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• Filters and Narrowing Searches

Searching PubMed: Filters and Narrowing Searches

Created by health science librarians.

• Basic Searches

PubMed Field Tags

Use filters to focus the search, article types, clinical queries.

• Find Full-Text Articles
• Save Search Results
• Saving Searches & Creating Alerts
• My NCBI Accounts
• Literature Reviews

You can use field tags in PubMed to limit your search to only the specified fields of the citations. For instance, you can add a title field tag and only search for a word or words in article titles. Without field tags, PubMed defaults to searching every field of a citation. This means you're searching the article title, abstract/summary, author-supplied keywords, PubMed indexing terms, and other fields like author names, authors' institutions, journal names, etc.

If your search seems to have too many irrelevant results, using field tags can help narrow your search. To use field tags, add the code in brackets immediately following the search term. For instance, to only search for dogs in the titles of articles, you'd search for dogs[TI] in PubMed.

A list of common field tags is below: 

• Learn more about PubMed Field Tags

Use the filter options available in the left sidebar of the search results page to focus the search.

Important : The "Free full text" filter does not include UNC-CH journals subscriptions. The "Full text" filter is not an accurate limit to UNC-CH journal subscriptions. Use the Find @ UNC button to find full-text articles.

Show Additional Filters

The default list of filter categories in the left hand sidebar does not include all options. Click on the link labeled "Choose additional filters" to add categories to the list. Filters are available to focus your search results by article types, text availability, publication dates, species, languages, sex, subjects, journal categories, ages, and search fields. Click on the boxes to activate the filters. For more filter options click on the additional filters option.

Type of Article, Species, Sex, and Ages filters are based on terms added by indexers. When these filters are selected they remove very recent articles that have not yet been indexed. Always look at the most recent search results before adding these filters.

Activated Filters Display on Search Result Pages.  Filters stay selected during the current search session until you change or clear them.

Once the filters are selected on the above screenshot they appear as boxes on the left hand of the screen on the results page. Tick those boxes to show the changes in the search results.

Go to PubMed Help to learn more about using filters. 

Research Study Filters

Add options to the "Article types" list by clicking on the "Additional Filters" link on the left of search result screen and selecting ones you want to use.

Therapy, intervention, and prevention search results can be limited to articles reporting clinical research by selecting Clinical Trial, Meta-Analysis, Randomized Control Trial or Systematic Reviews from the "Articles types" list.       

You can then select the filter you want. Following that check the left hand box to have it appear in the search results.

• Clinical Trial : "Work that is the report of a pre-planned clinical study of the safety, efficacy, or optimum dosage schedule of one or more diagnostic, therapeutic, or prophylactic drugs, devices, or techniques in humans."
• Meta-Analysis : "Works consisting of studies using a quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate therapeutic effectiveness, plan new studies, etc. It is often an overview of clinical trials."
• Randomized Control Trial : "Work consisting of a clinical trial that involves at least one test treatment and one control treatment, concurrent enrollment and follow-up of the test- and control-treated groups, and in which the treatments to be administered are selected by a random process, such as the use of a random-numbers table."
• Systematic Reviews --retrieves "citations identified as systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine, consensus development conferences, guidelines, and citations to articles from journals specializing in review studies of value to clinicians." Systematic Review Filter Search Strategy

Other Research Article Type Filters

• Comparative Study --"comparison of outcomes, results, responses, etc for different techniques, therapeutic approaches or other inputs."
• Evaluation Studies --"studies determining the effectiveness or utility of processes, personnel, and equipment."
• Research Support , ...--"organizational source for funding of research activity"

Quoted definitions are from the PubMed MeSH Browser

Clinical queries makes it easy to find research-based articles in Pubmed.   Click on "Clinical Queries" from Pubmed homepage.

Enter a search term/search terms in the box.  Click the Search button.

Clinical Study Categories displays results by diagnosis,etiology, therapy,etc. Use the drop-down menus to change the category or scope.  Select a Category: Therapy, Diagnosis, Etiology, Prognosis, or Clinical prediction guides.  Then, select a Scope: Narrow (specific search) or Broad (sensitive search).

Systematic Reviews displays citations identified as systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine, and/or guidelines.

Medical Genetics displays citations focused on diagnosis, management, genetic counseling, and related topics.

• << Previous: Basic Searches
• Next: Find Full-Text Articles >>
• Last Updated: Aug 13, 2024 11:48 AM
• URL: https://guides.lib.unc.edu/search-pubmed

Literature Searching

In this guide.

• Introduction
• Steps for searching the literature in PubMed
• Step 1 - Formulate a search question
• Step 2- Identify primary concepts and gather synonyms
• Step 3 - Locate subject headings (MeSH)
• Step 4 - Combine concepts using Boolean operators
• Step 5 - Refine search terms and search in PubMed
• Step 6 - Apply limits

Steps for Searching the Literature

Searching is an iterative process and often requires re-evaluation and testing by adding or changing keywords and the ways they relate to each other. To guide your search development, you can follow the search steps below. For more information on each step, navigate to its matching tab on the right menu. 

1. Formulate a clear, well-defined, answerable search question

Generally, the basic literature search process begins with formulating a clear, well-defined research question. Asking the right research question is essential to creating an effective search. Your research question(s) must be well-defined and answerable. If the question is too broad, your search will yield more information than you can possibly look through.

2. Identify primary concepts and gather synonyms

Your research question will also help identify the primary search concepts. This will allow you to think about how you want the concepts to relate to each other. Since different authors use different terminology to refer to the same concept, you will need to gather synonyms and all the ways authors might express them. However, it is important to balance the terms so that the synonyms do not go beyond the scope of how you've defined them.

