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IJPHM 5,4

Drug prescription practices in Brazil: a structural equation model

Wagner Junior Ladeira
University of the Vale do Rio dos Sinos, Rio Grande do Sul, Brazil

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Marlon Dalmoro
Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil

Alisson Eduardo Maehler

Federal University of Pelotas, Rio Grande do Sul, Brazil, and

Clecio Falcao Araujo

Faculty of Technology Senacrs, Rio Grande do Sul, Brazil
Abstract
Purpose The papers aim is to analyze the functional relationships between factors related to the prescription of medical drugs in Brazil. Design/methodology/approach A survey was conducted among 232 medical doctors in Brazil. Data were collected using a structured questionnaire. Five hypotheses on the factors impacting drug prescription were proposed, and the constructs were validated using a set of techniques pertaining to the calculation of structural equations. Findings The process of medical drug prescription in Brazil is positively correlated with all the presented constructs. However, the study found that the ve proposed hypotheses demonstrated varying degrees of positive effect levels, ranging from strong to weak. Particularly, factors such as the characteristics of the drug and information available on a drug have the weakest effect, while the cost-benet ratio of a drug has a moderate effect. The drugs brand and its related advertising have the strongest effect. Practical implications The results demonstrate the success of specic applications of advertising tools and brand construction in pharmaceutical marketing strategies targeting Brazilian physicians. Originality/value The study provides a broad map to understand the inuences on drug prescriptions. Despite a prior study that found the behavior of physicians to be impacted by a different set of factors, this new research clearly shows that, in the Brazilian context, branding and advertising remain the major inuences. Keywords Prescription drugs, Cost-benet ratio, Product characteristics, Product information, Brand and advertising, Brazil, Drug administration, Medicines Paper type Research paper

International Journal of Pharmaceutical and Heathcare Marketing Vol. 5 No. 4, 2011 pp. 262-278 q Emerald Group Publishing Limited 1750-6123 DOI 10.1108/17506121111190103

Introduction The diverse forms of economic consumption have always interested marketing professionals and academics alike. The use of prescription drugs has been studied by several authors, both in terms of the growth of the pharmaceutical industry (Kim and King, 2009; Fogel and Novick, 2009; Delorme et al., 2009; Limbu and Torres, 2009) and the specicity of consumption in this industry (Diehl et al., 2008; Miao-Sheng and Yu-Ti, 2008; Kess et al., 2008; Jambulingam et al., 2009).

The prescription drug is the primary source of revenue for the pharmaceutical industry. The prescription represents a doctor-patient relationship, substantiated by the action or intervention of the active medical prescribing agent (doctor) on the passive receptor patient agent (patient). Unlike in the case of other economic decisions, here it is not up to the consumers, or the patients, to make the nal decision of purchasing the product (Kim and King, 2009). On the basis of this atypical feature, this article aims to analyze the functional relationships between the factors related to the prescription of medical drugs. Given the multitude of research opportunities on the pharmaceutical industry (Stros et al., 2009), this paper focuses on a particular market-Brazil. The Brazilian pharmaceutical market is the largest among the Latin American nations and is the eighth largest in the world, with a turnover of almost US$20 billion in 2010 alone (Interfarma, 2011). In Brazil, the demand for pharmaceutical products has seen a growth of approximately 10 percent per year (Osec, 2010). Here, 75 percent of the medicines are sold in pharmacies, and consumers are responsible for close to 80 percent of the total spending on drugs. Given the limited amount of drugs available in the public health system, this is one of the highest rates in the world (Interfarma, 2011). These numbers put Brazil among the worlds major pharmerging markets (Osec, 2010). Overall, the pharmaceutical market is divided into prescription and non-prescription drugs. In Brazil, the sale of pharmaceutical products is tightly regulated by the National Health Surveillance Agency (ANVISA), equivalent to the American FDA, restricting the supply of non-prescription drugs. The regulations do not affect the demand for prescription drugs, as these are not inuenced by changes in prices. This is owing to the impossibility of substituting one product for another after a specic drug has been prescribed. To analyze this phenomenon, a theoretical base was created in which the medical prescription was seen as an act of buyer decision. Within this framework, ve theoretical constructs were developed, containing factors that could inuence the medical prescription. These are the cost-benet ratio, product characteristics, product information, branding, and advertising. Model operationalization was performed by conducting a survey among a sample set of Brazilian doctors. Physicians were the most important sources of information for both prescribed and non-prescribed pharmaceuticals (Delorme et al., 2010). At the end of the study, the obtained results demonstrated the importance of each factor in the doctors prescription process. These results could be useful for pharmaceutical companies in adapting their current promotional strategies to the Brazilian market. At the same time, the observations reect actual doctor practices and thus, provide guidance for planning future studies in emergent pharmaceutical markets. Conceptual framework Unlike over-the-counter (OTC) drug market that do not require a doctors prescription (Delorme et al., 2010), consumers can buy controlled drugs only with a medical prescription. This process refers to the use of a prescription form to recommend drugs, by a qualied medical professional (Kim and King, 2009; Planchon et al., 2009). In this context, a medical prescription can be viewed as the result of a decision making process (Rehn and Mldrup, 2008) that involves different agents, specically, the

