Is There an Improvement on the Web Sites of the National and International Pharmaceutical Companies in Turkey? A Follow-Up Study

Abstract

Objective: In this follow-up study, we aimed to assess national and international pharmaceutical companies' Web sites using guidelines of The Association of Research-Based Pharmaceutical Companies (AIFD) and Pharmaceutical Manufacturers Association of Turkey (IEIS) to define whether there has been progress since 2004. Materials and Methods: We used two national guidelines in order to evaluate the Web sites of pharmaceutical companies in our study. The first guideline was from IEIS, and the second was from AIFD, which was issued recently. We collected our data between February 1 and April 30, 2011. Data analyses were performed using SPSS version 15.0. Chi squared test was done for comparing the two assessments in different years (2004 and 2011). Results: In general, the progress that we were expecting was not satisfactory for both the international and national companies. The percentage of unmet criteria increased for “links” (from 48.0% to 52.0%) and for “mentioning the responsible person/firm for the Web site design” (from 40.6% to 59.4%) among national companies. We observed statistically significant progress only for the “information for the public” criterion (from 52.9% to 100%) among international companies. On the other hand, there was progress and a statistically significant difference in terms of not displaying any “drug ads” on the Web sites of national firms (from 55.9% to 87.5%), availability of “mail address” (from 88.2% to 100%), “telephone number” (from 88.2% to 100%), “indication of the target group” (from 23.5% to 52.1%), and “disclaimer stating the given information cannot replace a physician or pharmacist” (from 29.4% to 53.1%). Conclusions: Our major recommendation to pharmaceutical companies is to update their Web sites with evidence-based scientific information about themselves and their products using international and national standards. From the companies' perspective, this should be a priority responsibility based on the ethical aspect of individual and community health.

Introduction

Recently, a health literacy concept has been described at both the individual- and community-based levels. In the traditional aspect, it is described in an individual-level construct, but public health literacy gives priority to a broader view, including social, ecologic, and systemic inputs that influence health very closely.¹ In this sense, Web sites of pharmaceutical companies may be accepted as good sources to cover the scientific-based information need of the community when designed with a health literacy concept. Using national and international standards as guidelines while designing Web sites will help to achieve a certain quality level. In this context, there are two major organizations leading the guidelines that the Turkish pharmaceutical companies use: The Pharmaceutical Manufacturers Association of Turkey (IEIS) and The Association of Research-Based Pharmaceutical Companies (AIFD). IEIS was the only body in Turkey since 1964, and AIFD is a new organization established in 2003. AIFD has mainly aimed at focusing on innovative and original products. Both IEIS and AIFD aim to transfer the information concerning drugs in a true and unbiased manner in accordance with medicinal product promotion guidelines in order to assure their rational use.^2,3 Such practices help individuals extract relevant information about drugs and related issues. Thus, drug companies take a responsible position by considering these guidelines to provide credibility and reliability in the eye of both the patients/people and healthcare providers.

Over the past decade, there has been an increasing trend of turning to the Internet as a health information source.^4
–6 For example, Grandinetti⁷ in 2000 highlighted more than 70,000 Web sites as a health information provider. Kim⁸ in 2011 emphasized that a pharmaceutical company Web site could be perceived as being as credible as a state health agency. And yet, standard approaches like IEIS and AIFD guidelines can help the Web sites' content relying on evidence-based data. Both IEIS's and AIFD's “Practice Guidelines for Websites of Pharmaceutical Companies” include information about the drug company (contact information), last updated date of the Web site, availability of the links, availability of references used for the content, brief information about drugs and their use, availability of the adverse drug reaction (ADR) reporting system, etc.^9,10

Previously, several studies investigated Web sites of pharmaceutical companies.^11

–14 However, we could not access any follow-up research showing changes including improvements, regressions, etc., over time.

With all the rationales above, in this follow-up study, we aimed to assess the Turkish national and international pharmaceutical companies' Web sites using AIFD and IEIS guidelines to define whether there has been progress or not since 2004.