3. Locate subject headings (MeSH)

Subject databases like PubMed use 'controlled vocabularies' made up of subject headings that are preassigned to indexed articles that share a similar topic. These subject headings are organized hierarchically within a family tree of broader and narrower concepts. In PubMed and MEDLINE, the subject headings are called Medical Subject Headings (MeSH). By including MeSH terms in your search, you will not have to think about word variations, word endings, plural or singular forms, or synonyms. Some topics or concepts may even have more than one appropriate MeSH term. There are also times when a topic or concept may not have a MeSH term. 

4. Combine concepts using Boolean operators AND/OR

Once you have identified your search concepts, synonyms, and MeSH terms, you'll need to put them together using nesting and Boolean operators (e.g. AND, OR, NOT). Nesting uses parentheses to put search terms into groups. Boolean operators are used to combine similar and different concepts into one query. 

5. Refine search terms and search in PubMed

There are various database search tactics you can use, such as field tags to limit the search to certain fields, quotation marks for phrase searching, and proximity operators to search a number of spaces between terms to refine your search terms. The constructed search string is ready to be pasted into PubMed. 

6. Apply limits (optional)

If you're getting too many results, you can further refine your search results by using limits on the left box of the results page. Limits allow you to narrow your search by a number of facets such as year, journal name, article type, language, age, etc. 

Depending on the nature of the literature review, the complexity and comprehensiveness of the search strategies and the choice of databases can be different. Please contact the Lane Librarians if you have any questions. 

The type of information you gather is influenced by the type of information source or database you select to search. Bibliographic databases contain references to published literature, such as journal articles, conference abstracts, books, reports, government and legal publications, and patents. Literature reviews typically synthesis indexed, peer-reviewed articles (i.e. works that generally represent the latest original research and have undergone rigorous expert screening before publication), and gray literature (i.e. materials not formally published by commercial publishers or peer-reviewed journals). PubMed offers a breadth of health sciences literature and is a good starting point to locate journal articles.

What is PubMed?

PubMed is a free search engine accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. Available to the public online since 1996, PubMed was developed and is maintained by the  National Center for Biotechnology Information (NCBI) , at the  U.S. National Library of Medicine (NLM) , located at the  National Institutes of Health (NIH) .

MEDLINE is the National Library of Medicine’s (NLM) premier bibliographic database that contains more than 27 million references to journal articles from more than 5,200 worldwide journals in life sciences with a concentration on biomedicine. The Literature Selection Technica Review Committee (LSTRC) reviews and selects journals for MEDLINE based on the research quality and impact of the journals. A distinctive feature of MEDLINE is that the records are indexed with NLM  Medical Subject Headings  (MeSH).

PubMed also contains citations for  PubMed Central (PMC)  articles. PMC is a full-text archive that includes articles from journals reviewed and selected by NLM for archiving (current and historical), as well as individual articles collected for archiving in compliance with funder policies.  PubMed allows users to search keywords in the bibliographic data, but not the full text of the PMC articles.

How to Access PubMed?

To access PubMed, go to the Lane Library homepage and click PubMed in "Top Resources" on the left. This PubMed link is coded with Find Fulltext @ Lane Library Stanford that links you to Lane's full-text articles online. 

• << Previous: Introduction
• Next: Step 1 - Formulate a search question >>
• Last Updated: Jul 10, 2024 2:17 PM
• URL: https://laneguides.stanford.edu/LitSearch

• Expert Searching
• Literature Searching Services
• Literature Review Process
• Formulating Your Research Question
• Which Databases to Use
• Choosing Search Terms
• Combining Search Terms
• Finding Spelling Variations
• Search by Parts of a Citation
• Limiting a Search with Filters
• Saving Your Search
• Finding Related Articles
• Systematic Reviews
• Searching with Google
• Other Types of Reviews
• PubMed Search Tips

1. When to Use PubMed

2. pubmed cool tools, 3. how to use mesh: medical subject headings, 4. how to use keywords, 5. pubmed pro tips, 6. combining search terms and concepts, 7. saving your searches, 8. pdf printable handout, 9. pubmed practice, 10. more information.

• Embase Search Tips
• Cochrane Search Tips
• More Welch Guides

New PubMed Video

Accessing Full Text

Find it @ jh.

In most databases, the FIND IT icon will often appear within an item record. Clicking the FIND IT icon will take you to a catalog page showing a list of full-text options.

You can also search FIND IT directly.

Interlibrary Loan

If the full-text is not available, you will see a heading that says, "Request a copy from Interlibrary Loan." Click on "Welch Medical Library Borrowers" link to request the article free of charge (available for Hopkins affiliates).

You can also submit an Interlibrary Loan request manually.

• New PubMed FAQs and User Guide
• New PubMed: Highlights for Information Professionals
• New PubMed: Trainer's Toolkit
• When to Use PubMed
• PubMed Cool Tools
• How to Use Medical Subject Headings
• How to Use Keywords
• PubMed Pro Tips
• How to Combine Search Terms and Concepts
• How to Save Your Searches
• Printable PDF Handout
• PubMed Practice
• More Information
• Access PubMed (Hopkins affiliates)
• Access PubMed (non-Hopkins affiliates)

PubMed is a platform that indexes journal articles and more back to 1947. It covers the areas of medicine, nursing, dentistry, veterinary medicine, health care systems, preclinical sciences, and related areas. PubMed is developed and maintained by the National Library of Medicine (NLM) and the National Center for Biotechnology Information (NCBI), both at the National Institutes of Health (NIH) in Bethesda, MD. As of December 2020, PubMed contains over 30 million records. PubMed is a platform that contains MEDLINE, PubMed Central, and additional PubMed records.

Clinical Queries

Use Clinical Queries to enable pre-made filters applying to different clinical research areas. Results are delineated into clinical studies, systematic reviews, and medical genetics. Enter your search exactly as you would in the PubMed search box.

