

Data availability

The data will be available upon proper request from corresponding author.

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