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prescriber who is usually the decision maker (doctor); the consumer (user); and the payer (insurance, state, user) ( Jaakkola and Renko, 2007; Stros et al., 2009). In Brazil, a validation of the prescription requires the use of a standardized written form authorizing the sale or delivery of drugs the lling of which is the responsibility of the pharmacists. When a doctor prescribes a particular drug, he or she is not only recommending a remedy that may alleviate a certain condition or disease, but also making a decision as to which specic medicine to prescribe (Diehl et al., 2008; Planchon et al., 2009; Kim and King, 2009). Consequently, it is neither the user nor the person who pays for it that makes the decision, but it is the doctor who prescribes the drug (Harms et al., 2002). While this decision is largely supported by technical data, the prescriber is also inuenced by the marketing strategies of the pharmaceutical companies. In this context, the decision can be inuenced by various marketing elements such as: . the cost-benet ratio (Rizzo, 1999; Miao-Sheng and Yu-Ti, 2008; Diehl et al., 2008); . product characteristics (Dao, 1984; Berndt et al., 1997); . product information (Kim and King, 2009; Fogel and Novick, 2009); . brand (Hollon, 1999; Gonul et al., 2001); and . advertising (Bond and Lean, 1977; Diehl et al., 2008). The cost-benet ratio is the monetary expression of the value of a product or service and is broadly dened as a exible element (See Figure 1). It is determined within economic conditions by seeking the best t between existing supply and demand. An effective cost-benet strategy involves an understanding of the competitive environment and elements that could generate value for the customer (Wyner, 2001). Such a strategy requires the accurate calculation and weighing of the costs, the perceived value of the offer by the buyers, and the actions of competitors. In the case of a prescription, the physician is responsible for making this measurement on behalf of the consumer. The consumption of medicine is largely linked to the purchasing power of the population. Thus, the cost-benet ratio could be important at the time of the prescription (Miao-Sheng and Yu-Ti, 2008; Diehl et al., 2008). Kim and King (2009) suggest that the medical practitioners should be well informed on the cost-benet ratio at the time of prescribing medicines. This is mainly because patients are also aware of the existence of cheaper, generic drugs and often ask for them instead. Consequently, physicians are also frequently confronted with the issue of the cost of a product and tend to decide on the basis of a price-to-performance ratio (Rizzo, 1999; Stros et al., 2009). Thus, the cost-benet ratio of a drug should be subject to the contingent factors of the prescription, particularly in a developing country where part of the population has restricted drug access, due to limited purchasing power and limitations in the public medicines supply. Following this argument, we arrive at the rst hypothesis to be tested: H1. Drug prescriptions are impacted by the cost-benet ratio of a drug. Apart from the cost-benet ratio, other characteristics of the product can also inuence the prescription. Products are goods purchased by the nal consumer for personal consumption (Gutman, 1997; Lefkoff and Manson, 1993). The characteristics of a

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Figure 1. The structural equation model applied in the study

