Hellenic Open University

Master in Business Administration (MBA)

Postgraduate Dissertation

The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Vasiliki Kipourou

Supervisor: Persefoni Polychronidou

Patras, Greece, July 2020

© Hellenic Open University, 2020 The content of this thesis/dissertation along with its results is owned by the Hellenic Open University and his/her author, where each of them has the sole and exclusive right to use, reproduce, and publish it (totally or partially) for educational or research purposes, with the obligation to make reference to the thesis’s title, the author’s name and to the Hellenic Open University where the thesis / dissertation was written.

The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Vasiliki Kipourou

Supervising Committee Supervisor: Co-Supervisor: Persefoni Polychronidou Christina Diakaki Assistant Professor at International Hellenic Adjunct Professor at School of Social University Sciences Hellenic Open University

Patras, Greece, July 2020 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

I would like to thank my supervisor Persefoni Polychronidou for her immediate response for help and the inspiration she gave me. Special thanks to my family for their love and support that gave me the boost to complete this dissertation.

I would like to dedicate this dissertation to my son, Evangelos, who fascinates me with his accomplishments every day and to my husband, Stefanos, who shares with me the same interests in our common life.

Postgraduate Dissertation iv Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Abstract

Advertising is considered as an integral part of pharmaceutical marketing, especially today in the world of the huge development of OTC drug market. The rapid increase of OTC drug consumption is resulted from the promotion of self-care and the conversion of prescription drugs to over-the-counter drugs (OTC). Self-medication with OTCs has become a global trend aiming to enhance the quality of human life and decrease the cost of pharmaceutical expenditure. The present dissertation aims to study the impact of advertising on OTC painkillers consumption in the regional unit of Florina. Self-managing with pain is focused and factors that influence consumers to buy an OTC painkiller are examined. Also, the attitude of the consumers towards OTCA and their general opinion about OTC analgesics are presented. Initially, a literature review was made for past studies concerning the effect of OTCA on consumers’ buying behavior. A questionnaire was then structured and administered to 130 citizens of Florina. The collected data were finally analyzed with the help of SPSS. Analysis has shown that OTC painkillers advertising makes the consumers aware of the drug rather than convinces them to purchase it. Doctor’s and pharmacist’s recommendations and the trust on the OTC analgesic are the main reasons that influence their decision making process. Also, most consumers have moderate attitude about OTC painkillers advertisements and this is reinforced by their moderate level of involvement with these drugs. As a conclusion, advertising cannot be excluded from pharmaceutical marketing, but it should be used as a piece of the great strategic marketing plan.

Keywords: OTC painkillers – OTCA - advertising effect – consumers’ preferences – pharmaceutical marketing

Postgraduate Dissertation v Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Περίληψη

Η διαφήμιση αποτελεί αναπόσπαστο στοιχείο του φαρμακευτικού μάρκετινγκ, ειδικά σήμερα όπου υπάρχει μεγάλη ανάπτυξη της αγοράς των ΜΗ.ΣΥ.ΦΑ. Η ραγδαία αυτή αύξηση της κατανάλωσης ΜΗ.ΣΥ.ΦΑ. οφείλεται στην προώθηση της αυτό-φροντίδας και στην μετατροπή των συνταγογραφούμενων φαρμάκων σε μη-συνταγογραφούμενα φάρμακα (ΜΗ.ΣΥ.ΦΑ). Η αυτό-θεραπεία με ΜΗ.ΣΥ.ΦΑ έχει γίνει παγκόσμια τάση με στόχο να βελτιώσει την ποιότητα της ανθρώπινης ζωής και να μειώσει το κόστος της φαρμακευτικής δαπάνης. Η παρούσα διπλωματική εργασία έχει στόχο να μελετήσει την επίδραση της διαφήμισης στην κατανάλωση παυσίπονων ΜΗ.ΣΥ.ΦΑ. στο νομό της Φλώρινας. Εστιάζεται η αυτό- αντιμετώπιση του πόνου και εξετάζονται οι παράγοντες που επηρεάζουν τους καταναλωτές να αγοράσουν ένα παυσίπονο ΜΗ.ΣΥ.ΦΑ. Επίσης, παρουσιάζονται η στάση των καταναλωτών απέναντι στην διαφήμιση μη-συνταγογραφούμενων παυσίπονων, καθώς και η γενική γνώμη τους για τα παυσίπονα ΜΗ.ΣΥ.ΦΑ. Αρχικά, πραγματοποιήθηκε βιβλιογραφική ανασκόπηση πάνω σε εργασίες που αφορούσαν την επίδραση της διαφήμισης ΜΗ.ΣΥ.ΦΑ στην αγοραστική συμπεριφορά των καταναλωτών. Κατασκευάστηκε ερωτηματολόγιο και μοιράστηκε σε 130 κατοίκους του νομού Φλώρινας. Τα δεδομένα, που συγκεντρώθηκαν, αναλύθηκαν τελικά με την βοήθεια του SPSS. Η ανάλυση έδειξε ότι η διαφήμιση μη-συνταγογραφούμενων παυσίπονων πιο πολύ ενημερώνει τους καταναλωτές, παρά τους πείθει να αγοράσουν το φάρμακο. Οι συστάσεις του γιατρού και του φαρμακοποιού, καθώς και η εμπιστοσύνη στο φάρμακο είναι οι κύριοι παράγοντες που επηρεάζουν την διαδικασία λήψης απόφασης. Επίσης, οι περισσότεροι καταναλωτές είναι μετριοπαθείς απέναντι στην διαφήμιση μη- συνταγογραφούμενων παυσίπονων και αυτό ενισχύεται από το μέτριο επίπεδο χρησιμοποίησης αυτών των φαρμάκων. Συμπερασματικά, η διαφήμιση δεν μπορεί να εξαιρεθεί από το φαρμακευτικό μάρκετινγκ, αλλά θα πρέπει να χρησιμοποιείται ως ένα μικρό κομμάτι του μεγαλύτερου στρατηγικού σχεδίου μάρκετινγκ.

Postgraduate Dissertation vi Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Λέξεις – Κλειδιά

Μη-συνταγογραφούμενα παυσίπονα – διαφήμιση ΜΗ.ΣΥ.ΦΑ – επίδραση διαφήμισης – επιλογές καταναλωτών – φαρμακευτικό μάρκετινγκ

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Table of Contents

Abstract ...... v Περίληψη ...... vi Table of Contents ...... viii List of Figures ...... x List of Tables...... xi List of Abbreviations & Acronyms ...... xii Chapter 1: Introduction ...... 1 1.1 Background information ...... 1 1.2 Research aim ...... 2 1.3 Research approach and methodology ...... 3 1.4 Importance of the research ...... 3 1.5 Limitations of methodology ...... 4 1.6 Structure of dissertation ...... 5 Chapter 2: The concept of Marketing and general elements of Pharmaceutical Marketing. 6 2.1 Marketing: Science or Art? ...... 6 2.1.1 Marketing Mix ...... 6 2.1.2 4 P’s of Marketing ...... 7 2.1.3 Pharmaceutical Marketing ...... 8 2.2 Communication Process ...... 10 2.2.1 Communication Mix in Pharmaceutical Marketing ...... 11 2.2.2 Steps in developing effective communication mix ...... 12 2.3 Content Marketing ...... 15 2.4 Guerrilla Marketing ...... 15 2.5 Success Factors in Pharmaceutical Marketing ...... 16 Chapter 3: Literature Review ...... 17 3.1 Over-The-Counter Drugs ...... 17 3.2 OTC drug market ...... 18 3.2.1 OTC drugs consumption...... 18 3.3 Over-The-Counter Drugs in Greece...... 20 3.4 Analgesics ...... 22 3.5 Advertising in Pharmaceutical Industry ...... 24 3.5.1 Direct-to-Consumer-Advertising (DTCA) ...... 26 3.6 OTC drugs Advertising Effectiveness ...... 26 3.6.1 OTC analgesics advertising effectiveness ...... 28 3.7 Consumer Behavior ...... 30 3.8 The Consumer Decision Making Process ...... 31 3.8.1 Steps in the consumer decision making process ...... 33 3.9 What is Self-Care? ...... 35 3.9.1 Benefits of self-care ...... 37 3.9.2 Problems arising from Self care ...... 38 3.9.3 Greek Responsible Health Self-care Campaign with focus on pharmacy ...... 38 3.9.4 The role of pharmacist to Self-care ...... 39