Materials and Methods

In this study, the authors evaluated pharmaceutical company Web sites according to the most recent established guidelines belonging to IEIS and AIFD. The first guideline was IEIS's document used previously in 2004.⁹ The other was the AIFD's document, which was issued a few years ago. The AIFD guideline differs from the IEIS's in the following headings: Availability of the links, availability of the ADR reporting system, and brief information about drugs and their use.^2,3,9,10

We hypothesized that there should be progress since our first evaluation, for which we published the details in 2005.¹² Also, we added new pharmaceutical companies in our evaluation that entered the market since 2004. In total, there were 54 companies, 22 of which were international firms. Nearly all the company Web sites were reached through the official Web sites of the AIFD (www.aifd.org.tr) and the IEIS (www.ieis.org.tr). Only a few were accessed by www.google.com.tr through the Web. Only one Web site was excluded as it was under construction during the study interval.

We collected our data between February 1 and April 30, 2011. Each Web site was evaluated for existence of an advertisement on the front page, contact information, availability of the last updated date, indication of the Web site's target group, availability of information for the public, availability of links, availability of references, appropriateness of the content intended for the target group, availability of a warning statement mentioning the information cannot replace a physician/pharmacist, availability of a separate physician/pharmacist section, availability of an ADR reporting system, availability of a statement declaring that the links' content was not the responsibility of the host Web site, and availability of brief product information.

Data analyses were performed using SPSS version 15.0 (SPSS, Inc., Chicago, IL). Chi squared test was done for comparing the two assessments in the different years (2004 and 2011).

Results

From 2004 to 2011 any changes that occurred concerning the Web sites of the pharmaceutical companies in Turkey are shown in Table 1.

Table 1.

Change in Pharmaceutical Companies' Compliance with Guidelines of the Turkish Pharmaceutical Manufacturers Association and The Association of Research-Based Pharmaceutical Companies from 2004 to 2011

	INTERNATIONAL COMPANIES					NATIONAL COMPANIES
	2004		2011			2004		2011
CRITERIA	N	%	N	%	P ^a	N	%	N	%	P ^a
Drug advertisement
Available	3	17.6	1	4.5	0.3	15	44.1	4	12.5	0.005
Not available	14	82.4	21	95.5		19	55.9	28	87.5
Mail address
Available	15	88.2	20	90.9	1.0	30	88.2	32	100	0.045
Not available	2	11.8	2	9.1		4	11.8	0	0
E-mail address
Available	9	52.9	9	40.9	0.455	24	70.6	27	84.4	0.182
Not available	8	47.1	13	59.1		10	29.4	5	15.6
Telephone number
Available	15	88.2	20	90.9		30	88.2	32	100	0.045
Not available	2	11.8	2	9.1	1.0	4	11.8	0	0
Fax number
Available	13	76.5	18	81.8	0.682	30	88.2	30	93.7	0.673
Not available	4	23.5	4	18.2		4	11.8	2	6.3
Update information
Available	10	58.8	13	59.1	0.987	9	26.5	9	28.1	0.880
Not available	7	41.2	9	40.9		25	73.5	23	71.9
Indication of target group
Available	7	41.2	17	77.3	0.426	8	23.5	17	53.1	0.013
Not available	10	58.8	5	22.7		26	76.5	15	46.9
Information for the public
Available	9	52.9	22	100	< 0.0001	9	26.5	12	37.5	0.336
Not available	8	47.1	0	0		25	73.5	20	62.5
Links
Available	12	70.6	20	90.9	0.101	22	64.7	19	59.4
Not available	5	29.4	2	9.1		12	35.3	13	40.6	0.655
References
Available	3	17.6	4	18.2	0.966	2	5.9	2	6.3	1.0
Not available	14	82.4	18	81.8		32	94.1	30	93.7
Appropriate content for the intended target group
Available	12	70.6	17	77.3	0.721	20	58.8	24	75.0	0.164
Not available	5	29.4	5	22.7		14	41.2	8	25.0
Disclaimer stating the given information cannot replace a physician or a pharmacist
Available	6	35.3	10	45.4	0.522	10	29.4	17	53.1	0.05
Not available	11	64.7	12	54.6		24	70.6	15	46.9
Responsible person/firm for the Web site design mentioned
Available	8	47.1	11	50.0	0.855	21	61.8	13	40.6	0.086
Not available	9	52.9	11	50.0		13	38.2	19	59.4
A separate pharmacist/physician information part
Available	12	70.6	17	77.3	0.721	11	32.3	15	46.9	0.228
Not available	5	29.4	5	22.7		23	67.7	17	53.1
ADR reporting system
Available	^*	^*	2	9.1	NA	^*	^*	3	9.4	NA
Not available	^*	^*	20	90.9		^*	^*	29	90.6
Availability of statement declaring that the links' content was not under the responsibility of the host Web site
Available	^*	^*	16	72.7	NA	^*	^*	5	15.6	NA
Not available	^*	^*	6	27.3		^*	^*	27	84.4
Availability of brief product information
Available	^*	^*	11	50.0	NA	^*	^*	25	78.1	NA
Not available	^*	^*	11	50.0		^*	^*	7	21.9