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product are communicated and delivered through its main attributes. For Gutman (1997), the product itself is represented by its attributes, which may be perceived as concrete, abstract, or both. The nature of these attributes suggest a hierarchical order since the consumption does not affect the attributes but the preference for certain attributes can affect the consumption (Lefkoff and Manson, 1993). In the case of a medical drug, it is not the responsibility of the physician to report the characteristics of the products contained in the prescription. These characteristics are not stated in the prescription, but are included in the consumer information provided with the drug. In such a situation, a positive perception of the products characteristics will, in turn, have a positive inuence on the drugs sales (Berndt et al., 1997). Thus, the prescription of drugs may involve different perspectives of the products and may be inuenced by various environmental aspects such as the characteristics and effects of the drug (Kim and King, 2009; Joseph et al., 2008), especially in emerging countries where the product quality can vary signicantly. With this in mind, it can be expected that, for the decision maker: H2. Drug prescriptions are impacted by the characteristics of a drug. Consumer knowledge can be determined by the amount of information that a person has about certain products or services, while the level of such knowledge refers to its inuence on the purchase decision process (Brucks, 1985; Chernev, 2005). Any selection process involves the acquisition and processing of new information, which, along with what has already been stored in our memory, is used to evaluate the purchase alternatives. However, the consumer can make use of certain strategies to facilitate the decision choice (Brucks, 1985). In the case of the medical prescription, the capacity to process information is largely concentrated in the doctor. No matter how much information the nal consumer may have regarding the drug, he or she does not make the decision to use it. The proliferation of the media in general, has provided doctors with numerous sources of information for decision making when prescribing drugs (Kim and King, 2009; Fogel and Novick, 2009). However, the internet provides consumers with easy, and often out of context, information on medicines (Kess et al., 2008; Delorme et al., 2010). Unlike doctors, they do not have the required background in medical study to properly process the information. They also do not have access to relevant physician information sources, such as scientic congress, journal publications and medical documentation to make an informed decision (Stros et al., 2009). This point is particularly relevant in developing countries, where the population has less information access. Given the importance of product information to the decision maker, it is expected that: H3. Drug prescriptions are impacted by the information available on a drug. Besides the product information, branding may be a factor that inuences drug prescription. Brand refers to the name, term, symbol, or a combination of these elements, used to identify the products or services of a company thereby differentiating it from its competitors (Aaker, 1996; Feldwick, 1996). Many theorists consider brand to be a critical factor for a companys success and, if used strategically, capable of generating substantial competitive advantage (Daldauf et al., 2003; Feldwick, 1996). In the act of decision making, brands frequently offer points of differentiation between

competing products and thus, can be considered crucial in inuencing choices (Aaker, 1996; Raggio and Leoner, 2007). The study of brands reveals that, besides their functions in terms of utility, they also have a symbolic dimension (Aaker, 1996). Pharmaceutical products often have large marketing budgets and use mass media to create a brand image among customers (Joseph et al., 2008). This has been considered a major marketing phenomenon in recent decades (Farris and Wilkie, 2005). In such an environment, winners in the prescription drug market are not going to be those with the best patent protection, but those with superior marketing and direct promotional efforts targeting physicians. This is because these medical professionals have been known to demonstrate intrinsic brand preferences (Hollon, 1999; Gonul et al., 2001). The Brazilian drugs market has a smaller share of generic and similar drugs which makes the role of the brand more evident. Based on these arguments, it can thus be expected that: H4. Drug prescriptions are impacted by the brand of a drug. Like corporate branding, advertising plays as important a role in informing the public about differences between competing products available in the market. Consequently, advertising may inuence decision-making (Barone et al., 2005). Specically, advertisements, through their content, inuence cognition, attachment, and intentions; interfering in the decision-making process, related to medical drug prescription (Chandy et al., 2001; Chen and Carroll, 2007). While most existing types of advertising generally offer doctors accurate product information (Kalyanaram, 2009), their ability to persuade decision making signies it as a powerful marketing tool (Diehl et al., 2008). In a landmark study, Bond and Lean (1977) concluded that promotional advertising was essential for the success of pharmaceutical products from a marketing and sales perspective. Thus, given its importance, pharmaceutical companies spend signicant amounts in advertising to perform three basic communication functionsto inform, to persuade, and to remind doctors about the attributes, functions, and benets of the drugs with the goal of inuencing recipients attitudes in a favorable manner (Diehl et al., 2008; Delorme et al., 2010). Given the limited restriction in drug advertising, Brazilian pharmaceutical marketing is characterized by large promotional efforts targeting doctors and inuencing the prescription process. Thus, the last hypothesis to be veried is: H5. Drug prescriptions are impacted by the advertising related to a drug. The conceptual framework and hypothesis generation sought to provide a broad perspective of the marketing elements that could inuence the drug prescription process. An integrated analysis of the aforementioned ve factors provides an extensive range of elements that can have an impact on the drug prescription. Focusing on the emergent Brazilian pharmaceutical market, in which the doctor has almost total power to decide on a particular drug, the analyses of these elements provide an integrated knowledge of the factors that inuence the drug prescription process. Methods This study seeks to establish a functional relationship between the factors related to the prescription of drugs in Brazil. With this agenda in mind, we tested a set of hypothesis related to the various inuences on drug prescription in Brazil. We used a quantitative approach with the survey method support. Data were collected using

