Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

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Currents in Pharmacy Teaching and Learning

journal homepage: www.elsevier.com/locate/cptl

Experiences in Teaching and Learning

Evaluation of first year student pharmacists’ perceptions of the

pharmaceutical industry
⁎
Bobby Jacob , Samuel Peasah
Mercer University College of Pharmacy, 3001 Mercer University Drive, Atlanta, GA, United States

AR TI CLE I NF O AB S T R A CT

Keywords: Background and purpose: There are a limited number of pedagogical studies evaluating student
Pharmaceutical industry pharmacists’ perceptions of the pharmaceutical industry. The objective of this two year pro-
Prescription drugs spective study was to evaluate changes in student pharmacists’ perceptions of the pharmaceutical
Student pharmacist industry during the first year of enrollment in the doctor of pharmacy curriculum.
Perception
Educational activity and setting: An online survey was developed and offered to all first-year
student pharmacists during the 2014 and 2015 Fall semesters prior to didactic instruction on the
pharmaceutical industry and then again at the end of the respective academic years. Descriptive
and inferential statistics were used to analyze the data.
Findings: A majority of students had a positive impression of the pharmaceutical industry in both
the fall (75%) and spring semesters (78%). Over the course of the year, significantly greater
numbers of student pharmacists reported favorable impressions of the pharmaceutical industry
with respect to research innovation, drug safety, and the provision of drug information. On the
other hand, findings suggest that many students remain skeptical regarding the benefits of pre-
scription medications relative to cost and there were significant increases in the number of
students who perceived pharmaceutical industry-based marketing practices to have a negative
impact on patients and society.
Discussion and summary: Didactic education may influence student pharmacists’ perceptions of
the pharmaceutical industry. Further research is warranted to evaluate the role of pharmacy
curricula and extra-curricular activities in influencing changes in student pharmacists’ percep-
tions and the potential implications of these changes to pharmacy practice.

Background and purpose

The pharmacy profession and the pharmaceutical industry share common public health interests in that both are involved in
improving the health of individual patients and the general public by promoting the effective use of prescription medications. In
2016, drug development activities by pharmaceutical manufacturers led to 21 novel prescription drug approvals by the United States
(US) Food and Drug Administration (FDA).1 Health policy discussions continue to place emphasis on evaluating the value of pre-
scription medications in order to promote clinically beneficial, cost-effective health outcomes. Pharmacists will continue to have
opportunities to contribute toward these clinical and economic improvements. While pharmacists may have limited direct contact
with pharmaceutical manufacturers, they do spend considerable time discussing prescription medications with patients and fellow
health care providers, and the profession depends on the pharmaceutical industry to provide products that have demonstrated
efficacy, safety, and value. Educational outcomes in pharmacy emphasize the need to develop pharmacists who are able to critically

⁎
Corresponding author.
E-mail addresses: Jacob_bc@mercer.edu (B. Jacob), Peasah_sk@mercer.edu (S. Peasah).

https://doi.org/10.1016/j.cptl.2018.01.005

1877-1297/ © 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Jacob, B., Currents in Pharmacy Teaching and Learning (2018),
https://doi.org/10.1016/j.cptl.2018.01.005
B. Jacob, S. Peasah Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