Postgraduate Dissertation viii Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.9.5 Self-care in the time of COVID-19 ...... 39 Chapter 4: Research Methodology ...... 41 4.1 Methodological approach ...... 41 4.2 The sampling method ...... 42 4.3 Data collection ...... 43 4.4 Questionnaire design ...... 43 4.5 The questionnaire structure ...... 44 4.6 Data analysis ...... 46 Chapter 5: Research analysis and Results ...... 48 5.1 Demographics ...... 48 5.2 Exposure to mass media and attention to OTC painkillers advertisements ...... 50 5.2.1 Most advertised and most purchased OTC painkillers...... 51 5.3 Reliability analysis ...... 52 5.4 Attitude towards OTC painkillers advertising ...... 52 5.4.1 Emotions that arise from OTC painkillers advertising...... 55 5.4.2 Advertising attitude mean score...... 56 5.4.3 The effect of demographics on ad attitude mean score ...... 57 5.5 Factors that influence the purchase of OTC painkillers ...... 59 5.5.1 Hierarchy of the factors that influence the purchase of OTC painkillers ...... 63 5.5.2 Buying OTC painkillers tendency mean score ...... 65 5.5.3 The effect of demographics on buying OTC painkillers tendency mean score . 66 5.6 General opinion about OTC painkillers ...... 68 5.6.1 OTC painkillers involvement mean score ...... 72 5.6.2 The effect of demographics on OTC painkillers involvement mean score ...... 73 Chapter 6: Discussion and further research ...... 76 6.1 Discussion of the main results from the survey ...... 76 6.2 Suggestions for further research ...... 79 References ...... 80 Appendix A: Ερωτηματολόγιο ...... 91 Appendix Β: Questionnaire ...... 97

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List of Figures

Figure 1 Types of exchanges in the Pharmaceutical market……………………………9 Figure 2 Schramm Communication Model……………………………………………….11 Figure 3 Total OTC purchases in different European countries………………………19 Figure 4 Purchases of self-care products based on AESGP and SFEE data………...20 Figure 5 Marketing Funnel…………………………………………………………………31 Figure 6 Customer Decision Journey……………………………………………………..32 Figure 7 The customer decision making process………………………………………..33 Figure 8 Exposure to advertising through mass media………………………………...50 Figure 9 Attention to OTC painkillers advertisements…………………………………50 Figure 10 Frequencies of the advertised OTC painkillers………………………………51 Figure 11 Frequencies of the purchased OTC painkillers………………………………51 Figure 12 Discomfort emotions due to OTC painkillers advertisements………………56 Figure 13 Hope emotions due to OTC painkillers advertisements……………………..56 Figure 14 OTC painkiller purchase influenced by pharmacist’s recommendation…...63 Figure 15 Asking for pharmacist’s advice prior purchasing an advertised OTC painkiller……………………………………………………………………………………………63

Postgraduate Dissertation x Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

List of Tables

Table 1 Absolute and relative frequency of the gender…………………………………48 Table 2 Absolute and relative frequency of the age……………………………………..48 Table 3 Absolute and relative frequency of the educational level…………………….49 Table 4 Absolute and relative frequency of the occupation……………………………49 Table 5 Absolute and relative frequency of the residence……………………………..50 Table 6 Results from the analysis of the statements about the attitude towards OTC painkillers advertisements on percents………………………………………………………….53 Table 7 Results from the analysis of the statements about the attitude towards OTC painkillers advertisements, mean and standard deviation…………………………….………54 Table 8 Ad attitude mean score……………………………………………………………57 Table 9 Gender based Mann-Whitney test……………………………………………….58 Table 10 Age based Kruskal-Wallis test……………………………………………………58 Table 11 Education level-based Kruskal-Wallis test …...... 59 Table 12 Occupation based Kruskal-Wallis test ………………………………………....59 Table 13 Place of residence based Mann-Whitney test…………………………………..59 Table 14 Percents of factors that influence the purchase of OTC painkillers………...60 Table 15 Median and standard deviation of factors that influence the purchase of OTC painkillers…………………………………………………………………………………………..61 Table 16 Hierarchy of factors that influence the purchase of OTC painkiller………64 Table 17 Mean score of buying OTC painkillers tendency…………………………….66 Table 18 Gender based Mann-Whitney test…………...…………………………………67 Table 19 Age based Kruskal-Wallis test …………………………….….………………..67 Table 20 Education level based Kruskal-Wallis test …………….…….……………….67 Table 21 Occupation based Kruskal-Wallis test ……………………..…………………68 Table 22 Place of residence based Mann-Whitney test.………………………………..68 Table 23 Results from the analysis of the statements about the general opinion about OTC painkillers on percents………………………………………………………………………69 Table 24 Results from the analysis of the statements about the general opinion about OTC painkillers, mean and standard deviation………………………………………………...70 Table 25 OTC painkillers involvement means score…………………………………….72 Table 26 Gender based Mann-Whitney test...…………………………………………….73 Table 27 Age based Kruskal-Wallis test ……………………………………...……..……74 Table 28 Education level based Kruskal-Wallis test ……………………………………74 Table 29 Occupation based Kruskal-Wallis test ………………………………………...75 Table 30 Place of residence based Mann-Whitney test...………………………...……..75

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List of Abbreviations & Acronyms

AESGP Association of European Self-care Industry AIDA model Awareness, Interest, Desire and Action AHPC Australian Health Policy Collaboration AMA American Marketing Association B2B Business to Business marketing B2C Business to Customer marketing CIM The Chartered Institute of Marketing DTCA Direct-to-Consumer-Advertising EEFAM The Greek Company of Pharmaceutical Management EFEX Greek self-medication industry EOF National Drug Organization EOPYY National Contact Point for Cross-border Healthcare FDA Food and Drug Administration GAP Global Access Partners HOE model Hierarchy of Effects model IMC Integrated Marketing Communication Process IOBE Foundation of Economic and Industrial Research in Greece JAMA Journal of the American Medical Association NSAID Non-Steroidal Anti-Inflammatory Drugs OTC Over-The-Counter Drugs OTCA Over-The-Counter Drugs Advertising SFEE Hellenic Association of pharmaceutical companies SPSS Statistical Package for the Social Sciences WHO World Health Organization

Postgraduate Dissertation xii Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Chapter 1: Introduction

1.1 Background information

Nowadays, self-care and self-medication have become global trends, which empower people to find solution for their health or prevent a health situation by themselves. Apart from having healthy habits and taking care of their organisms, people are able to use Over- The-Counter (OTC) drugs in order to deal with minor illnesses. OTC drugs are non- prescription drugs, which can be purchased by the consumer for use without the intervention of a health care professional. An OTC drug is considered safe and effective for use by the general public without a prescriber’s authorization (FDA, 2020). The promotion of self-medication and the conversion of prescription drugs to OTC led to the huge development of OTC drug market according to IBIS World Industry Reposts 2009 (DeLorme et al, 2010). Also, the release of retail prices and sales points contributed to the increase of OTC drugs consumption. In Greece, the OTC drugs, which can be purchased outside pharmacies since 2016, are called General Purpose Drugs and include analgesics, antipyretics, anticonvulsants, topical use drugs, laxatives and oral solutions (IOBE, 2017). All these actions create more and more demand for OTC drugs, so the pharmaceutical companies try to be differentiated between their rivals in their effort to have more profit. Advertising is a very useful tool of pharmaceutical marketing in order to inform, persuade and remind consumers the characteristics, functions and benefits of OTC drugs. It is a fact that the top 10 US companies in 2002 spent for marketing and administration 31% of sales, compared with only 14% for R&D (Marcia Angell, 2002). Many researchers have analyzed the effect of OTC drugs advertising (OTCA) on the decision making process of consumers and in most cases the conclusion was that advertisements play more important role in creating the awareness of the product rather than in taking the final decision (Global Self-Care Federation, 2020). According to research the main factors that affect the buying decision process of OTC drugs are drug safety, fast action, effectiveness, pharmacist's and doctor's advice and recommendation from friends and family.