For more information, see:

• Documentation on the Clinical Studies filters
• Documentation on the Medical Genetics filters
• Documentation on the COVID-19 filters

Journals in NCBI Databases

Use Journals in NCBI Databases to limit your search to a specific journal or to find out more information about journals indexed in MEDLINE. text

Single Citation Matcher

Use the Single Citation Matcher to find citations in PubMed. You may enter or omit any field.

Special Queries

Searchers at the National Library of Medicine have created search filters for multiple common topics. See and enable them on the PubMed Special Queries page .

Controlled Vocabulary: MeSH

• MeSH Database
• NLM's MeSH Tutorial
• MeSH stands for Medical Subject Headings . It is a controlled vocabulary of terms assigned to records to make them discoverable.
• These are a standardized set of terms that are used to bring consistency to the searching process. In total, there are approximately 29,000 MeSH terms , and they are updated annually to reflect changes in terminology.
• Use the MeSH database to identify Medical Subject Headings (MeSH) which will help you to find literature indexed with the MeSH term.
• Using MeSH terms helps account for variations in language, acronyms, and British vs. American English.
• MeSH can be searched from the MeSH Database
• Terms are arranged hierarchically by subject categories with more specific terms arranged beneath broader terms. MeSH terms in PubMed automatically include the more specific MeSH terms in a search. This is called "explode."
• To turn off this automatic explode feature, click on the button next to, "Do not include MeSH terms found below this term in the MeSH hierarchy" in the MeSH record or type [mesh:noexp] next to the search term, e.g. neoplasms [mesh:noexp] . See next page for additional information on no explode.
• Use the PubMed Search Builder on the right side of the screen to add your selected MeSH term to the box, and click Search.

Explode, No Explode, and Major Heading

• Explode will search with all narrower headings beneath the main heading you have chosen. PubMed will default to explode any MeSH term you search.
• No Explode will only search for your chosen MeSH term without including any of the narrower headings in the MeSH hierarchy. You can select this option from the MeSH record.
• Major Heading will narrow your search to only find MeSH terms listed as a major topic of an article. You can select this option from the MeSH record. Major headings are shown in the article record with an asterisk.

Subheadings

MeSH terms can be made more specific by the addition of correlated or free-floating subheadings .

• When in the MeSH record, add subheadings by clicking on the boxes next to the desired subheadings. Then click "Add to Search Builder." Warning: Adding too many subheadings may lead to missing important articles.
• MeSH/Subheading Combinations: You can manually add subheadings in the search box by using the format MeSH Term/Subheading, e.g. neoplasms/diet therapy . See abbreviations of MeSH subheadings, which can also be used. ( MeSH Subheadings ).
• For a MeSH/Subheading combination, only one subheading at a time may be directly attached to a MeSH term. For example, a search of Hypertension with the subheadings Diagnosis or Drug Therapy will appear as Hypertension/diagnosis [mesh] OR Hypertension/drug therapy[mesh] .
• As with MeSH terms, PubMed search results, by default, include the more specific terms arranged beneath broader terms for the MeSH term and also includes the more specific terms arranged beneath broader subheadings .

Automatic Term Mapping

• PubMed uses Automatic Term Mapping (ATM) when you enter terms in the search box.
• Automatic Term Mapping means that the search terms you type into the search box are automatically mapped to MeSH terms.
• To see Automatic Term Mapping in action, click on the Details arrow in your Advanced > History and Search Details box.
• Using quotes around a phrase or truncation turns off Automatic Term Mapping. The terms are instead searched exactly as entered, with no mapping applied.

Using Keywords

• Keywords can be any words used to describe your idea or concept.
• Keywords can be single words or phrases.
• Use quotes around all phrases to ensure that the phrase is searched together.
• For more ideas, visit the MeSH database and look at the entry terms listed in the MeSH record.
• Also consider using synonyms, acroynyms, initialisms, variations in spelling, and other closely-related terms used interchangeably to describe the topic.

Keyword Generation

Keywords can be generated by:

• browsing entry terms in PubMed's MeSH, and synonyms in Embase's Emtree to add additional keywords to a concept;
• looking at a few key articles and seeing how the terminology is used; and by
• doing a few preliminary searches and browsing the results to see how the terminology is used.

You can use filters to narrow your search results by article type, text availability, publication date, species, language, sex, subject, journal category, and age. See more on Filters on PubMed's Help guide .

• On the left side of the results are options to filter your search.
• You can access additional filters through the link at the bottom of the filters bar.
• "Text availability" is for users who are not affiliated with an institution. You do not need to limit by text availability since you have access to the JH Catalog and Interlibrary Loan.
• Use filters cautiously. Limits other than date or language will limit your search to MeSH-indexed records only.
• For example, if you would like to limit your results to "human studies," use the following search to exclude animal studies instead of using the "humans" limit from the search results page. Simply add this to the end of your search:

Phrase Searching

Surround phrases with double quotes to search as a phrase to use a more specific search with more precision, and not as disparate words, which will result in a more sensitive search with higher recall. See more on Phrase Searching on PubMed's Help guide.

In PubMed you can use a * at the root of a word to find multiple endings.  For example:

Note: In New PubMed, you can now truncate a phrase inside quotes. "catheter infection*" will return catheter infections. See more on on Truncation on PubMed's Help guide .

Use search field tags to specify in which field the database queries for the search term. In PubMed, first type the search term and then the search field tag in brackets. e.g. Cardiology [tiab] searches for cardiology in the title and abstract.