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structured questionnaires adapted from modeling based on the researched theoretical references. Responses could be classied under a scale of 1 (strongly disagree) to 5 (strongly agree) in 30 questions (Appendix 1). In preparing this study, an exploratory perspective was obtained from face-to-face interviews conducted with ten doctors in Brazil. The purpose of these preliminary interviews was to check if the intended content of the questionnaire could be correctly understood by the sample. In the interviews, the doctors were able to put forward their own views and values regarding the proposed topic, thus contributing to the development of the collection instrument. The nal questionnaires were answered by a total sample of 232 doctors with ofces located in Brazil. The selection of respondents was conducted through a non-probabilistic sample-by-convenience method. Descriptive statistical analysis of the 232 responses showed that 55.6 percent of the respondents were male and that most (84.1 percent) were over the age of 30. A majority of the respondents (66.8 percent) had been engaged in the medical profession for over ten years and 78.3 percent earned more than ten times the minimum wage in Brazil. In the case of medical specialties, the following categories were surveyed: (1) 47 cardiologists (20.3 percent); (2) 40 psychiatrists (17.2 percent); (3) 34 neurologists (14.7 percent); (4) 32 gynecologists (13.8 percent); (5) 30 general practitioners (12.9 percent); (6) 18 dermatologists (7.8 percent); (7) 12 otolaryngologists (5.2 percent); (8) 7 surgeons (3.4 percent); (9) 6 proctologists (3.1 percent); (10) 4 pulmonologists (1.7 percent); and (11) 2 urologists (0.9 percent). Structural equation modeling was used to test the proposed model. We tested the scales for dimensionality, reliability, and validity using a conrmatory factor analysis (Hair et al., 1998). Results An initial analysis indicated inadequate t indices with coefcients lower than 0.5 (Kline, 1998). To adjust the model, it was removed eight variables and added nine covariances between the errors. After this, the nal model showed the appropriate t indices ( p , 0.05), following limits propose by Hair et al. (1998). With respect to the reliability of the construct, the extracted variance and reliability were above the limit suggested. At the same time, with Cronbachs Alpha, all the constructs obtained favorable rates above 0.7. The standard deviation was relatively low in all the cases and the z-test rejected the null hypothesis as all the indexes were above 1.96 ( p , 0.05). Table I shows the initial and nal t index of the model. As shown in Table I, the Chi-square remained signicant, even though the relationship of Chi-squared and degrees of freedom reached a value of 2.9 and below

Final analysis Index Chi-squared Degrees of freedom Probability level GFI Goodness-of-t CFI Comparative Fit Index NFI Normed Fit Index NNFI Non Normed Fit Index RMR Root Mean Square Residual RMSEA Root Mean Squared Error of Approximation Extracted variance Reliability Cronbachs Alpha Initial 1,256.831 132 0.00 0.719 0.761 0.711 0.768 0.063 0.142 0.96 0.63 0.911 Final 369.865 127 0.10 0.893 0.971 0.935 0.931 0.03 0.09 0.96 0.65 0.963

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Table I. Initial and nal index of t of the model of customer satisfaction