Undergraduate Thesis / Postgraduate Dissertation 1 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

1.2 Research aim

Among OTC drugs categories, cough and cold drugs and analgesics or painkillers or pain relievers are the most popular. In Greece, these two OTC drug categories have the most purchases through the years 2013-2017 (IOBE, 2017). Also, according to IQVIA (2019) the pain relievers value share was 15.9% globally and 16% in Europe among OTC drugs. Pain relief is concerned to be one of the most common daily heath problems and for this reason “selling the solution” to headache, toothache, period pains, joint or muscle pains and cold and flu conditions or fever has become a huge business all around the world. The competition between different pharmaceutical companies is enormous, since the active ingredients on this category are not many. In Greece, paracetamol (Depon, Panadol, and Apotel), acetyl-salicylic acid (Aspirin-Bayern), ibuprofen (Nurofen, Algofren) and combinations (Algon) are most commonly used. So, differentiation should be emphasized and this can be done successfully through advertising. We have chosen this category of OTC painkillers and more specifically tablets or capsules (per os or oral administration), because they are known and widely used by the consumers. Also, there are many advertisements in the mass media concerning OTC painkillers. The aim of this study is to estimate whether advertising of OTC painkillers affects the consumers’ purchase choices in the regional unit of Florina. The research objectives that will be examined in this dissertation are the following: 1. What is the consumers’ attitude towards OTC painkillers advertising? 2. Are there any differences between groups of the sample with the same demographic characteristics, concerning their attitude about OTCA and thus the degree they are affected on their buying decision process? 3. What are the main factors that lead the consumers to the purchase of OTC painkillers? 4. What is the general opinion of consumers about OTC painkillers?

Undergraduate Thesis / Postgraduate Dissertation 2 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

1.3 Research approach and methodology

The purpose of this study is to analyze the connection between OTC painkillers advertising and consumers’ preferences in the regional unit of Florina. A structured questionnaire was the tool of the research, which was conducted in a sample of OTC consumers either in the city of Florina or in the wider area of Florina. It was detected through the questions the frequency in which consumers use mass media and come in contact with an OTC painkiller advertisement. Additionally, it was examined the consumers’ opinion about OTC painkillers advertising and the factors that influence their buying decision in the case of OTC painkillers. Also, the general opinion about OTC painkillers was investigated, including the frequency of use, the trust on OTC painkillers, the price increases and the debate whether selling OTC painkillers outside pharmacies is right or not. A field survey was carried out with a structured questionnaire consisting of closed-ended questions. Google Drive form application was used in order to collect the data and then these data were processed using quantitative analysis method. SPSS was used for the statistical analysis of the data and finally results were discussed.

1.4 Importance of the research

In our modern world, OTC drug market is one of the biggest and continuously growing markets and pharmaceutical companies adopt many marketing strategies, so as to promote their products. Especially in the case of OTC painkillers the target group is huge, because the majority of the population has the need to deal with an emerging pain at any given time. OTC painkillers are drugs, which are part of our daily lives; a humorous advertisement on TV, a discussion with a friend about our headache, the migraine we cannot deal with, fever as a result of flu or sore muscles from a difficult activity. The demand of OTC painkillers becomes even greater, when there is the convenience to purchase them in the neighborhood pharmacy without a prescription from the doctor. Additional factors such as the Rx-to-OTC switch, the promotion of self-care and self- medication and the OTC drugs presence outside the pharmacies have as result the increase of OTC painkillers consumption. It is clear that there is big competition between

Undergraduate Thesis / Postgraduate Dissertation 3 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

pharmaceutical companies, which try to differentiate their brand, so as to maximize their profits. Advertising through mass media is a means of promotion and although it has some limitations by the law, it has great power. So, it is very important to study the consumers’ behavior in the OTC painkillers market and understand the reasons that trigger the consumer to purchase an OTC analgesic among others. Also, exploring how advertising can affect their preferences and the final buying decision would be very helpful for pharmaceutical companies to improve their marketing practices. Another interesting part is the area, where this case study is carried out. The regional unit of Florina is located in West Macedonia in Greece and its remote provincial population has some special characteristics. Florina is isolated from the rest country and this probably affects the general point of view and attitude of residents concerning some issues, such as the modern trend of self-care. In addition, the regional unit of Florina is characterized by high unemployment and in combination with the hard survival conditions in winter the economic status of the area is low. Thus, it is worth to examine the profile of these consumers and find out if there are differences with the rest population in Greece.

1.5 Limitations of methodology

The questionnaires were completed either by the individual or with the help of the researcher. Also, questionnaires were administered online targeting residents in the area of Florina. The participants had probably little time at their disposal, so we do not know the degree of the reliability of their answers, even if the time needed was 10 minutes. In addition, there was the possibility that some participants did not understand exactly the question or they were unable to express their opinion especially in the cases of old people or those with lower educational level. In the cases that there was the help of the researcher, there were some people that answered some questions according to what it is considered to be right and not according to their opinion, due to the researcher’s presence in the questionnaire completion. Also, in the case of the respondents living outside the city of Florina, the majority of them completed the questionnaire in the pharmacy of Sitaria village.

Undergraduate Thesis / Postgraduate Dissertation 4 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Another limitation of the research was the method of sampling, the convenience method, which uses available persons of the target population, but this sample may be not representative. Finally, the time period that the questionnaires were administered (February-April) was the time, when the pandemic phenomenon of COVID-19 had just began. This situation affected the people’s responses, as they were psychologically charged with quarantine.

1.6 Structure of dissertation

The dissertation has the following structure:  Chapter 1 presents the research aim, the research objectives, the importance of the study and the limitations of methodology.  Chapter 2 presents the concept of marketing and an introduction to pharmaceutical marketing including the success factors of pharmaceutical marketing and the steps in developing effective communication mix.  Chapter 3 presents the literature review, which starts with an overview of OTC drugs in general and the OTC painkillers specifically. Also, the importance of advertising in pharmaceutical industry and past studies for the effect of OTC drugs and painkillers advertising on consumers’ buying behavior are listed. The consumer decision making process is analyzed and finally, it is noted the modern trend of self-care and its role to all aspects of our lives.  Chapter 4 presents the research methodology, which includes the methods applied for the sampling, the data collection, the questionnaire structure and the data analysis.  Chapter 5 presents the research analysis and results.  Chapter 6 presents the discussion of the main research findings, the conclusion and suggestions for future research.

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Chapter 2: The concept of Marketing and general elements of Pharmaceutical Marketing

2.1 Marketing: Science or Art?

Marketing as a practice has been in existence since buyers and sellers began to do their exchanges of goods and services in a market, but the term “marketing” used to describe “the management process responsible for identifying, anticipating and satisfying customer requirements profitably” (CIM, 2015) became popular around 1950. It was the time when Paul Converse (1945) introduced marketing as “science” in the Journal of Marketing and since then there is the huge debate of whether marketing is art or science. According to Roberts (2019), the classic advertising era would attribute marketing to art, while the digital era would attribute marketing to science. His opinion is clear that both science and art are necessary in a marketing campaign. Science finds what is appealing based on data, creates the demand of the product and makes the campaign to be well performed. On the other hand, art uses creativity and intuition in order to deliver the message of the campaign to the consumers. According to the American Marketing Association (2017), marketing is defined as the activity, set of institutions and processes for creating, communicating, delivering and exchanging offerings that have value for customers, clients, partners, and society at large. The father of modern marketing Philip Kotler (2002) distinguishes marketing definition between a social and a managerial aspect. From the social point of view marketing is a societal process, by which individuals and groups obtain what they need and want through creating, offering and exchanging products and services of value freely with others. From the managerial point of view, marketing is “the art of selling products.” Another definition by Kokemuller (2019) is that marketing is a combination of product research and development, merchandising and distribution processes and communication or promotion.

2.1.1 Marketing Mix

Performing marketing is so demanding, as the marketer tries to take the right decisions that will lead to customer’s satisfaction and thus the firm’s success. The marketer has to

Undergraduate Thesis / Postgraduate Dissertation 6 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

do with product development, distribution of the product, sales and advertising. He is the head of the marketing campaign, so he must have a marketing program in order to achieve his goals. The marketing tools that he uses constitute “the marketing mix”. The concept of marketing mix was first used by Neil Borden in 1953 in his American Marketing Association presidential address and according to him he was inspired by his colleague Culliton and used this term to answer to his students “what is marketing”. Marketing mix took its modern form later by Jerome McCarthy (1960), who classified the marketing tools into four broad categories, the “4 P’s”: product, price, place and promotion. It was Philip Kotler (2002) though, who made the 4 P’s model famous and since then many marketers use this model, when they want to take crucial decisions for influencing the distribution channels and the final consumers.