• [All Fields] or [all] – Untagged terms and terms tagged with [all fields] are processed using  Automatic Term Mapping . Terms enclosed in double quotes or truncated will be searched in all fields and not processed using automatic term mapping.
• [Text Words] or [tw] – Includes all words and numbers in the title, abstract, other abstract, MeSH terms, MeSH Subheadings, Publication Types, Substance Names, Personal Name as Subject, Corporate Author, Secondary Source, Comment/Correction Notes, and Other Terms.
• [Title/Abstract] or [tiab] – Words and numbers included in the title, collection title, abstract, and other abstract of a citation. English language abstracts are taken directly from the published article. If an article does not have a published abstract, NLM does not create one.
• NCBI explanation of Field Descriptions and Tags  

Boolean Operators

• A comprehensive search of PubMed will include both controlled vocabulary (MeSH) and keyword terms.
• Boolean operators are used to combine search terms. In PubMed, you can use the operators AND, OR, and NOT.
• Go to the  “Advanced Search” page  to combine searches. This is where your search history is located during your search session.
• Boolean operators MUST be used as upper case (AND, OR, NOT).
• OR —use OR between similar keywords, like synonyms, acronyms, and variations in spelling within the same idea or concept
• AND —use AND to link ideas and concepts where you want to see both ideas or concepts in your search results
• NOT —use to exclude specific keywords from the search; however, you will want to use NOT with caution because you may end up missing something important

To save searches and create alerts in PubMed, you must first create an account.

• Create an NCBI account* by clicking on the "log in" button in the upper-right corner of the screen (sign up for a My NCBI account ).
• Once you complete a search, click on Create alert underneath the search box. From here you can create a search alert or save your search strategy.

*NLM changed the way you need to log into NCBI in 2021.  Information and updates can be found in NCBI Insights.

• PubMed Searching Tips
• PubMed Tips 2020

If you would like to practice comprehensive searching in PubMed, use the links below to access PubMed, and the three worksheets to achieve steps within the search process. See also the National Library of Medicine's Training Module on Using PubMed in Evidence-Based Practice .

• More detailed information about MeSH vocabulary
• Use of MeSH in Online Retrieval
• PubMedTutorials
• PubMed YouTube Channel
• Open Educational Resource: PubMed in Evidence-Based Practice

Related Research Guides

• Systematic Reviews and Other Expert Reviews
• Citation Management
• << Previous: Database Tipsheets
• Next: Embase Search Tips >>
• Last Updated: Aug 20, 2024 12:02 PM
• URL: https://browse.welch.jhmi.edu/searching

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MEDLINE is the National Library of Medicine's (NLM) premier bibliographic database that contains references to journal articles in life sciences, with a concentration on biomedicine. See the MEDLINE Overview page for more information about MEDLINE.

MEDLINE content is searchable via PubMed and constitutes the primary component of PubMed, a literature database developed and maintained by the NLM National Center for Biotechnology Information (NCBI).

Last Reviewed: February 5, 2024

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Primary Research Article

Review article.

Identifying and creating an APA style citation for your bibliography: 

• Author initials are separated by a period
• Multiple authors are separated by commas and an ampersand (&)  
• Title format rules change depending on what is referenced
• Double check them for accuracy 

Identifying and creating an APA style in-text citation: 

• eg. (Smith, 2022) or (Smith & Stevens, 2022) 

The structure of this changes depending on whether a direct quote or parenthetical used:

Direct Quote: the citation must follow the quote directly and contain a page number after the date

eg. (Smith, 2022, p.21)

Parenthetical: the page number is not needed

For more information, take a look at Harvard Library's Citation Styles guide !

A primary research article typically contains the following section headings:

"Methods"/"Materials and Methods"/"Experimental Methods"(different journals title this section in different ways)

"Results"

"Discussion"

If you skim the article, you should find additional evidence that an experiment was conducted by the authors themselves.

Primary research articles provide a background on their subject by summarizing previously conducted research, this typically occurs only in the Introduction section of the article.

Review articles do not report new experiments. Rather, they attempt to provide a thorough review of a specific subject by assessing either all or the best available scholarly literature on that topic.

Ways to identify a review article: 

• Author(s) summarize and analyze previously published research 
• May focus on a specific research question, comparing and contrasting previously published research 
• Overview all of the research on a particular topic 
• Does not contain "methods" or "results" type sections
• << Previous: Scenarios in PubMed
• Last Updated: Oct 3, 2023 4:16 PM
• URL: https://guides.library.harvard.edu/PubMed

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The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

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Quantitative research

Affiliation.

• 1 Faculty of Health and Social Care, University of Hull, Hull, England.
• PMID: 25828021
• DOI: 10.7748/ns.29.31.44.e8681

This article describes the basic tenets of quantitative research. The concepts of dependent and independent variables are addressed and the concept of measurement and its associated issues, such as error, reliability and validity, are explored. Experiments and surveys – the principal research designs in quantitative research – are described and key features explained. The importance of the double-blind randomised controlled trial is emphasised, alongside the importance of longitudinal surveys, as opposed to cross-sectional surveys. Essential features of data storage are covered, with an emphasis on safe, anonymous storage. Finally, the article explores the analysis of quantitative data, considering what may be analysed and the main uses of statistics in analysis.

Keywords: Experiments; measurement; nursing research; quantitative research; reliability; surveys; validity.