the limit considered acceptable by many authors (Kline, 1998; Hair et al., 1998). The other measures of absolute t (GFI, RMR, and RMSEA), as well as the comparative measures (CFI, NFI, and NNFI) were all within the desired range ( p , 0.05), indicating a good t of the model. Therefore, the removal of non-signicant relationships and the insertion of covariance led to a substantial improvement in the values of adjustment when compared to the original model proposed. The standard deviation and z-test were signicant ( p , 0.05) for both constructs. The integrated model is shown in Figure 2. Discussion of ndings Based on the results observed in the integrated model, all the hypotheses stated in this study were conrmed as true ( p , 0.05). The estimation of the theoretical model was based on the standardized coefcients (beta) of the structural equation modeling, following recommendation of Kline (1998). Looking for a more precise model analysis, the degree of linear dependence between the variables was evaluated using the Pearson Product-Moment Correlation Coefcient (or Pearson r). After this, it was possible detect different effects. While H1 showed a moderately positive effect, H2 and H3 displayed a weak positive effect and in both H4 and H5, a strong positive effect was observed. Table II gives the details of the hypothesis tests. By analyzing each hypothesis, it was possible to conclude that drug prescription is moderately impacted by the cost-benet ratio of a drug. These ndings corroborate only in part the thesis provided by Kim and King (2009) who suggested that the cost-benet ratio of a drug should be subject to the contingent factors of the prescription. Surprisingly, Brazilian physicians are more concerned with the prescribed compound than with the product price. This result contradicts previous studies (Rizzo, 1999; Stros et al., 2009) in which doctors were chiey concerned about the price of the medicine. The hypothesis that drug prescriptions are impacted by the characteristic of a drug was also conrmed albeit with a weak relation. Previous studies ( Joseph et al., 2008; Kim and King, 2009) argue that the prescription of drugs may involve different perspectives, especially with regards to the product characteristics. Yet, among the sample set of Brazilian doctors analyzed, this construct did not prove to be the most

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Figure 2. Final model of drug prescription

Hypotheses 0,565 0,496 0,513 0,657 0,783 0,735 0,663 0,601 0,781 0,723 0,682 0,535 0,432 0,312 0,248 0,234 0,735 0,352 0,319 0,243 0,277 0,678 0,456 0,441 0,181

Standardized coefcients (b) R Positive Positive Positive Positive Positive

Rsquare

Adjusted Rsquare

Std. error of the estimate

Observed Hypothetical effect effect Moderate positive Weak positive Weak positive Strong positive Strong positive

H1: Drug prescriptions are impacted by the cost/benet ratio of a drug H2: Drug prescriptions are impacted by the characteristic of a drug H3: Drug prescriptions are impacted by the information available on a drug H4: Drug prescriptions are impacted by the brand of a drug H5: Drug prescriptions are impacted by the advertising related to a drug

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Table II. Hypotheses tested in the model

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relevant. This was due to the fact that well-known and well-established brands are rarely exchanged for generic or similar options. These alternatives are comparatively newer, having been in the market for little over ten years. Representing just 20 percent of the prescription drugs market, they have not yet been assimilated into the local medical culture (Interfarma, 2011). The ndings of this study also support, but with a weak relation, the hypothesis that addresses the relationship between the prescription of a drug and the information available on it. The established theoretical basis for such a relation (Kim and King, 2009; Fogel and Novick, 2009) stipulates that product information interferes with the prescription. However, in this study, the amount and quality of the available information does not exercise a strong inuence. One possible explanation for this phenomenon may be the constant launching of new products by the pharmaceutical industry, making it hard for the doctors to actualize them. Another possible explanation could be a failure to access the information provided by laboratories. Personal visits by sales people have been a strategy widely used by laboratories to relay their product information to physicians (Gonul et al., 2001). However, these occurrences should be carefully scheduled in terms of frequency, length of visits, and number of free samples given, to obtain an effective result (Stros et al., 2009). The results show that the brand of the product is the main aspect considered in the drug prescription. The hypothesis that drug prescriptions are impacted by the brand of a drug, presented a strong relation in the observed effect. This nding conrms another study ( Joseph et al., 2008) that made an argument for the power of branding in pharmaceutical products. To look at the phenomenon in the context of this analysis, pharmaceutical laboratories in Brazil are predominately multinational companies with strong commercial brands. Moreover, in the last few decades, the medicines market has consistently grown, in keeping with increasing corporate investments in brand strategy. Yet, despite the growth in demand, few laboratories command large market shares. Finally, the last hypothesis test showed that drug prescription is strong impacted by the advertising related to a drug. This nding supports the argument that the proliferation of advertising media available affect the process of drug prescription (Kess et al., 2008; Delorme et al., 2009; Limbu and Torres, 2009; Chen and Carroll, 2007). In addition, this result demonstrates the success of advertising strategies used by pharmaceutical companies. In the Brazilian pharmaceutical market, pharmaceutical companies have used the personal salesmans visit as an effective advertising tool. The close relationship between doctor and seller tends to be more direct under such a premise directly resulting in a higher inuence on the doctor at the time of prescribing medication. In addition, fringe benets such as travels offers made available to the doctors have shown to possess strong persuasive powers in promoting pharmaceutical products. In light of these revealing results, the analysis of the various factors inuencing medical prescription in Brazil has proved to be important in the evolution of marketing studies in an emergent pharmaceutical industry. The relationship between the doctors or pharmacists and the medical laboratories in Brazil has specic peculiarities. The size and growth of the Brazilian medicine market give it a unique character that needs to be carefully considered by international pharmaceutical companies interested in investing in Brazil. The establishment of durable and reliable relationships with the key actor in the drug prescription, the doctor, must be fundamental to a successful marketing strategy in Brazil. The pharmaceutical companies could spend millions of