evaluate data regarding the benefits and risks associated with these newly marketed prescription medications and to effectively
communicate these findings for the purpose of positively influencing health outcomes for individuals and health systems.2 Pharmacy
curricular content addresses various aspects of the pharmacist's relationship with the pharmaceutical industry.
Several studies have evaluated medical students’ perceptions of the pharmaceutical industry with most being focused on mar-
keting practices.3–7 A search of the pharmacy pedagogical literature revealed that only a limited number of prospective studies have
evaluated student pharmacists’ perceptions of the pharmaceutical industry.8,9 Of these, none have evaluated changes in student
perceptions that occur during the course of enrollment in the doctor of pharmacy (PharmD) curriculum. Monaghan et al.8 conducted
a cross-sectional survey that included 53 student pharmacists and found low knowledge scores regarding pharmaceutical industry
marketing techniques and professional statements on ethical interactions with the pharmaceutical industry. In a separate study at a
single college of pharmacy, Naik et al.9 conducted a cross-sectional assessment regarding direct-to-consumer (DTC) advertising
involving 120 student pharmacists from the first, second, and third year. Students expressed an overall negative impression of DTC
advertising and the authors noted significant deficiencies in students’ knowledge regarding DTC advertising. Two published studies
have described the design and implementation of elective courses for student pharmacists related to the pharmaceutical industry, but
neither evaluated student pharmacists’ perceptions of the pharmaceutical industry.10,11
Many student pharmacists receive their first exposure to the role of the pharmaceutical industry in health care delivery during
first-year introductory courses in the PharmD program. Most, if not all, required didactic instruction specifically regarding the
pharmaceutical industry is provided during these courses. From a pharmacy educator perspective, this period of time is significant in
order to characterize early changes in students’ perceptions that may result from required curricular content and other factors. The
objective of this study was to evaluate changes in student pharmacists’ perceptions regarding a broad range of topics associated with
the pharmaceutical industry during enrollment in the first year of the PharmD program.

Educational activity and setting

This was a two year, prospective study of student perceptions on the pharmaceutical industry using an online survey. The setting
for the study was the college of pharmacy at a private university located in the southeastern US. First-year student pharmacists were
selected for this study since all required didactic instruction related to the pharmaceutical industry at the study institution was
provided during first-year introductory courses. The investigators wanted to specifically evaluate changes that occur during the first-
year of the program, given the concentration of required didactic curricular content. Specific didactic classroom sessions relevant to
pharmaceutical industry practices during the first-year of the program included discussions regarding the pharmacists’ role in in-
terpreting pharmaceutical industry based DTC advertising, phases of pre-clinical and clinical prescription drug development, roles for
pharmacists in the pharmaceutical industry, and evaluation of cost analysis models for prescription drug utilization. These didactic
lectures were offered during a required fall semester course on introduction to pharmacy and a required spring semester course which
discussed various elements of the US health care system including the role of pharmaceutical manufacturers, health care providers,
payers, and policy makers. The college offers elective didactic courses and advanced pharmacy practice experiences related to the
pharmaceutical industry; however, only second-, third-, and fourth-year student pharmacists are eligible for enrollment in these
courses. A number of factors can influence student pharmacists’ perceptions regarding the pharmaceutical industry. The premise of
this study was to look specifically at changes that occur among first-year student pharmacists as they experience the required didactic
components of the curriculum that directly address the pharmaceutical industry. Future studies are planned to evaluate changes that
occur over the entire course of enrollment in the PharmD program from admission to graduation.
The design for evaluation of student perceptions was based on a publically available 33-item survey developed by the Kaiser
Family Foundation and Harvard University School of Public Health to assess the general public's perceptions regarding the phar-
maceutical industry and prescription drugs.12 Faculty members modified several questions from this survey and developed several
additional questions to form a new five-point Likert scale survey instrument (strongly agree, agree, neither agree or disagree, dis-
agree, strongly disagree). There were a total of 85 items in the modified survey instrument. Positively and negatively worded
statements were included in the survey to minimize the risk of acquiescent response bias (tendency to agree with statements re-
gardless of the content). Questions were categorized into specific topical sections pertaining to student pharmacists’ perceptions
regarding the favorability and trustworthiness of the pharmaceutical industry, safety and costs associated with prescription drugs,
promotional advertising for prescription drugs, research and drug development, and governmental regulation of the pharmaceutical
industry. Additional questions were included to assess students’ understanding of specific roles and responsibilities of pharmacists
within the pharmaceutical industry, as well as types of drug information provided by the pharmaceutical industry. Furthermore, the
survey also included questions on student demographics, work history, and future career plans in the pharmaceutical industry. The
goal in developing this survey instrument was to create an assessment tool that allowed faculty to stimulate students’ thinking
regarding the pharmaceutical industry and to evaluate students’ perceptions regarding a broad range of topics related to pharma-
ceutical industry practices and prescription drug development and commercialization.
The survey was offered to two different cohorts of first-year student pharmacists at the beginning of the 2014 and 2015 Fall
semesters prior to students receiving any didactic curricular instruction related to the pharmaceutical industry. All first-year student
pharmacists were eligible to participate. The survey was prepared using a data collection and analysis software program designed by
Qualtrics® (Qualtrics® Lab, Provo, UT). Students received an electronic link to the survey and were given the first 20 min of class to
complete the survey during a class session on the drug development process (pre-survey). Twenty minutes was provided for com-
pletion of the survey based on previous experiences administering surveys related to the pharmaceutical industry. Students had an
additional 10 min to submit answers before the survey was closed out. The same survey was offered to these student pharmacists