2.1.2 4 P’s of Marketing

Product refers to an item that satisfies the needs of the customer and can be an idea, a physical entity (good) or a service or any combination of the three (AMA, 2017). It is very important for the marketer to know exactly what he sells and how this product is differentiated among others in order to survive in the modern digital world full of competition. Price refers to the amount (money, service, goods) that the customer pays for a product (AMA, 2017). Pricing strategy is “the alpha and the omega” in the brand marketing, where the marketer should calculate the price not to be too high or too low. Place refers to providing customers access to the product. A physical market is called marketplace contrary to the marketspace, which is a virtual market (Tsiames, 2005). Adcock shortly describes it as sense of the right product, in the right place, at the right time and at the right price (Petkova et al, 2014). Promotion refers to marketing communications that use channels, such as advertising, direct marketing, sales promotion and others. Today B2C marketing solutions are provided by many firms and personalization is more evident than in the past. B2C or business to customer marketing refers to the strategies that a company uses in order to promote its products and services to the individual person.

Undergraduate Thesis / Postgraduate Dissertation 7 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

4 P’s have been used many years already, but they remain still a special tool for marketers in the rapid changing world of marketing. Technology, globalization and deregulation are the main forces that influence the modern market (Kotler, 2002), so marketers must be aware of the changes and ready to adjust their marketing strategy to the future market trends.

2.1.3 Pharmaceutical Marketing

The Greek Company of Pharmaceutical Management, EEFAM (2014), defines pharmaceutical marketing as the activities aiming to the promotion of the selection, the release, the prescription, the provision, the purchasing, the administration or the consumption and generally the proper use of pharmaceutical products indented for human use. According to Marcia Angell (2004) pharma companies spent much more for marketing and administration than for R&D or anything else. Pharmaceutical marketing is defined as a process, by which individuals and companies actualize pharmaceutical care in the market (Smith, 1988). This is occurring through exchanges between two or more parties, who want to satisfy their needs or have something of value to offer, although good communication and delivery are required. In the pharmaceutical market, these exchanges are complex (at least three parties involved) and interactive (both complex and univocal reciprocity arrangements, this means that one party is satisfied indirectly from the other party) and Smith depicted them in Figure 1. The emphasis should be given to the patient and anyone that can be part of the pharmaceutical care, such as pharmacists, doctors, pharmaceutical manufactures, drug wholesalers should be involved in the pharmaceutical marketing (Smith, 1988).

Undergraduate Thesis / Postgraduate Dissertation 8 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Figure 1: Types of exchanges in the Pharmaceutical market

Source: (Smith, 1988)

The code of Ethics as modified by the General Assembly of EEFAM in 2014 refers to pharmaceutical marketing and how this can be exercised only by pharmaceutical companies. This code forms the principles and procedures under which the pharmaceutical companies:  Can promote the prescription drugs to health professionals such as doctors, pharmacists and can inform the health executives and the public. The medical visitors are the appropriate trained persons with adequate knowledge and skills for medical information.  Can promote and advertise the non-prescription drugs (OTC drugs) to the public. These drugs are categorized to the self-care products, which can be used without prescription by the doctor and with the recommendation of the pharmacist if necessary. In the case of OTC drugs promotion to health professionals, then same directions as prescription drugs are followed.

Nowadays, there is not a successful pharmaceutical product without marketing, unless this is so innovative product that there is no other like this. Pharmaceutical marketing is an integral part of a pharma company and the marketer should not only understand health professionals (doctors, pharmacists, nurses etc) and final consumers, but also study the

Undergraduate Thesis / Postgraduate Dissertation 9 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

competition products and their promotion strategies and ensure the good flow through the delivery channels.

2.2 Communication Process

Communication is a complex, multidimensional process and essential part of marketing. It refers to the transmission of a message from a sender through a channel to the receiver. It is the share of meaning (Tsiames, 2005). In the pharmaceutical industry, marketing communications include information sent form the companies to health professionals, intermediaries, final customers and statistical data gathered on the market referring to customer preferences, trends in the economy etc. Marketing communication tries to satisfy needs through market offer as a social means between the company and its environment (Owusu, 2017). Aristotle (384-322 B.C) was the first to develop a linear model of communication and this model is widely used from speakers, so as to influence their audience. Many others have followed until Wilbur Schramm published the circular communication model (Figure 2) in 1954, which has three elements: 1) the sender, 2) the message and 3) the receiver (Janse, 2019). More specifically, the sender or source sends the message, which should be clear and simple and converts its meaning into ideas, concepts or thought (encoding). This encoding process is influenced by knowledge, skills, perceptions, culture and other characteristics of the sender. The receiver or recipient or audience is a person or a group that decodes the message or with other words gives a meaning to the message. The crucial part in this process is the right interpretation of the message. The message can be verbal (speech, e-mails, and phone calls) or non-verbal (behavior, body language, gestures). Feedback plays an important role to the communication process as the audience should respond to the message sent by the source.

Undergraduate Thesis / Postgraduate Dissertation 10 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Figure 2: Schramm Communication Model

Source: (www.toolshero.com)

In the pharmaceutical industry marketers have the great challenge to communicate the value propositions of their products to the public. Value proposition is the value that the company promises to its customers if they choose its product (Twin, 2020). There is not a winning formula for the marketing promotion, but marketers try to create a mix, which works under a specific situation, the communication mix (Rizwan et al, 2014).

2.2.1 Communication Mix in Pharmaceutical Marketing

Communication or promotional mix refers to the combination of communication tools and methods that a company uses in order to promote its brand and convince the customers to buy (Tsiames, 2005). A brand is a name, term, design, symbol or any other feature that identifies one seller’s good or service as distinct from those of other sellers as defined by AMA (2017). The communication mix includes advertising, personal sales, sales promotion, public relations and direct marketing.

Undergraduate Thesis / Postgraduate Dissertation 11 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Advertising is any paid non-personal form of communication and promotion of products, services, organizations or ideas by a company or an organization to a target market or audience. Personal selling is face to face selling method, in which there is a specially trained brand salesman, who tries to convince the customer to buy the product (The Economic Times, 2020). Sales promotion refers to short term incentives for the purchase of a product. While advertisements provide a reason to buy, sales promotion gives an incentive to buy (Tsiames, 2005). Consumer promotion tools are samples, free trials, discounts, gifts, prizes and others, while trade promotions tools are shows and conventions, specialty advertising, free goods and others (Tsiames, 2005). The main goals of the companies are increasing revenue and cash flow, attracting new customers and clearing out inventory (Kokemuller, 2019). Public relations refer to the creation of a good image of your product or service in the public domain through mass media. The difference between advertising and public relations is that in the latter the company does not pay and there is the risk of a bad reputation (Kokemuller, 2019). Today public relations and brand image creation exist mainly in the social media. Direct marketing uses consumer-direct channels such as e-mails, telephone, facebook wall and generally social media in order to promote the product. Digital marketing (today’s direct marketing) gives small businesses the advantage of advertising without paying enormous amounts of money on TV and also helps the brand to have a part in the trends zone (Bhasin, 2017).

2.2.2 Steps in developing effective communication mix

 Identifying the target audience. The marketer should have a target audience in mind, when he sends the message. When the receiver is a doctor, the message should include results from clinical trials, safety profile of the drug, published articles, when there is a pharmacist, the cost of the drug, its popularity, the rate that it is prescribed or recommended from the doctors are interesting information. And

Undergraduate Thesis / Postgraduate Dissertation 12 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

in the case of the public, basic profile of the drug and its actions described with a simple, clear without technical terms way are necessary (Rizwan et all, 2014).  Determining the communication objective. After the target audience is determined, the marketer should decide what response to expect and according to this he will make the message. In the case of health professionals (doctors, pharmacists) the message should be simple when the receiver has knowledge of this or the drug is widely known to them. In opposite situation of junior professionals or when there is a new active ingredient or when the drug is for serious medical conditions, the message should be analytical (Rizwan et al, 2014). As concern the final consumer, the response may be cognitive, affective or behavioral (Tsiames, 2005). The marketer should put something in mind (cognitive), change the consumer’s mind (affective) or convince the consumer to buy the product (behavioral).  Designing the message. The message should attract attention, maintain interest, create desire and take action; this is the AIDA model, which is developed by Elmo Lewis in 1898.  Choosing communication channels. The delivery of the message can be done personally (face to face, e-mail, internet, between friends or family members) or non-personally (mass media, events) (Rizwan et al, 2014). In both cases, the source of the communication plays important role.  Establishing the budget. According to Smith (1991), as marginal approach suggests the optimum budget should be set, so that the marginal revenue becomes equal with the marginal cost for promotional purposes. This approach is very difficult, because a firm cannot estimate how many salespeople to hire or fire and the advertising effect is a short term phenomenon. In the real world, four methods are usually used in order to calculate the budget (Tsiames, 2005): affordable method (minimum expenses in promotion), percentage of sales method (budget allocation in relation with sales), competitive-parity method (money spent is proportional with the competitors) and objective and task method (certain promotion targets should be succeeded).