dollars in advertising a drug but even such large investments would fail without the support of the prescribing doctors (Reynolds, 1992; Delorme et al., 2010). Therefore, sound knowledge of the factors that have an impact on the prescription of a drug is an especially important key to understanding the pharmaceutical market in Brazil. This study provided a broad map for understanding the factors inuencing medical drug prescription in Brazil. Among the ve factors analyzed, branding and advertising were observed to have the greatest inuence on the decision to prescribe a specic medicine. Despite existing research that proposed that the behavior of the end user was impacted by the price and the characteristic of the product (Delorme et al., 2010), the results of this study prove that, in the Brazilian context, branding and advertising are the major inuences on the prescriber. Thus, these results show the success of a specic application of advertising tools and brand construction in developing marketing strategies that focus on the medicine prescribers. However, in addition to the discussed contributions, the results also demonstrate limitated reexibility during medical practice. Practical factors such as the cost of the product remain relevant in a context where 30 percent of the population of Brazil have limited access to medicine (Interfarma, 2011). Similarly, while the product characteristics and information remains of great importance in a dynamic industry with constant innovations (Roberts, 1999), they show less inuence than factors such as brand and advertising. From this perspective, these results can be used to guide medical practice to change in favor of using more practical sources of information when selecting a medicine for prescription. Conclusions and implications for future work This study aimed at analyzing the functional relationships between the factors related to the prescription of medicines by doctors and pharmacists in Brazil. After formulating a theoretical base, focused on studies correlating drug prescription and marketing, the following factors were put forward as being inherent in prescribing drugs: the cost-benet ratio, product characteristics, product information, branding, and advertising. These factors were later grouped in the tested model. The ve tested hypotheses were conrmed, albeit with differences in their degrees of the relationships. Thus, we concluded that (H1) the cost-benet ratio of a drug has a moderate positive effect on drug prescriptions; (H2) drug prescriptions are impacted, with a weak positive effect, by the characteristic of a drug; (H3) the information available on a drug has a weak positive effect on the prescription of a drug; (H4) drug prescription are strongly impacted by the brand of a drug; and (H5) drug prescriptions are impacted by the advertising related to the drug with a strong positive effect. Based on the theoretical and empirical evidence, these results provide an applied model containing the different forces of the factors in the impact of drug prescription. In addition, the integrated model provides a unied understanding of the functional relationships between factors related to medical prescriptions. Previous studies (Rizzo, 1999; Miao-Sheng and Yu-Ti, 2008; Diehl et al., 2008; Dao, 1984; Berndt et al., 1997; Kim and King, 2009; Fogel and Novick, 2009; Hollon, 1999; Gonul et al., 2001; Bond and Lean, 1977) have found these factors in an isolated manner; the integrated model tested the possibility of a deeper understanding of the drug prescription process in Brazil. This research reinforces the importance of the doctor in the decision-making process of prescribing medicines. In this type of consumption, the decision-making process