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B. Jacob, S. Peasah Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

toward the end of the subsequent 2015 and 2016 Spring semesters during a required introductory course on health care delivery in
the US (post-survey). Participation in the study was voluntary and informed consent was obtained from all participants. Institutional
Review Board approval was obtained.
Demographics of the student respondents were summarized. The differences in students’ five-point Likert scale responses in the
fall and spring were analyzed using the sign test and the Wilcoxon signed-rank test. A p-value of less than 0.05 was considered
statistically significant. Additionally, for ease of presentation and interpretation, the five-point Likert scale was collapsed into a three-
point Likert scale where agree or strongly agree responses were grouped together (agreed with the statement), disagree or strongly
disagree responses were grouped together (disagreed with the statement), and neither agree or disagree responses were kept separate.
Results are presented as the percentage of students who agreed or strongly agreed with various statements related to the pharma-
ceutical industry during the pre-survey (Fall semester) and the post-survey (spring semester). SAS® software, version 9.3 (SAS® Inc.,
Cary, NC) was used for the analyses.

Findings

Survey administration was accomplished with relative ease given the use of class time. A total of 298 students participated at the
beginning of the Fall semesters (98% response rate) and 283 students participated toward the end of the Spring semesters (94%
response rate). There were 269 students (90% response rate) who completed both the pre-survey (Fall) and post-survey (Spring). The
entering student population was mostly female (61%), between the ages of 19 and 30 years (89%), and was born in the US or had
been living in the US for greater than 10 years (85%). Only five students (2%) reported prior work experience in the pharmaceutical
industry. Reported prior pharmacy work experience included retail pharmacy (63%) and hospital pharmacy (16%). Thirty percent of
students reported no prior pharmacy work experience. By the end of the Spring semester, there was an increase in the number of
student pharmacists who reported being confident in their understanding of the pharmaceutical industry (30% vs. 52%).
In general, overall favorability of the pharmaceutical industry remained high as shown in Table 1; however, by the end of the
Spring semester, nearly one in five students (n = 50) agreed or strongly agreed with the statement that prescription drugs have a
negligible impact on society, which was a change from baseline (12% vs. 19%). There were statistically significant shifts toward more
students finding the pharmaceutical industry to be a trustworthy and reliable source for prescription drug information. Despite these
improvements, significant numbers of student pharmacists remained skeptical about information that comes from the pharmaceutical
industry regarding product efficacy and safety, and some even questioned the industry's ethical standards as it relates to putting the
public's interest above theirs. As shown in Table 2, the percentage of students with confidence in prescription drug safety increased
from 61% to 77%; however, similar improvements were not seen regarding perceptions on the value of prescription medications
relative to their cost. While there was an increase in the number of students who agreed or strongly agreed that prescription drugs
reduce overall health care costs (55% vs. 70%), by the end of the Spring semester relatively few students believed that prescription
drug costs are reasonable (23%). Furthermore, the number of students who agreed or strongly agreed that the benefits of prescription
drugs justify the price that society must pay remained essentially unchanged.
The study found some significant changes in student pharmacists’ perceptions regarding prescription drug advertising as seen in
Table 3. There was an increase in the percentage of students who agreed or strongly agreed that DTC advertising encourages patients
to take unnecessary prescription medication (59% vs. 69%). In the Fall, 100 students agreed or strongly agreed with the statement
that DTC advertising was good for patients and society; however, by the end of the Spring semester slightly more than half of these
students had changed their opinion (29 students changed to disagree or strongly disagree and 22 students became neutral). On the
other hand, 70 students disagreed or strongly disagreed in the Fall with the statement that DTC advertising was good for patients and

Table 1
Perceptions on favorability and trustworthiness of the pharmaceutical industrya.