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Finding Qualitative Research Articles

• General Strategies
• Grey Literature
• Other Resources

• Qualitative Research  [research that derives data from observation, interviews, or verbal interactions and focuses on the meanings and interpretations of the participants. Year introduced 2003]
• Interviews as Topic  [conversations with an individual or individuals held in order to obtain information about their background and other personal biographical data, their attitudes and opinions, etc. It includes school admission or job interviews. Year introduced: 2008 (1980)]
• Focus Groups  [a method of data collection and a qualitative research tool in which a small group of individuals are brought together and allowed to interact in a discussion of their opinions about topics, issues, or questions. Year introduced: 1993]
• Grounded Theory [The generation of theories from analysis of empirical data. Year introduced 2015]
• Nursing Methodology Research  [research carried out by nurses concerning techniques and methods to implement projects and to document information, including methods of interviewing patients, collecting data, and forming inferences. The concept includes exploration of methodological issues such as human subjectivity and human experience. Year introduced: 1991(1989)]
• Anecdotes as Topic  [brief accounts or narratives of an incident or event. Year introduced: 2008(1963)]
• Narration  [the act, process, or an instance of narrating, i.e., telling a story. In the context of MEDICINE or ETHICS, narration includes relating the particular and the personal in the life story of an individual. Year introduced: 2003]
• Video Recording  [the storing or preserving of video signals for television to be played back later via a transmitter or receiver. Recordings may be made on magnetic tape or discs (VIDEODISC RECORDING). Year introduced: 1984]
• Tape Recording  [recording of information on magnetic or punched paper tape. Year introduced: 1967(1964)]
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Pharmaceutical Drug Promotion and Rational Drug Use: Assessment of Healthcare Workers Perspective

Churchill akena.

1 Pharmacovigilance Department, Wide spectrum Enterprises (U) Limited, Kampala, Uganda

Musa Ssemanda

2 Department of Product Marketing, Wide spectrum Enterprises (U) Limited, Kampala, Uganda

Ahmed Hamed Saleh Abdelaziz

3 Executive Department, Wide spectrum Enterprises (U) Limited, Kampala, Uganda

Edson Ireeta Munanura

4 Department of Pharmacy, College of Health Science, Makerere University, Kampala, Uganda

Associated Data

The dataset for this project is available in an Excel sheet and will be provided upon request to the corresponding author, Churchill Akena.

Pharmaceutical drug promotion has the potential to improve rational drug use by creating awareness among healthcare workers and patients as well as increasing access to life-saving medicines. This study aimed to determine whether pharmaceutical drug promotion can improve rational drug use among healthcare workers.

Semi-structured questionnaires were filled by selected dispensers and prescribers in central Uganda. Forms of pharmaceutical drug promotion, sources of drug information, and views on the influence of drug promotion on rational drug use were investigated. Associations amongst selected variables were tested at bivariate and multivariate levels.

Of the 383 participants enrolled in the study, 49.6% were dispensers. More dispensers (49.0%, 92/188) favored 1 on 1 discussion whereas prescribers (32.0%, 61/191) preferred continuous medical education. Most dispensers (85.6%, 161/188) and prescribers (68.6%, 131/191) reported that drug promotion influences their choice of drug use, with most (dispensers: 85.1%, 160/188 vs prescribers: 72.3%, 1/191) admittedly relying on drug promotion as their primary source of drug information.

Pharmaceutical drug promotion influences prescription and dispensing practices among health workers, and it should be strictly regulated to ensure accurate and essential information for health workers while prioritizing rational use of medicines.

Introduction

Pharmaceutical drug promotion could, arguably, improve rational drug use by creating awareness among healthcare workers and patients and increasing access to life-saving medicines. 1 However, the profound unethical nature of the practice, the profit-driven motivation behind it, and the aggressive nature of its intensity have overshadowed the importance it has on information dissemination about medicines, medical conditions, and laboratory testing. 2 In the US, where direct-to-consumer promotion is practiced, some reports indicate the result being better-informed consumers of medical information. 3 Currently, pharmaceutical drug promotion is the industry’s greatest spending, with an estimated US$29.9b spent in 2016 on drug promotion activities, 2 , 4 and its estimated growth is 14% per year. 5

Far from the belief in the pharmaceutical industry that drug promotion provides health workers with educational and scientific information for better treatment practices, 6 it spurs outrageous returns on investment, driving huge profit margins for pharmaceutical investors. For context, a study found that pharmaceutical spending on drug promotion was twice that of Research and Design (R&D) for new medicines in the US, the world’s biggest pharmaceutical market. 7

Regulation regarding medicinal drug product promotion is still a big issue throughout the world. Pharmaceutical companies often treat regulatory requirements with contempt and are constantly lobbying for deregulation, even in countries where Direct-to-consumer advertising (DTCA) is widely practiced like the US and New Zealand. 5 In Uganda, all drug advertising materials – including medicine brochures, must be approved by the National Drug Authority (NDA) before use. The guideline for advertising NDA drugs specifies that promotional materials and approaches aimed at healthcare professionals should differ from those aimed at the general public. The guideline, however, does not address the use of pharmaceutical sales representatives, whose claims about a specific medicine may not align with the claims on the drug brochures and other promotional materials approved for use by the NDA. 8 The World Health Organization (WHO) has set regulatory precedence for national regulatory bodies to follow in regulating pharmaceutical drug promotion under their jurisdiction. According to these guidelines, the WHO defines drug promotion as all informational and persuasive activities by manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase and/or use of medicinal products. 9

Pharmaceutical drug promotion is a broad term used synonymously with drug marketing, which is defined as what an organization or firm usually should do to create and exchange values with customers. 10 Similarly, advertising is one of the approaches used in pharmaceutical drug promotion and it involves the publication of promotional literature in electronic or internet media. 11

Rational prescribing and dispensing have been identified as critical concerns in Uganda’s healthcare system. 12 , 13 Healthcare professionals in Uganda face numerous challenges that may undermine rational prescribing and dispensing practices. These include inadequate training, lack of access to up-to-date information on drugs, and inadequate resources to support proper dispensing of medicines and monitoring of patients. 14 One study at a community health center in western Uganda revealed that 74% of antibiotic prescriptions for children were irrational. 15 Similarly, a study assessing the overall rational drug use using WHO indicators at a teaching hospital revealed noncompliance in all areas; for example, 90.73% (WHO standard is 100%) of respondents reported noncompliance in recording prescriptions, and 61.88% (WHO standard is <30%) reported encountering antibiotics. 13 One of the consequences of irrational drug use is the high cost of treatment, as a study showed that as many as 94.3% of patients could not afford their prescribed antidiabetic medicines. 16