p values marked in bold type indicate significant differences.

Criteria did not exist.

ADR, adverse drug reaction; NA, not available.

First, we observed that the total number of both international and national companies included in the evaluation has changed since 2004. For international pharmaceutical companies, the number has increased from 17 to 22, whereas for national pharmaceutical companies the number has decreased from 34 to 32.

Newly added criteria from the AIFD's guideline, such as availability of an ADR reporting system, a statement declaring that the links' content was not the responsibility of the host Web site, and brief product information, are still lacking in many of both the international and national company Web sites.

In general, the progress that we were expecting was not satisfactory for both the international and national companies. The percentage of unmet criteria increased for “links” (from 48.0% to 52.0%) and for “mentioning the responsible person/firm for the Web site design” (from 40.6% to 59.4%) among national companies. The following criteria stayed stable among national companies: Availability of fax number, last updated date, and references; the only stable criterion was availability of “e-mail address” among international companies.

We observed statistically significant progress only for the “information for the public” criterion (from 52.9% to 100%) among international companies. The Web sites of national companies had a statistically significant decrease for “drug advertisement” (from 44.1% to 12.5%) and progress with a statistically significant difference in terms of not displaying any “drug ads” (from 55.9% to 87.5%), availability of “mail address” (from 88.2% to 100%), “telephone number” (from 88.2% to 100%), “indication of the target group” (from 23.5% to 52.1%), and “disclaimer stating the given information cannot replace a physician or a pharmacist” (from 29.4% to 53.1%).

When looking in-depth for advertisements, we can say that of all the 54 Web sites evaluated in 2011 only 5 had an advertisement. Also, there was a statistically significant difference in terms of not putting a product advertisement in the home pages of both international and national pharmaceutical companies. In addition, there was progress for the availability of both mail address and telephone number of the companies. We observed again statistical significance for the criterion of “indication of the target group” compared with 2004. Another progress that was statistically significant was found for displaying the disclaimer stating the given information cannot replace a physician/pharmacist.

Discussion

There are 35,000 Internet users or 45.0% of the population in Turkey as of June 2010.¹⁵ In Turkey, it is quite common that people use the Internet for health-related search. For example, Demirel et al.¹⁶ stated that 94.9% of individuals using the Internet have looked for health information at least once. According to Turkish national statistics health-seeking behavior takes the sixth place for Internet use aim ranking in 2010, and 47.3% of people have done an Internet search for health-related information.¹⁷ Moreover, Web sites from official authorities are more reliable for Internet users.¹⁸ Thus our study results could be used to improve the Web sites of national and international drug companies in this sense. Turkey has a big pharmaceutical industry with consumption of pharmaceuticals totaling around US $3 billion, 90% of the drugs consumed are manufactured domestically, and foreign companies run 80% of this manufacturing. This accounts for 40% of total spending on healthcare and medical services. Turkey's total pharmaceutical production makes it 16th among the world's 35 leading pharmaceutical-producing countries. It is the largest pharma market in the Middle East and the fastest growing in the Mediterranean region.¹⁹ In parallel with these facts and figures our expectation was to observe significant progress in each of the set guidelines' criteria for the Web sites of pharmaceutical companies operating in the country since our first publication in this journal.¹² We shared our findings with both IEIS and AIFD authorities upon our publication in 2005; however, it seems that not enough attention has been given to this issue since then.