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occurs in a disconnected manner between the prescriber and the user with the decision-making focused on the doctor prescribing the medicine. To know how the doctor nally selects a specic medicine for prescription would provide essential inputs that could help guide the marketing strategies of pharmaceutical industries. By identifying biases and limitations in the information sources accessed before the drug prescription, this also provides an insight to the medical practice as a whole. To extend the applicability of these factors, additional analyses could focus in other cases where the doctors make other decisions, as the prescription of medical procedures and diagnostics. To know the decision-making process of physicians would impact not only the conduct of marketing activities directed at them, but also the relationship between the doctor and patient and consequently, the service evaluation. Today, consumers are better educated about their medical options, with an unprecedented access to health information provided largely by the internet (Baker et al., 2003). There has also been a documented increase in consumer-directed prescription drug advertising (Kalyanaram, 2009; Delorme et al., 2009). This study reinforces the importance of understanding the factors behind drug prescription behavior, while indicating avenues for further research. A possible future research topic could be an interpretation of the drug prescription from the consumers perspective. Finally, further analyses need to be carried out to overcome the limitations of this study. The most signicant limitations are that the sample is not probabilistic and that the location is restricted to doctors practicing in Brazil. The Brazilian pharmaceutical market provides rich contexts to pharmaceutical studies, with local peculiarities and rapid growth, as it attempts to become a hotbed for pharmaceutical industry investments. Unlike other BRIC countries, like India and China, which have a large number of local generic-drug manufacturers and intense price competition, and Russia, where the government has a special plan to encourage the local pharmaceutical industry, the Brazilian market is formed basically by few multinational companies and limited local generic producers. This makes the study of the medical prescription process an obvious topic to be explored in the context of a pharmaceutical emerging market. This is especially due to the complex relationship between the doctor and patient, or client, as an exchange relationship in which the growth and power of the pharmaceutical industry and the increasingly frequent use of marketing tools in this environment play important roles.
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Appendix. Questionnaire

Construct

Variables

Strongly disagree 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Strongly agree 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Prescription practices in Brazil 277

Cost/benet ratio Drug price interferes with my prescription Patient incomes interfere with my prescription The existence of generic drugs interfere with my prescription Drugs that can be obtained without payment by governmental supports interfere with my prescription Patient history interferes with my prescription Relation cost/benet interferes on my prescription Age of the product in the market Characteristic interferes with my prescription Effect of drugs interaction interferes with my prescription New product development interferes with my prescription Product image interferes with my prescription Collateral effects interfere with my prescription Kind of product category interferes with my prescription Information Products with detailed explanations on available the label interfere with my prescription Products that have information available on the Internet interfere with my prescription Products that have information provided by personal sellers interfere with my prescription Products with information available in simple language for consumers interfere with my prescription Collateral effects mentioned in the packaging interfere with my prescription Suspicion of allergies interferes with my prescription Information about the product interferes with my prescription Knowledge about the laboratory Brand inuences my prescription New laboratories interfere with my prescription New brands interfere with my prescription

4 5 (continued)

Table AI.

IJPHM 5,4

Construct

Variables Experience of other physicians related to a drug inuence my prescription Drug brand inuence my prescription Brand and laboratory interfere with my decision Promotion interferes with my prescription Complementary services offered by laboratories, such as events or sites, inuences my prescription Gifts and souvenirs accompanying the product inuence my prescription Free samples inuence my prescription Visit by personal seller inuence my prescription

Strongly disagree 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4

Strongly agree 5 5 5 5 5 5 5 5

278
Advertising

Table AI.

About the authors Wagner Junior Ladeira is a Professor of Marketing in the School of Business of the UNISINOS University of the Vale do Rio dos Sinos Brazil. Currently, Ladeira is a PhD Candidate in the Management School of the Federal University of Rio Grande do Sul Brazil. He received a Msc from Federal University of Rio Grande do Sul - Brazil (2006) and a BA from Federal University of Vicosa Brazil (2003). His research addresses quantitative research, marketing practices and technology management. He has published several articles in Brazilian journals. Wagner Junior Ladeira is the corresponding author and can be contacted at: wjladeira@ea.ufrgs.br Marlon Dalmoro is a PhD Candidate in the Management School of the Federal University of Rio Grande do Sul Brazil. He earned a MSc in Administration from Federal University of Santa Maria Brazil (2009). He has been visiting scholar at EDHEC Business School France. His current research interests include consumer behavior and international marketing. His research appears in numerous academic outlets including Advances in Consumer Research and Brazilian journals. Alisson Eduardo Maehler is Assistant Professor in the Management and Tourism Department of the Federal University of Pelotas Brazil. He is also PhD student in the Management School of the Federal University of Rio Grande do Sul Brazil. He was visiting scholar in the Technical University of Lisbon Portugal. He graduated in Business Administration (BA) from Federal University of Pelotas Brazil (2004) and holds a Master (MSc) in Administration from Federal University of Santa Maria Brazil (2005). His research addresses innovation and international strategy in multinational companies. Clecio Falcao Araujo is Research Assistant at Faculty of Technology SENACRS. Prior positions include several corporate works in large Brazilian companies. Currently, he is developing several researches in industrial marketing and strategy. He earned a technology degree in Marketing from Faculty of Technology SENACRS.

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