Statement Fall(n = Spring (n = 269)

269)

I have a favorable view of the pharmaceutical industry 75% 78%

Prescription drugs developed over the past 20 years have had a positive effect on society in the United Statesb 89% 93%
The impact of prescription drugs on our society is negligible 12% 19%
Pharmaceutical companies that research and develop new drugs make a greater contribution to society's welfare 55% 68%
compared to companies in other industriesb
Pharmaceutical companies are an example of bad business and health care practice in our society 11% 14%
Pharmaceutical companies are trustworthy in offering reliable information about the efficacy of their productsb 48% 55%
Pharmaceutical companies are trustworthy in offering reliable information about safety concerns and adverse side effects 54% 62%
related to their productsb
Pharmaceutical companies are trustworthy to develop new and effective prescription drugsb 65% 74%
Pharmaceutical companies are trustworthy to price their products fairlyb 19% 27%
Pharmaceutical companies are trustworthy to inform the public quickly when they learn of a safety concern with one of 49% 56%
their productsb

a
Students were asked to read the statements and indicate by a 5-point Likert scale if they strongly agreed, agreed, neither agreed or disagreed, disagreed, or strongly
disagreed. The table indicates the percentage of students that agreed or strongly agreed with the statement during the fall semester as compared to the spring semester.
b
P-value < 0.05 for change from Fall semester to Spring semester based on statistical analysis with sign test and/or sign ranked test using student responses’ to the
5-point Likert scale.

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B. Jacob, S. Peasah Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

Table 2
Perceptions on prescription drug safety and costsa.

Statement Fall (n = 269) Spring (n = 269)

b
I am confident that prescription drugs sold in the United States are safe 61% 77%
Pharmaceutical companies do not do enough to ensure the safety of prescription drugs 16% 17%
There should be more government regulation to ensure the safety of prescription drugsb 55% 45%
The cost of prescription drugs in the United States is reasonableb 20% 23%
Insurance companies should only pay for prescription drugs that have been proven to be more effective or safer than 34% 36%
existing available treatments
The government should only approve prescription drugs that have been proven to be more effective or safer than existing 52% 55%
available treatments
The benefits of prescription drugs justify the price society must pay for them 30% 29%
Prescription drugs do not reduce the need for expensive medical procedures and hospitalizationsb 36% 25%
In the long run, prescription drugs reduce health care costsb 55% 70%
There should be more government regulation on pricing of prescription drugs 62% 60%
Pharmaceutical companies do not do enough to help people who cannot afford their medication 55% 49%

a
Students were asked to read the statements and indicate by a 5-point Likert scale if they strongly agreed, agreed, neither agreed or disagreed, disagreed, or strongly
disagreed. The table indicates the percentage of students that agreed or strongly agreed with the statement during the fall semester as compared to the spring semester.
b
P-value < 0.05 for change from Fall semester to Spring semester based on statistical analysis with sign test and/or sign ranked test using student responses’ to the
5-point Likert scale.

Table 3
Perceptions on promotional advertisinga.

Statement Fall (n = Spring (n = 269)

269)

Direct to consumer advertising on the television and the Internet is good for patients and societyb 37% 32%
Pharmaceutical companies should not be allowed to market their products directly to consumers 35% 38%
There is not enough government regulation to ensure that prescription drug advertising is truthful and accurate 59% 57%
Prescription drug advertising does a good job of describing potential benefits of products 57% 55%
Prescription drug advertising does a good job of describing potential adverse side effects and safety considerations for 35% 34%
products
Prescription drug advertising does a good job of describing conditions or disease states that prescription drugs are used to 58% 58%
treat
Prescription drug advertising is usually inaccurate and misleading 30% 32%
Promotional advertising costs do not contribute to making prescription drugs too expensiveb 18% 17%
Advertising for prescription drugs encourages people to take medications they don’t needb 59% 69%
Prescription drug advertising educates people about valuable treatments and encourages them to seek medical attention 58% 59%
for conditions they might not be aware of
Pharmaceutical companies spend too much money on prescription drug advertising 54% 61%

a
Students were asked to read the statements and indicate by a 5-point Likert scale if they strongly agreed, agreed, neither agreed or disagreed, disagreed, or strongly
disagreed. The table indicates the percentage of students that agreed or strongly agreed with the statement during the fall semester as compared to the spring semester.
b
P-value < 0.05 for change from Fall semester to Spring semester based on statistical analysis with sign test and/or sign ranked test using student responses’ to the
5-point Likert scale.