Because this study is a second step of a general assessment, we can easily see the progress and regression on the Web sites. Although there are improvements, many points are still missing from the Web sites that could have been easily covered technically. For instance, it is a simple task to provide “contact information” such as mail and e-mail addresses and telephone and fax numbers, but it seems that companies ignore even putting these criteria on their home pages. On the other hand, by displaying fewer ads on the home page the pharmaceutical companies' approach is promising in terms of ethical expectations. This behavior seems to becoming common in various studies abroad too.^20,21

Other missing criteria were mentioning the responsible person/firm for the Web site design, last updated date, and the disclaimer stating the given information cannot replace a healthcare professional. Likewise, the findings of a study conducted by López Hidalgo et al.²¹ indicated that of the 60 analyzed pharmaceutical company Web sites with patient health information only 51.7% specified the address of the person responsible for the site, nearly two-thirds showed the date of publication of content, but only 13.3% gave the date last updated; a total of 41.7% omitted saying their information does not replace medical advice. However, the Health on the Net Foundation emphasizes that the responsible person/firm for the Web site designer information is important for transparency of a Web site.²²

Currentness or displaying the last updated date is lacking in some other studies like in our study.^23,24 For instance, in a study that evaluated United Kingdom Web sites related to rheumatoid arthritis, of the 55 Web sites more than three-fourths did not provide any information concerning authorship, ownership, and currency, and only one-fifth gave references to scientific literature.²⁴ But beyond this, we think that as Breckons et al.²⁵ discussed in one of their studies that it makes more sense when the companies put in the information on whether their Web site has been updated in the last 6 months rather just indicating their last updated date.

The number of national and international drug companies that indicated their target group on their Web sites increased since 2004, and the improvement was statistically significantly different only for the national companies (p=0.013). Although it is technically very simple to meet this criterion for companies, there are still 20 companies without any indication.

As Web sites of pharmaceutical companies are good information sources for the community, it is expected that all of the Web sites should meet this criterion. International firms were successful in this part without any distinction. Nevertheless, 62.5% of the national companies still did not have “information for the public.” In a world in which health-seeking behavior from the Internet has increased in the community,^13,26 drug companies should have used their Web sites in this regard and refresh the scientific-based information periodically.

It is almost crucial to design the Web site for doctors and the public separately because of the former's medical and scientific background. For the public, the information should be simple and understandable without any medical terminology, etc. In this study, we found international companies were more successful than national ones in terms of “a separate pharmacist/physician part.” Nevertheless, this criterion was not 100% met for the international companies as well. In parallel with this criterion, the companies were unsuccessful in terms of availability of an ADR reporting system. Without this part on their Web sites, the consumers' health-seeking behavior will not have been met by the companies. By providing an ADR reporting system drug companies take responsibility for their own product, and they show their concern for the consumers. An ADR reporting system is very important for both patients/patients' relatives and healthcare providers when a suspected adverse reaction occurs. In a prospective observational study done in the United Kingdom, it was found that the burden of ADRs on the National Health Service is high, accounting for considerable morbidity, mortality, and extra costs.²⁷ Likewise, in another nationwide study, this one originating in Spain, covering a period of 6 years, 19,734 patients died during an ADR-related hospitalization; in addition, the total cost of ADR-related hospitalizations to the health system was high.²⁸

In our study, we had some limitations. First, it is almost a Web-based search, and this probably limited gathering more detailed information and further analysis that could have been possible through direct contact with the Web masters of the drug companies. Second, our current assessment done 7 years after the first evaluation¹² cannot let us to see the annual progress or regression in the Web sites.

In conclusion, in the light of all the above discussion, our major recommendation to the pharmaceutical companies is to update their Web sites with evidence-based scientific information about themselves and their products using international and national standards. From the companies' viewpoint, this should be of concern as a priority responsibility based on the ethical aspect of individual and community health.

Footnotes

Disclosure Statement

No competing financial interests exist.

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