Undergraduate Thesis / Postgraduate Dissertation 13 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

 Deciding the communication mix. Marketers should take into account the brand loyalty, the customer readiness to make a purchase decision, the stage in the product life cycle (Kotler, 2002). For example, in the case of a famous brand, advertising is the best choice (pull strategy), while sales promotion is better for a low loyalty brand (push strategy). Another example is the moment of promotion, where advertising and direct marketing make the customer aware of the product, but personal selling is important on the moment of purchase. In the world of pharma marketing, social media presence, building relationships with health professionals, offering free samples, participating in conferences, connecting with customers emotionally through context marketing and growing your brand through guerrilla marketing are helpful tactics (www.linchpinseo.com).  Collecting feedback. After the message is sent the marketer should know if the communication is successful. Number of product sales, doing surveys to the doctors or the public are methods to estimate the success of decoding the message (Rizwan et al, 2014).  Managing the Integrated Marketing Communication Process (IMC). As defined by the American Association of Advertising Agencies (4A’s), integrated marketing communications (IMC) is a concept of marketing communications planning that gives emphasis to the added value of a comprehensive plan that evaluates the strategic roles of a variety of communications disciplines and combines them to provide clarity, consistency and maximum communications’ impact through the seamless integration of discrete messages. The purpose of IMC is to deliver a core message through one or more routes to a target market and simultaneously to build a brand by emphasizing on the benefits of the branded product. Consistency helps the costumer to remember the brand (Schulz, 2009). Warner-Lambert, maker of Benadryl, has creatively used IMC to promote its antihistamine drug. The company used advertising and public relations to increase brand awareness among allergy sufferers and to promote a toll-free number, which informed people for pollen count in their area (Kotler, 2002). Aspirin from Bayern is a strong brand in Greece, and has the classic green packaging that is recognizable from the consumers and although there are other OTC NSAID drugs, the majority of the public selects this aspirin.

Undergraduate Thesis / Postgraduate Dissertation 14 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

2.3 Content Marketing

In pharmaceutical industry, marketing is a great challenge as it is a business of illnesses, therapies and technologies and new ideas are created difficulty, especially when there are regulations in the pharmaceutical campaigns (Roberts, 2018). B2B (business to business) marketing is easier in relation with B2C (business to consumer) marketing, as the latter has to do with the patient’s emotions and the promotion of the drug should be discreet. But in both situations there is lack of creativity and differentiation among companies. So, here it comes content marketing to inspire and give imagination to pharmaceutical firms, so as to differentiate from their rivals and also help businesses and final consumers to be more familiar with the pharmaceutical products and the related health disorder. Some examples of pharmaceutical content marketing according to Roberts (2018) from Orientation Marketing are the following:  The Bayer Scientific Magazine and Bayer Magazine are two magazines published by the organization containing articles, images, videos and aim to explain basic information and to attract businesses and the public.  Johnson and Johnson created the Distinctly Dad film, which shows three dads’ life and how they raise their children and this is an effort to attract the viewer and potential consumer though an emotional way.  Speak your migraine is a innovative website by Novartis, where sufferers can find support through sharing their problem with a doctor or other people and learn how to deal with this medical disorder in their life.

2.4 Guerrilla Marketing

Guerrilla marketing is an unconventional and creative marketing strategy that intends to get maximum results from minimum resources according to AMA (2017). So, this is a good alternative for small businesses or unknown new brands. Publicity stunts, public relations, viral videos, graffiti, memes are some of the means that guerrilla marketing uses. Spreading something by word of mouth or through social media, going viral, generating

Undergraduate Thesis / Postgraduate Dissertation 15 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

curiosity and something newsworthy are ideas for this non-traditional marketing (www.linchpinseo.com). Inspiration and a smart picture, video, slogan or structure that can attract the attention is all that this form of marketing needs to transmit the message and make the product an interesting and possible potential purchase.

2.5 Success Factors in Pharmaceutical Marketing

 The message that the pharmaceutical firm transfers to its customers should be differentiated according to the nature of the final sender. Doctors, pharmacists and the public are attracted to different attributes of a potential product, so the marketer should have a different promotion strategy to each group. If there is the same massage, the product’s promotion will fail.  In the case of prescription drugs, the demand of the product is related with the doctor who prescribes the drug, the patient and the insurance agent that compensates the drug. Also, there are regulations from the government such as determination of the price and legal restrictions on the advertisements. In the case of over-the-counter drugs, the legislative framework is “looser” and the marketer has more options in his communication mix such as advertising, internet marketing and influencer marketing.  Companies should give emphasis to deliver value propositions to their customers more from their competitors (Tsiames, 2005). An effective way to differentiate from the other is brand construction. The brand name helps the customer to distinguish a specific product from the others in the market and protects the launch of new products under the brand umbrella. For instance, depon is the brand name of paracetamol in Greece and Cyprus and OTC drugs under this name are very popular and reliable in our country.  Distribution is a vital part of pharmaceutical marketing. Channels that make products available at the right time, the right place and the right quantities to the customers are the marketing channels. They aim to customer satisfaction and are part of a greater concept “the value network”, a system of participants and allies that the firm employs to deliver its products to the target markets (Tsiames, 2005).

Undergraduate Thesis / Postgraduate Dissertation 16 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Chapter 3: Literature Review

3.1 Over-The-Counter Drugs

Over-The-Counter drugs are medicines available to the consumers without a prescription from the doctor and constitute the main tools of self-medication. OTC drugs are developed by pharmaceutical companies and approved by the national organizations for drugs so as to be safe and effective for the public. It is very important though the consumer to be properly informed and take the right recommendations from the pharmacist and read the information sheet before he proceeds to drug administration. OTC drugs main categories are the following according to IOBE (2017):  Cough and cold drugs and for disorders of the upper aspiratory system such as syrups and lozenges  Pain relievers or analgesics for the pain and fever  Digestive system drugs  Vitamins and food supplements  Products for skin care and for skin diseases such as fungal infections, irritations or topical infections  Eye care products such as eye drops or ointments

European legislation defines non-prescription medicines in Article 72 of Directive 2001/83/EC as medicinal products which:  Are drugs of wide use concerning the general public, not administered parenterally, not prescribed by a doctor  Do not put in danger the human health, either directly or indirectly, even when used correctly, if utilized without medical supervision  Do not put in danger the human health, either directly or indirectly when used frequently and to a very wide extent incorrectly  Do not contain substances the activity and/or adverse reactions of which require further investigation

Undergraduate Thesis / Postgraduate Dissertation 17 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.2 OTC drug market

Two important factors that have dramatic effect on developing OTC drug market are the promotion of self-medication and the conversion of prescription drugs to OTC according to IBIS World Industry Reposts, 2009 (DeLorme et al, 2010). It is a fact that self-care and self-medication have been developed and are expected to grow more in the future with the aid to empower the role of citizen-patient to drug accessibility and treatment and additionally decrease the pharmaceutical expenditure of health systems. According to a research of AESGP which included 7 European countries, the conversion of 5% prescription drugs to OTC drugs will save 16 billion Euros annually (IOBE, 2017).