society; however, close to half of these students changed their opinion by the end of the year (nine students changed to agree or
strongly agree and 23 students become neutral). Furthermore, over one-third of students expressed the view that pharmaceutical
companies should not be allowed to directly market products to patients (35% vs. 38%).

Discussion

This study adds to the limited pharmacy pedagogical literature on the pharmaceutical industry by evaluating changes in student
pharmacists’ perceptions of the pharmaceutical industry that occurred during the first year of enrollment in the PharmD curriculum.
The first year is significant since most, if not all, required didactic curricular instruction regarding the role of the pharmaceutical
industry in health care occurs during this year. Prior studies have been based on single cross-sectional data and were limited to
students’ perceptions related to promotional activities. This two year, pre-post prospective study examined students’ perceptions
regarding a broader range of issues related to the pharmaceutical industry including favorability and trustworthiness of the phar-
maceutical industry, safety and costs associated with prescription drugs, and marketing practices. Many of these aspects of phar-
maceutical industry practice have direct implications for pharmacists who are involved in patient care roles. The findings suggest that
pharmacy curricular content may have had an impact on the changes in students’ perceptions observed during the study period.
Other factors may have also influenced perceptions including students’ involvement in professional organizations, patient care ex-
periences, interaction with other students and health care practitioners, and exposure to media reporting on the pharmaceutical
industry during the first year of enrollment in the PharmD program.

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B. Jacob, S. Peasah Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