Lack of reliable information, poor healthcare worker training, and coercive marketing by pharmaceutical companies are identified as contributing factors to irrational drug use. 12 Furthermore, some studies suggest that the widespread use of drugs promotion by pharmaceutical companies may negatively influence prescribing behavior by doctors. 6 , 17 However, some studies refute this claim and instead counterclaim that drug promotion improves physicians’ knowledge, especially regarding recent medical advancements, leading to overall better decision-making for their patients. 18 Coupled with this, pharmaceutical drug promotions are ranked as important sources of information when prescribing by physicians. 19

This study aimed to determine the potential of drug promotional tactics for promoting rational drug use among health workers in Uganda, the different information and promotional strategies deployed by pharmaceutical companies, the influence of drug promotion on the sources of information prescribers and dispensers frequently use in decision-making and the factors influencing the opinion of health workers on the use of pharmaceutical drugs to improve rational drug use in Uganda were investigated.

Materials and Method

Study design.

This was a cross-sectional study carried out among selected prescribers and dispensers in medical outlets from October to November 2023 using a self-administered semi-structured questionnaire.

Study Setting

The study was carried out in medical outlets operating in the Kampala and Wakiso districts in Uganda. Kampala and Wakiso are located in central Uganda and have a combined population of at least 6.5 million inhabitants as of 2022. The medical outlets included both public and private medical centers, clinics, and hospitals licensed under the different health professionals’ councils; pharmacies; and “Class C” drug shops licensed by the National Drug Authority (Uganda). Class C drug shops are those licensed to sell over-the-counter (OTC) medicines without a prescription or pharmacist’s presence.

Inclusion Criteria

The inclusion criteria for the study were:

Healthcare workers of any specialty (nurses, midwives, pharmacists, physicians, surgeons, and others) aged 18 and above,

Healthcare workers practicing either as prescribers or dispensers at the time of the study,

Healthcare workers stationed in a medical outlet in the Wakiso or Kampala districts in central Uganda, and

Healthcare workers who consented to participate in the study.

Exclusion Criteria

Healthcare workers who practice in specialized clinics, such as Hypertension, Diabetes, and Ear Nose and Throat (ENT) clinics, where only a limited range of medicines are likely to be prescribed, were excluded from the study.

Data Collection

Multistage sampling was used to select the participants. The first stage involved city divisions with the Wakiso and Kampala metropolitan areas. The second stage involved health facilities within the selected divisions. Simple random sampling was used to select the study participants from the chosen healthcare facilities. Data were collected using a self-administered semi-structured questionnaire preprogrammed into the Kobo toolbox© data collection tool on a mobile device upon successful pretesting. Questions were generated based on the research objectives during questionnaire development. Further modifications were made following a pretest of the questionnaire in 30 volunteers selected purposely from hospitals and pharmacies. During data collection, questionnaires were completed by the participants in the presence of research assistants who were pharmacists and had prior experience in research data collection using semi-structured questionnaires. The semi-structured questionnaire collected the following information: demographic data, the different drug promotional strategies used by pharmaceutical companies, the sources of drug information healthcare workers are exposed to, and the views of healthcare workers on the impact of drug promotion on the rational use of medicines. For clarity purposes, novel or new drugs are those that have never been approved for use in Uganda before, while commonly used drugs are those that are widely recognized and have been used for some time in Uganda.

Independent Variables

Categorization of health care workers, dispensers, and prescribers.

Dependent Variables

• Forms of pharmaceutical drug promotion.
• Sources of drug information.
• Views of participants on the influence of drug promotion on rational drug use.

Data Analysis

The data analysis was performed using STATA version 18 software. The collected data were extracted from the Kobo toolbox website, downloaded into Microsoft Excel™ and cleaned. We then carried out bivariate analysis using a chi-square test for selected variables and a Poisson regression model for multivariate analysis to determine associations between the dependent and independent variables.

This study enrolled 383 participants, 55.4%) of whom were female, with the majority (66.6%) aged between 25 and 40 years. The highest proportion (42.3%) of the participants had a university degree, and the majority (48.9%) of the respondent dispensers were working in pharmacies. See Table 1 .

Background Characteristics of Participants (n=383)

Notes : The median age of the participants was 28.0 years (Q1–Q3; 26.0–32.0 years), and the mean age (SD) was 30.0 years ± 6.6 years. Others a include; laboratory technicians, procurement officers, and psychiatric nurses.

Pharmaceutical Sales Representatives (PSRs) were the most common form of drug promotion used by healthcare workers (dispensers: 93.1%; prescribers: 96.3%). See Table 2 . Dispensers and prescribers appeared to have similar proportions of individuals exposed to any given form of drug promotional practice. The least common form of drug promotional practice in either category of healthcare workers was clinical trials (dispensers: 11.2%; prescribers: 20.4%). However, there was a difference in the preference for drug promotional approaches between prescribers and dispensers. More dispensers preferred one-on-one discussions with PSRs (49.0%), whereas prescribers preferred continuing medical education (CME) (32.0%). In either category of healthcare workers, similar observations were made when interacting with PSRs. In either category, the PSRs spontaneously mentioned drug’s indication (dispensers: 97.9%; prescribers: 94.2%), drug’s dosage (dispensers: 92.0%; prescribers: 95.8%), drug’s interaction (dispensers: 27.1%; prescribers: 37.2%) and drug’s common adverse effects (dispensers: 32.4%; prescribers: 37.7%). In addition, most of the dispensers (78.7%) and prescribers (82.2%) did not have their questions about medical contraindications, precautions, or adverse effects of a drug marketed answered by the PSR. See Table 2 .