3.2.1 OTC drugs consumption

According to Sakai (2019), global OTC purchases were about 114 billion dollars in 2017 in comparison to about 95 billion dollars in 2007. US market was the largest, as many people here do not have medical insurance and it is common to buy OTC products when they experience mild symptoms. Another source, statista.com, indicates that the global OTC pharmaceuticals revenue was 110 billion dollars in 2018, putting the Swiss in the first place with 84 dollars per capita, followed by Australia and US. The same source estimates the global OTC pharmaceuticals revenue to be 113 billion dollars in 2020. According to IQVIA (2019), 83% of global OTC growth comes from developing countries such as South Asia, while Western Europe and the US are now slowly growing. Thus, the opportunities for pharmaceutical industries are found to these developing countries. Another interesting part is that Internet pharmacies are gaining prominence in Germany, online sales as a percentage of total OTC drug sales in 2018 topped 17%, the highest in the world (Sakai, 2019). In years 2015 and 2016, Germany was the first country in EU in OTC consumption, when Greece was in the last places among other countries in Europe as shown in Figure 3

Undergraduate Thesis / Postgraduate Dissertation 18 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

(IOBE, 2017). It should be noted that OTC drugs include different categories in each country.

Figure 3: Total OTC purchases in different European countries according to AESGP and EFEX.

Source: (IOBE, 2017)

It is noticeable, too, that the density of pharmacies in Greece, the highest, is 97 pharmacies per 100,000 citizens in 2017, when this mean is 31 pharmacies per 100,000 in the European member states in EE28 (IOBE, 2017). The country has many spots of self-care, but not many OTC purchases. According with IQVIA (2019), the OTC expenditure in Greece in 2019 was 57 Euros per capita with 12% growth rate. Greece together with Portugal has the highest growths in Western Europe and this is due to the increase in per capita expenditure and price rises. Although the consumption of OTC drugs in Greece is not high, the country is growing fast and promising more purchases in the future.

Undergraduate Thesis / Postgraduate Dissertation 19 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.3 Over-The-Counter Drugs in Greece

In Greece OTC drugs are defined by the Minister of Health and National Drug Organization (EOF). EOF contributes to the right categorization of OTC drugs taking into account the global practice and scientific knowledge. According to a legal regulation in 2016 concerning the release of OTC delivery channels, 216 from 1,582 OTC drugs, available to the Greek market, can be sold outside pharmacies without their percentage exceeds 13%. These drugs are composed a subcategory of OTC drugs, the General Purpose Drugs, which include analgesics, antipyretics, anticonvulsants, topical use drugs, laxatives and oral solutions (IOBE, 2017). According to the report of pharmaceutical market in Greece in 2018 by IOBE and SFEE (Hellenic Association of pharmaceutical companies), analgesics and cough and cold are the two main categories with the most purchases in Greece through the years 2013 -2017 (Figure 4).

Figure 4: Purchases of self-care products based on AESGP and SFEE data.

2013 2014 2015 2016 2017 %17/16 Analgesics 60 65 64 65 71 9.2% Cough and Cold 67 69 66 65 75 13.9% Digestive 23 24 25 28 32 12.7% Skin care 33 32 32 32 30 -5.1% Vitamins 62 70 68 67 72 7.2% Rest categories 81 64 24 83 89 7.7% TOTAL 323 340 335 339 368 8.4%

Source: (IOBE and SFEE, 2018)

Nevertheless, the absence of a fast track process in the approval of these drugs and the limitations in the advertising create obstacles in their availability outside pharmacies. Here a huge debate arises: can we purchase OTC drugs without the recommendation of a health professional? The pharmacist is the legal person that has the knowledge and the jurisdiction to give medication to the public, as he controls what he gives to the customer, decides about the right OTC drug and draws the attention for the side effects of the drug,

Undergraduate Thesis / Postgraduate Dissertation 20 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

either it is prescribed or not. This has a result to avoid the misuse and abuse of OTC drugs. On the other hand, pharmaceutical companies and the government want to increase the OTC drugs’ consumption by releasing either the points of sales or the retail price (Karafillis, 2018). These release actions have already done, but the OTC consumption in Greece is not satisfying. In 2017, drug purchases in pharmacies and pharmaceutical warehouses were 4 billion Euros (68.8% compared with 31.2% provided to hospitals and EOPYY pharmacies), when the OTC purchases were 165 million Euros. This means that the OTC drugs share was 4% of the pharmaceutical market purchases. Although it is a small share, the purchases of OTC drugs showed increase by 35.2% in comparison with 2013 (IOBE and SFEE, 2018). The pharmacists talk about new economic burden for the consumers of OTCs after the release of their retail price, as they have noticed extravagant increases on the wholesale prices in many cases (Bouloutza, 2018). An example is depon syrup which was sold 1.45 Euros and the present price is 2.45 Euros. And the problem becomes bigger when the pharmaceutical company indicates the price in the package of the product, which is lower even from the wholesale price! Then the pharmacist is called to explain this situation to the consumer and sometimes is forced to cover the difference in prices. These are problems that government should solve in the near future. An average increase of 14% noticed in the retail prices of OTC in 2018, one year after the release of retail prices. This has led to higher turnover in 2018 compared with 2017 (+7.8%) but lower sold pieces in 2018 compared with 2017 (-5.3%) according to data from Pharmacy Insights. Concerning the OTC categories, cough and cold OTC drugs have the largest share of 26.4%, following nervous system OTC drugs, mainly analgesics, with 21.5% share and in the third place are the OTC drugs for joint and musculoskeletal disorders with 15.7% share. In the case of analgesics, 9 out of 10 products have paracetamol as active ingredient (Healthmag Team, 2019). OTC drugs are the solution to pharmaceutical companies and pharmacies for liquidity, as the retail price had an 8.4% increase in 2019. Last year has closed with 287 million Euros turnover and a marginal increase in the sold pieces. First were Cough and Cold products with 3.2% increase, second musculoskeletal products such as ibuprofen, with 17.1% rise and third analgesics with 11.6% increase (Sakkas, 2020). It is obvious that Greek people burden more and more with the years for their self-care following this global trend.

Undergraduate Thesis / Postgraduate Dissertation 21 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

The OTC consumption for self-medication and the release of price and place should have decline the cost for health as it was expected. But now we see that retail prices increase instead of falling. The limitations on advertising may be a reason for this action. More specifically in circular 49393/2011 of National Drug Organization (EOF) pharmaceutical companies are restricted to advertise the price discounts and promotion actions of OTC drugs. EOF is the responsible means of supervising compliance with the existing legislation regarding advertising of pharmaceutical products and can intervene when there is violation (Michalopoulou and Associates Law group, 2019). In Greece the advertising of prescription drugs is prohibited and only OTC drugs are allowed to be advertised under conditions (MD 32221/2013 advertisement of non-prescription medicinal products). According to the articles 119 and 121, the advertising medicinal products to the public must be displayed in a way that the message is clear and the product is clearly identified as a medicinal product. The advertising message must include some information such as the name of the product, information for the correct use, recommendation for reading the instructions on the leaflet and also, must not contain misleading information, suggestions that the health can be enhanced or damaged if not taking the medicine, suggestions that it can be directly given to the children and others (Michalopoulou and Associates Law group, 2019). Additionally, SFEE and SEE, self-auditing organizations, have the right to perform control over delinquent behaviors.

3.4 Analgesics

Analgesics or pain relievers or painkillers are medicines that reduce or relieve pain. The main categories of analgesics (Harvey et al, 2007) are:  NSAID (non-steroidal anti-inflammatory drugs), such as aspirin, ibuprofen, naproxen, diclofenac.  Acetaminophen or paracetamol, known with the brands Depon, Panadol, Tylenol etc.  Opioid, such as codeine, morphine etc, which have the risk of addiction.

Undergraduate Thesis / Postgraduate Dissertation 22 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

It should be mentioned that the most of analgesics are prescription drugs. More specifically all opioids analgesics and the most of NSAID analgesics require doctor’s prescription and only paracetamol and some NSAIDs such as ibuprofen (less than 400mg), aspirin, naproxen are OTC drugs. The OTC analgesics are very popular to the public and a very fast growing category of OTC and generally of self-care products for the following reasons (www.pharmamanage.gr):  The consumer try to self-manage mild pains such as headache, toothache, period pains, sore muscles, joint pains, cold and flu conditions and fever.  The intense and continuous advertising through mass media increase the popularity of a brand and also the competition among the brands.  OTC analgesics is a safer solution in comparison with the prescription NSAIDS, which should not be used for a long time.