The results suggest that enrollment in pharmacy school does not diminish overall positive impressions of the pharmaceutical
industry. The most recent studies evaluating post-graduate practicing pharmacists are several years old; however, they found si-
milarly favorable perceptions toward the pharmaceutical industry.13,14 This contrasts with the most recent Gallup poll which found
that only 35% of the general American public had a positive impression of the pharmaceutical industry.15 At the same time, student
pharmacists reported concerns related to the societal value of prescription drugs and pharmaceutical industry-based drug information
practices, which may influence the interactions they have with other health care providers and patients regarding medication use.
Furthermore, the study revealed concerns regarding the potential negative impact of promotional advertising on patients and
medication utilization. At the beginning of the academic year, 181 first-year students disagreed or strongly disagreed with the
statement that prescription drugs make a negligible impact on society; a finding not unexpected given their pursuit of a career in
pharmacy practice. Interestingly, by the end of the spring semester one in five students had changed their opinion regarding the
impact of prescription drugs on society. This is a significant shift in opinion. Further research is warranted to determine the basis for
students’ changing impressions, potential implications for patient care, and if curricular content has any direct impact on influencing
perceptions.
While this study suggests improvements in students’ perception of the trustworthiness and reliability of the pharmaceutical
industry, a large segment of student pharmacists was skeptical of the pharmaceutical industry as a reliable source for drug in-
formation. Pharmaceutical manufacturers remain highly active players in generating and distributing product information to health
care providers and policy decision makers in the form of sales material, formulary dossiers, and medical responses to drug in-
formation inquiries. In the course of their academic career, student pharmacists are trained to rely on peer-reviewed, tertiary and
primary literature to guide drug therapy recommendations that align with evidence-based medicine. Recent studies have demon-
strated that evidence-based medicine is poorly adhered to in many at-risk populations who have close interactions with pharmacists
such as those with history of myocardial infarction or heart failure.16–18 Student pharmacists increasingly interact with industry-
based personnel regarding prescription drug options and they may participate in components of the clinical and economic reviews of
newly approved prescription drugs. Skepticism toward pharmaceutical industry-facilitated drug information may have potential
implications related to patient care recommendations that are made in practice settings and may influence specific policies related to
medication use in diverse health systems. Studies have not extensively evaluated the relationship between pharmacy practice and the
pharmaceutical industry as it relates to medical decision-making regarding prescription drug use. Further research is warranted to
determine the factors that underpin these findings and to determine if student pharmacists view the pharmaceutical industry as
reliable partners in the pharmacy profession's goal of protecting and improving public welfare.
Historically, pharmaceutical manufacturers and many health care providers have viewed regulatory approval, based on Phase 3
efficacy and safety studies, as the primary hurdle for gaining entrance into the health care market for prescription medications. That
hurdle appears to be more enhanced in today's health care environment due to the increased regulatory and payer attention placed on
cost-effectiveness and comparative effectiveness research. Private and public insurers of health care increasingly expect to receive
and evaluate data that provides compelling clinical and economic arguments to support utilization of specific prescription medi-
cations. This study reflects the challenge for pharmaceutical manufacturers and health care providers by demonstrating that while
most students acknowledge that prescription drugs have the potential to minimize long-term health care costs, many question
whether prescription medications provide enough value to justify the cost paid by individuals and society as a whole. Further
research would be beneficial to explore the relationship between student pharmacists’ perception of the value of prescription
medications, economic costs, and practice guidelines for the management of various acute and chronic medical conditions. Pharmacy
curricular emphasis should continue to focus on providing students with the competencies required to objectively and critically
evaluate the overall healthcare cost implications of medication therapies.
Health care providers, including practicing pharmacists, have expressed mixed views regarding the potential benefits and harms
of prescription drug DTC advertising.13,14,19–21 Promotional advertisements have become an important component of marketing
strategies and the FDA devotes significant resources to regulate these activities. Limited knowledge regarding regulatory practices
may influence students’ negative views on pharmaceutical industry-based marketing practices. This study corroborates findings from
previous pedagogical literature suggesting students’ have a negative view toward DTC advertising, but additionally suggests that
these student pharmacists viewed DTC advertising as potentially counteracting their efforts to promote the best medication utili-
zation for patients. Pharmacy educators may be able to explore opportunities to encourage discussion among students in balancing
companies’ rights of free expression, access to medical and drug information, patient unfamiliarity with complex medical topics, and
the need to optimize prescription drug use in a manner that promotes improved clinical outcomes and cost benefits.
This study evaluated students from only one institution and did not include knowledge-based questions. However, unlike previous
research this study includes a relatively high response rate, most likely due to the fact that class time was provided for completing the
survey. Another limitation of this study is that student pharmacists’ perceptions regarding the pharmaceutical industry are likely to
continuously evolve during the second, third, and fourth years of the program as students participate in direct patient care ex-
periences and elective components of the curriculum. Furthermore, perceptions are likely to be further influenced by a variety of
factors including student pharmacists’ interactions with health care providers in the clinical setting, interactions with representatives
of the pharmaceutical industry at professional and medical meetings, and exposure to media reporting on the pharmaceutical in-
dustry. This study was designed as part of a longitudinal study; therefore, future research will allow for several years of data to be
analyzed. There may be value in examining responses from students at multiple geographic locations and to evaluate changes in
perceptions that occur from admission to graduation.

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B. Jacob, S. Peasah Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

Summary

There was an increase in the number of first-year student pharmacists who reported favorable views of the pharmaceutical
industry particularly as it relates to contributions to health care, innovation, drug safety, and drug information; however, students
also expressed skepticism regarding the value of prescription medications relative to cost and concern regarding the potential ne-
gative impact of promotional advertising. First-year didactic instruction may influence students’ perceptions of a broad range of
topics associated with pharmaceutical industry practices and prescription drugs. Educators should be aware of these potential in-
fluences as they develop curricular content that addresses the relationship between pharmacy practice and pharmaceutical manu-
facturers. Further research is warranted to determine the role of pharmacy curricula and extra-curricular factors on influencing these
changes and the potential implications on student pharmacists’ interactions with health care providers and patients as it relates to
optimization of prescription drug therapy.

Conflicts of interest

The authors report no conflicts of interest.

Financial disclosures

The authors report no financial conflicts of interest.

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