Drug Promotional Strategies for Health Care Workers in Uganda

Note : a Pharmaceutical sales representative, b Continuous medical education. *P value<0.01, **p value<0.001. For #, the p-value is greater than 0.05.

As Table 3 shows, the highest proportion of dispensers and prescribers use clinical guidelines as their main source of drug information. The second most commonly used source of drug information among both dispensers and prescribers was promotional material like drug information leaflets, drug brochures, etc (dispensers: 64.9%; prescribers: 62.8%). However, a greater proportion of dispensers (64.9%) tended to consult professional colleagues for drug information than did prescribers (55.0%), who tended to rely on medical journals and textbooks more than dispensers did (dispensers: 58.0%; prescribers: 61.8%).

Sources of Drug Information Among Healthcare Workers in Uganda

Notes : Others a includes WHO guidelines, Medscape, the Internet, and Wikipedia. *P value<0.01, **p value<0.001. For #, the p-value is greater than 0.05.

In the ranking of drug information sources, both dispensers and prescribers ranked medical journals as the best source of drug information for new or novel drugs (dispensers: 31.4%; prescribers: 45.5%). See Table 3 . Although pharmaceutical drug promotion was the second most preferred source of information for new drugs with dispensers (28.2%, 53/188), it was less preferred among prescribers (18.3%, 35/191). For the least ranked sources of drug information for commonly used or established (old) drugs, both dispensers (58.0%, 109/188) and prescribers (60.7%, 116/191) had the highest proportion of drugs choosing promotional materials. A greater proportion of dispensers (57.4%, 108/188) still considered promotional material to be a primary information source for commonly used drugs, although a minority of the prescribers (37.2%, 71/191) thought so. The majority of both dispensers (75.5%, 142/191) and prescribers (72.8%, 139/191) considered promotional material a primary information source for new drugs. However, this difference was not statistically significant (p=0.540).

In this study, the majority of dispensers (91%, 171/188) and prescribers (97.0%, 185/191) understood the concept of rational drug use, as shown in Table 4 . A greater proportion of healthcare workers in both categories believed that pharmaceutical drug promotion can improve rational drug use (dispensers: 77.1%; prescribers: 82.2%), although this difference was not statistically significant. However, most dispensers (85.6%) and prescribers (68.6%) reported that drug promotion influences their choice of drug use, with most admittedly relying on drug promotion as their primary source of drug information (dispensers: 85.1%; prescribers: 72.3%). For those who answered that drug promotion influences their choice of medicine, most of them chose pharmaceutical sales representatives (dispensers: 63.3%; prescribers: 53.4%) as their preferred form of drug promotion. The same proportion of dispensers and prescribers also indicated that pharmaceutical drug promotion (dispensers; 81.4% vs prescribers; 74.8%) makes drug choice more rational. However, the majority of them admitted that they only dispensed or prescribed the promoted medicine after consulting with the drug literature first (dispensers: 46.2%; prescribers: 72.7%). See Table 4 .

Views of Healthcare Workers on the Impact of Drug Promotion on Rational Drug Use

Notes : Characteristics—the preferred form of drug promotion; if drug promotion makes drug choice more rational; and if a health worker prescribed/dispensed a marketed medicine category—were analyzed for those who indicated that their choice of medicine is influenced by drug promotion (dispensers; 162 and prescribers; 131). *P value<0.01, **p value<0.001. For #, the p-value is greater than 0.05.

Among prescribers, promotional materials were chosen 0.73 (95% CI: 0.61, 0.87) times more often than other sources of the best-ranked source of information for old drugs compared to dispensers, while controlling for other variables. See Table 5 . In addition, pharmaceutical drug promotion was reported to influence the choice of medicine prescribed/dispensed by 0.88 (95% CI: 0.81, 0.95) times more among prescribers than dispensers when other variables were controlled for.

Poisson Regression Model for Selected Characteristics

Notes : a incidence rate ratio, b confidence interval, and c reference. Poisson regression models were adjusted for variables with p values less than 0.05 in the bivariate analysis. The p values shown here are for the adjusted Poisson regression model. *P value<0.01, **p value<0.001. For #, the p-value is greater than 0.05.

As Table 5 shows, a Pharmaceutical Sales Representative (PSR) was 0.97 (95% CI: 0.87, 1.08) times more preferred as a drug promotion strategy than media and journal advertisements among prescribers when other variables were controlled for. Consequently, the most preferred forms of interaction with the PSR among prescribers appear to be CMEs and one-on-one discussions with the PSR, which are 1.06 (95% CI: 0.96, 1.18) and 0.84 (95% CI: 0.76, 0.93) times, respectively, more preferred than giving of the medicine while controlling for other variables.

This study aimed to determine the different forms of drug promotional strategies used by pharmaceutical companies targeting healthcare workers, the influence of drug promotion on drug information sources used by healthcare workers when choosing their patients’ medication, and health workers’ views on the impact of drug promotion on rational drug use. This was done to determine the potential of pharmaceutical drug promotion for promoting rational drug use among healthcare workers.