According with IQVIA (2019) the pain relievers value share is 15.9% globally and 16% in Europe among OTC drugs. In Greece paracetamol was the most popular OTC drug with 42% share according to data of wholesale from AESGP and Assosalute Italia, which were presented from Panos Zarogoulidis in the second Symposium of Pharmaceutical Epidemiology in Alexandroupolis in 2017 (Sarafi, 2017). Xylometazoline with 5.4%, aspirin with 3.4%, ibuprofen with 3%, diclofenac gel 2.8% and oxymetazoline with 2% were the other popular self-medication products. Concerning the advertising of analgesics OTC drugs, most of the popular advertisements display a drug of this category and this is due to the huge need of people to deal with pain. Pharmaceutical companies invest more and more on the marketing of OTC analgesics, and try to focus on the strong and fast action of the drug. Impressive packaging, clever advertisements on TV, combination of 2 or 3 active ingredients for better action (Algon), placement on front shelves on the pharmacy and sometimes marketing campaigns (Novartis-migraine) are effective tricks for the promotion of OTC painkillers and generally OTC drugs.

Undergraduate Thesis / Postgraduate Dissertation 23 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.5 Advertising in Pharmaceutical Industry

Advertising is the means of communication with the potential consumers of the product or service, while advertisement is the paid message sent from the pharmaceutical company with the aim to inform and influence people to buy it (The Economic Times, 2020). Advertising is any paid form of non-personal presentation and promotion of ideas, goods, or services by an identified sponsor (Kotler, 2002). The advertiser makes 5 crucial decisions known as 5 M’s: Mission, Money, Message, Media and Measurement:  Mission defines the advertising objectives that can be classified to a) informative advertising (the consumer becomes aware of a new product or new attributes of established products), b) persuasive advertising (the consumer is convinced to buy a product with or without comparisons to other brands) and c) reminder advertising (the consumer is in contact with an already known product) (Tsiames, 2005). According to Hoog (1994), in the first years of product introduction, the OTC drug advertisements should be more argumentative or informative (give more information about the product) than persuasive (give emphasis to emotion), while some years later the consumer is aware of the product and the competition increases, so the advertisement should be more persuasive and less informative. Reminder advertising is important in mature products such as depon, so as to remind people to purchase a good OTC pain reliever.  Money means the advertising budget. According to Kotler (2002), the marketer should decide the budget having in mind the product life cycle, the established market share, the competition, the substitute products and the advertising frequency. Generally, the money spent in advertising are much more in

comparison with R&D. For example, the top 10 US companies in 2002 spent for marketing and administration 31% of sales, compared with only 14% for R&D (Angell, 2004)  Message is generated, evaluated, selected and executed (Tsiames, 2005). Creating an effective message presupposes that the targeted audience is related to it and believe it. In the case of OTC painkillers, the advertisements show people to use a drug in order to relieve their pain. The message should be easily understood, memorable and make the product exclusive. Also it is important how the message

Undergraduate Thesis / Postgraduate Dissertation 24 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

is said, rationally or emotionally. In rational advertisements, it is noted the purpose of the product, while in emotional advertisements, there is appealing music or images, humor or attractive colors. Other characteristics of an effective message are the style and size of letters, colors, illustrations, music. Finally, ad message should be according to social and legal norms.  Media selection involves finding the most cost effective media to deliver the desired number of exposures to the target audience. The message should reach the consumer and create an impact to him (the qualitative value of the exposure) (Kotler, 2002). The most major media types are television, radio, newspapers, magazines, telephone, e-mail, outdoor, internet. o Television has a dominant role in the advertising world and its advertisements are very effective as their pictorial and sonic presentation give an impressive and lasting impression on people’s mind. TV advertising is the most expensive and the duration is only around 30 seconds, but it can transmit the message to a large audience. o Radio is a less costly media and has the advantage to select targeted audience as the type of music is related with demographics. Radio advertisements can be live read, sponsorships and spots with duration from 15-70 seconds. o Press (newspapers, magazines, brochures) is the traditional form of print advertising and is still used today. Colors, texts, the place of the ad on the page are important factors of an effective advertisement. o E-mail and telephone are more personal means of advertising, but have relatively high cost and sometimes can be annoying. o Outdoor advertising can be posters, signs, banners, billboards. It is a fresh and creative approach of advertising, but it works only as a team player with other media. o Internet or online advertising include ppc (pay per click), paid social and online display advertising. Today this way of advertising is growing fast and is suitable for businesses of all sizes, can reach and find new costumers and diversify their streams. Although online advertising is trend today, the competition is huge, ad fatigue is common and the advertisers should notice

Undergraduate Thesis / Postgraduate Dissertation 25 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

where to display their advertisement and have new ideas to promote their product (Emma, 2019).  Measurement of the advertisement’s effectiveness can be done through a) communication-effect research (before and after the campaign) and b) sales-effect research (more complex as the sales are influenced by many factors such as price, availability, competition products) (Kotler, 2002).

The purpose of advertising pharmaceutical products has no difference from that of advertising any other product; you try to produce an awareness that will motivate the potential consumer to utilize or prescribe your product. The major difference is that advertising a pharmaceutical product has limitations from the government (Smith, 1988).

3.5.1 Direct-to-Consumer-Advertising (DTCA)

Direct-to-Consumer-Advertising is the advertising of prescription drugs directly to patient or the health professional through mass media or internet platforms. DTCA is totally legal only in the United States and in New Zealand. Also, Canada does allow DTCA that mention either the drug or the indication, not both (Ventolla, 2011). According to the Journal of the American Medical Association (JAMA), there has been a drastic increase in DTC prescription drug marketing budgets, jumping from $1.3 billion in 1997 to more than $6 billion in 2016; that is a 361% increase. These companies use DTCA to promote prescription drugs, because it increases the volume of drugs sold (Das, 2019). In the European Union and Greece, the advertising of prescription drugs is prohibited and only Over-The-Counter Drugs are allowed to be promoted through mass media and the internet.

3.6 OTC drugs Advertising Effectiveness

OTC drug advertising has gained ground last years and especially when Rx-to-OTC switch occurs, the pharmaceutical companies run to promote their products better than their competitors. Branding is the key to the promotion of an OTC drug through

Undergraduate Thesis / Postgraduate Dissertation 26 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

advertising, because as it happens with all consumer goods, a good brand name creates trust, something of major importance in the case of health. According to DeLorme et al (2010), OTC drug advertising helps to:  The promotion of self-medication  Increased awareness of health conditions and better knowledge of self-treatment  The purchase choice of OTC drugs by positing them as the best solutions for relieving symptoms.

Although pharma companies spent a lot of money to the promotion and advertising campaigns, research has proved that adverting has greater impact on the awareness of the product rather than the buying decision. According to Tiwari (2016) and data collected from 400 consumers in Nepalese context, OTC drugs advertisements have positive effect (41.2%) on the awareness level of people, while there was a negative impact on the buying behavior of consumers (60.44%). A similar survey in Greece conducted to 1000 citizens showed that 42% of citizens are not be influenced by OTC drug advertising at all, when the main factors affect the buying decision are the drug safety (72%), fast action and effectiveness (62.5%) and pharmacist’ advice (54.9%) (IOBE, 2017). According to Hanna and Hughes (2011), advertising of non-prescription medicine is not one of the major reasons that influence the consumers to make the purchase.1461 people of Northern Ireland participated in this survey and 95.9% agreed that they were influenced by the effectiveness of OTC drug, 71.9% by the familiarity with the brand and 77.8% by the safety. The advertising effect was obvious only on the 35% of the sample. Another study conducted at 70 randomly selected community pharmacies in Skopje, which has as participants female pharmacists, resulted that 61.5% of patients are greatly affected by OTC drug advertising and 81.4% of patients choose the OTC drug influenced by the advertisement. Also, 77.7% of the pharmacists believe that the OTC drug advertising has no impact on the pharmacists’ recommendation (Kapedanovska- Nestorovska et al, 2016). The strong role of pharmacist is evident additionally when 6 from 10 citizens first ask the pharmacist before they purchase an OTC drug according to IOBE (2017). Also, 53.3% of the respondents strongly disagree that they do not purchase an OTC drug regardless of the pharmacist’s recommendation (Hanna and Hughes, 2011).