This study revealed that pharmaceutical sales representatives were the most common drug promotional strategy prescribers and dispensers were exposed to during their routine practice, and a clinical trial was the least common. Pharmaceutical sales representatives have previously been reported to be the mainstay of pharmaceutical drug promotion. 11 These methods are often referred to as the “detailing” approach and provide more details about medicines than other promotional options, such as television and media advertisements. Pharmaceutical sales representatives are often seen favorably among physicians because they provide an opportunity to interact with and discuss more in-depth information about medicines, provide a better background about the pharmaceutical company, and establish a rapport based on mutual trust and benefits. 20 In Uganda, it’s important to note that the relationship between PSR and healthcare professionals is largely unregulated, a common phenomenon in low-income countries. Physicians in other healthcare settings have often emphasized the need for a preparatory course, integrated into the school curriculum, to prepare medical students on how to best handle their interaction and relationship with pharmaceutical companies through their PSRs. Ethical practice regulation by the respective associations of medical and allied healthcare professionals currently provides the backbone of regulation of the behavior of health professionals in the face of pharmaceutical drug promotion. 21

In addition, this study showed that prescribers and dispensers preferred one-on-one Discussions and CMEs with the PSRs to other methods, such as gifts and branded items. This is because some physicians consider gifts from the pharmaceutical industry to be unethical and because they purchase their decisions. Some studies have reported that gifts may lead to unfavorable prescription practices and may lead to irrational drug use among health workers. 22 This study corroborates previous observations about the increased use of pharmaceutical sales representatives by pharmaceutical companies to promote drugs to health workers. Pharmaceutical drug promotion using sales representatives provides better opportunities for regulation and ethical drug promotion, which may eventually lead to more rational drug use. Medical doctors share this view in other healthcare settings. 23

The most commonly used source of information by both categories of health workers was clinical guidelines, especially the Uganda clinical guidelines, with promotional materials being the second most commonly used source. When asked to rank the sources of information for new drugs, promotional material was ranked the least common by both dispensers and prescribers. However, most of the health workers, in both categories, agreed that promotional materials are an important source of information for new drugs. These findings mirror those from a similar study performed elsewhere. 24 Although healthcare workers do not typically admit that pharmaceutical drug promotion is their primary source of information for drug decisions, the influence it has on their prescribing and dispensing patterns has been well-established. 25

Our study showed that promotional material is not among the best-ranked sources of novel or new drug information, contrary to findings from a different setup. 26 The majority of the promoted medicines in low-income countries such as Uganda are generic, and no new studies have been performed on them. 27 This could explain why promotional materials were not considered important sources of new drug information. However, the influence of drug promotion on clinical guidelines, published literature, and other sources of drug information cannot be overstated. 28 An older study was done to determine whether promotional materials provide truthful and valid reports in the affirmative. However, there was a plot twist. A closer examination of the supporting published literature found that the majority of these studies (80%) were pharmaceutical industry-sponsored. 29 This could present an unethical conflict of interest–especially for me-too drugs, which underscores the scientific validity of these studies, and their eventual clinical application in patient care when choosing patient medications. 28

This study revealed that the majority of health workers understood the concept of rational drug use, and most of them believed that pharmaceutical drug promotion improved rational drug use. With pharmaceutical sales representatives being their most preferred form of drug promotion, they indicated that they rely on pharmaceutical drug promotion for drug information. Although they did not rank drug promotion as the preferred source of drug information, it could be because healthcare workers are often unwilling to openly admit that drug promotions are their primary source of drug information due to ethical concerns. 30 Relying on drug promotion has been shown to increase the number of prescriptions written by health workers for that medicine, sometimes at the expense of the extra costs incurred by the patient. 31 However, since most health workers indicated that they prescribed or dispensed a marketed medicine after consulting the drug literature, there is a possibility of a more covert indirect influence of drug promotion on rational drug use. Similar observations were made in a Nigerian study. 32 The approach of using pharmaceutical drug promotion to encourage rational drug use should consider the influence exerted by professional colleagues, especially consultants and other senior healthcare workers. 33 In addition, although pharmaceutical sales representatives are most preferred among health workers, conferences and seminars are just as important, and this has been highlighted in other studies. 34 Regarding accepting drug promotion, studies have shown that it is more than just the message and the drug being detailed. The channel used, the reputation of the company, and the rapport with the PSR are just as important. 35 There seems to be an interplay among the company’s reputation, rapport with PSR, and ethicality of the drug promotion approach in determining physicians’ acceptance of drug promotion. 36

Both categories of healthcare workers reported pharmaceutical drug promotion to influence drug prescription and dispensing practices. Pharmaceutical drug promotion is a heavily funded but inadequately regulated investment in the pharmaceutical industry worldwide which does not seem to be going away. This investment can be channeled in the right direction with an adequate show of responsibility from the industry’s side. Furthermore, there is a need for healthcare professionals to exercise heightened vigilance, preparedness, and discernment when engaging with pharmaceutical companies to ensure that drug promotion activities align with the ultimate goal of rational drug use. By adopting a more astute and informed approach, health workers can effectively navigate the complex landscape of pharmaceutical marketing, make informed decisions, and prioritize patient needs above commercial interests. Ultimately, this will lead to better health outcomes, enhanced patient care, and a more responsible use of pharmaceutical resources. To gather more evidence on the potential of drug promotion in promoting rational drug use among healthcare workers, it would be helpful to conduct a more analytical study, with clearly differentiated groups of exposed and non-exposed drug promotion groups in a cohort or case-control fashion. This study should also include pharmaceutical drug promoters and regulatory agencies as respondents since they are key stakeholders in drug promotion practices.

Acknowledgments

This study would not have been possible if the study participants and research assistants had not participated in the collection of the data.

Funding Statement

Wide spectrum Enterprises (U) Limited provided full funding for this study.

Abbreviations

CME, Continuing Medical Education; ENT, Ear, Nose, and Throat; NDA, National Drug Authority of Uganda; POM, Prescription Only Medicine; PSR, Pharmaceutical Sales Representative; WHO, World Health Organization.

Data Sharing Statement

Ethics approval and consent to participate.

This study obtained ethical approval from the Research and Ethics Committee, School of Health Science, Makerere University (HS3012ES). Participants provided written informed consent for this study using a formal consent form.

Consent for Publication

All the authors have read and approved the submission of this manuscript.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

CA, MS, and AHSA work for Wide Spectrum Enterprises (U) Limited, a private pharmaceutical company that carries out drug promotion. Wide Spectrum Enterprises (U) Limited was not included in the study sample. The authors have no other conflicts of interest to declare for this work.