Undergraduate Thesis / Postgraduate Dissertation 27 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Stephens and Johnson (2000) examined the age differences in the decision making process to purchase an OTC cold/allergy drug. According to the findings, older people spend more time on TV, but both older and younger are little influenced by OTC advertising. Concerning the factors that trigger them to make a choice, older people are affected more by health care professionals, such as doctors and pharmacists, while younger people are affected more by friends and family. There is no significant difference in the case of positive past experience of an OTC cold/allergy drug. Concerning the content of the advertising Kavanoor et al (1997) found that the direct differentiate comparative ads, in which the advertised brand is compared with the rival, usually the market leader is effective on OTC drugs. This strategy would be helpful for pharmaceutical companies that introduce a new OTC drug and additionally, credibility enhancement measures of the ad should be taken in order to support their claims. Also, according to Anderson et al (2009), in the comparative advertising of OTC analgesics in USA larger firms are more likely to be attacked and for this attack the advertised firm would pay 45cents of dollar. In the case of non-comparative or self-promoting advertising, higher market share companies prefer these ads and have more impact on consumers compared with outgoing attacks. Lee et al (2015) studied the factors influencing the responses to DTCA and OTCA and found that the exposure to DTCA was higher than to OTCA, but the levels of attention were moderate to low in both cases. Among other interesting findings were the following:  Positive attitude toward OTCA predicted more given attention to OTC advertising  Lower ages and increased use of OTC drugs predicted more attention to OTCA  Higher levels of education and lower age were related with less involvement with OTC drugs

3.6.1 OTC analgesics advertising effectiveness

Selling pain relief is a huge business all around the world, but there is so much competition between the many almost homogenous medicinal products. The solution is to be differentiated and this can succeed with the advertising. . In Greece the most often

Undergraduate Thesis / Postgraduate Dissertation 28 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

active ingredients of OTC drugs used for aches are paracetamol (acetaminophen), acetyl- salicylic acid (aspirin), ibuprofen and combinations. The main advertised brand names, which are familiar to the public, are Depon, Panadol, Apotel (paracetamol), Aspirin- Bayern (acetyl-salicylic acid), Nurofen, Algofren (ibuprofen <400mg) and Algon (combination of paracetamol, acetyl-salicylic acid and caffeine). In 1961 Lavidge and Steiner have introduced the Hierarchy of Effects model (HOE model) for predictive measurements of advertising effectiveness. This model is composed by three stages a) cognitive (awareness and knowledge) b) affective (liking and preference) and c) conative (conviction and purchase). These stages correspond to thinking, feeling and behavior respectively, are closely related to consumer decision process and the advertiser should lead the consumer to the final step, the purchase of the product. Huh et al (2015) tested a HOE-based model to explore how OTC drug advertising (OTCA) affects people’s response to OTC analgesics. Examining the ad attention, they found that 87% of the respondents had seen or heard an OTC analgesic advertisement in the past month, indicating that consumers give emphasis to advertising of OTC analgesics. Finally, they resulted in two major patterns from their study: a) the message of the OTC drug is more important than the advertising itself and b) the cognitive response was stronger than the affective response; the consumers first take into account the informational value of the OTCA and then decide with the emotion. So, as concerns OTCA the marketers should give emphasis to problem-solving message of the ad and the effectiveness of the ad should be measured by cognitive and affective effects rather than behavioral effects, which work better in other promotional ways such as coupons. Examining the relationship between TV advertising and buying decisions on OTC analgesics among the students of Warsaw Medical University, it was found that there is a significant effect from TV commercials (29.31%), following the pharmacist’s advice (18.1%) and internet (18.1%), family and friends recommendations (17.4%) and prices (15.51%). Also, 46.55% of students buy the OTC analgesic based on its efficacy and among OTC analgesics headache tablets is the most popular (90%) (Czerw et al, 2015). It is noticeable that even in this group of population, which learns about medicines during lectures, the effect of advertising is evident. According to Paddison and Olsen (2008) and their study conducted in UK, advertising does not influence the OTC painkiller choice and it is more for reinforcement reasons

Undergraduate Thesis / Postgraduate Dissertation 29 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

rather than persuading the consumers. Although, it was found that the younger consumers give more emphasis to OTC painkillers advertisements and it is more likely to remember such an advertisement in comparison with older people.

3.7 Consumer Behavior

Understanding people’s needs and wants is a vital and complex part of marketing known as consumer behavior. Needs are human requirements and become wants when they are aim to specific entities that will satisfy them. Then, demand is defined as these wanting entities backed by the ability to pay (Tsiames, 2005). Consumer behavior is “the actions and the decision processes of people who purchase goods and services for personal consumption” (Engel et al, 2001). Three factors affect consumer behavior:  Psychological Factors. Perception of a need or situation (the process of interpreting information), the ability of someone to learn information, the person’s beliefs (personal thoughts about something) or attitude and motivation (an internal force that lead to individual activities).  Personal Factors that are unique characteristics to each person. Demographic factors such as age, sex, race, family life cycle, income, occupation (Tsiames, 2005). Lifestyle, personality and self-image.  Social Factors are family, any social interaction group such as work or school, social class or status (someone’s position on a group) that is related with the income, educational level and living conditions.

According to a Salesforce report (2020), 76% of consumers expect companies to understand their needs and expectations. Also, Drucker and Levitt emphasized that it is very important for the marketers when they study customer behavior to have in mind not only to create customers, but retain them as well (Mamali and Diderich, 2017).

Undergraduate Thesis / Postgraduate Dissertation 30 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.8 The Consumer Decision Making Process

In the traditional marketing funnel concept, developed by Lewis in 1898, the buying decision process is composed by four stages: awareness, interest, desire and action (AIDA) (Gilbert et al, 2014). This means that consumers start with many alternatives or brands and then methodically reduce them in order to make the purchase (Figure 5).

Figure 5: Marketing Funnel

Source: (Court et al, 2009)

Based on research with 20,000 businesses in USA, Germany and Japan, in 2009, Court et al (2009) suggested a dramatic alternative to the traditional purchase funnel. They proposed a loop model instead of the usual straight line approach of marketing funnel and this model can fill many gaps and prevent lost sales opportunities. This circular model known as customer decision journey (Figure 6) includes four phases: initial consideration (options on consumer’s mind), active evaluation (researching potential purchases), purchase and post-purchase (building expectations by experiencing his purchase).

It should be noted that the act of purchasing in only one step of the process and not all processes lead to the purchase. The consumer may end the process at any stage and sometimes the whole process does not include all phases. (Tsiames, 2005) For example, if the customer has become loyal to the brand, his initial need to buy a product leads straight to the moment of purchase (loyalty loop depicted in Figure 6).

Undergraduate Thesis / Postgraduate Dissertation 31 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Figure 6: Customer Decision Journey

Source: (Court et al, 2009)

From the view of Global Self-Care Federation (2020), this model takes the following form as depicted in the Figure 7.

Undergraduate Thesis / Postgraduate Dissertation 32 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Figure 7: The customer decision making process

Source: (Global Self-Care Federation, 2020)

3.8.1 Steps in the consumer decision making process

 Awareness phase. Before there is a health-related problem or need, the consumers are exposed to numerous available information sources that they help them to their search. Advertising is the most important tool that marketers use, so as to display the brand, differentiate it among the competition, provide information about the health benefits and the condition, for which it is suitable and finally, they create the awareness to the public. According to Huh et al (2016), attentiveness is driven by the necessity of the OTC drug at the time consumers are exposed to the advertising. The greater the need for a solution to a health issue, the greater the attentiveness will be to the message. Sometimes the marketers create the awareness of an OTC product, which is not perceived as needed in the absence of advertising (Wilson and Kollander, 2011).  Need Recognition. This is the moment when the consumer recognizes a health problem and proceeds to self-treatment (such as common cold symptoms, allergy,

Undergraduate Thesis / Postgraduate Dissertation 33 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

pain or insect bite) or he wants just to prevent an incoming problem (such as reinforce his immune system to prevent the common cold).  Information Search. In this phase, people search and gather information with the aim to find a solution to their problem. If they had a past experience with the same health issue, they are more ready to buy the same drug. If they experience the health problem for the first time, there are many sources to gather information apart from advertising such as doctor, pharmacist, friends and family. According to Court et al. (2009) 37% of the touch points during the searching phase involve Internet reviews and word of mouth recommendations from family and friends. Another research by IOBE (2017) concerning the effect of mass media on people’s OTC drug selection shows that 54% of Greek consumers are affected by brochures in the drug store, followed with 32% TV advertising and only 8% digital advertising and 6% print advertising. According to Global Self Care Federation (2020), the impact of advertising is low on the OTC drug purchases, but advertising is an important means of awareness and helps the brand to be differentiated from the competition.  Evaluation of Alternatives. The consumer uses evaluation criteria with different weights to them in order to choose the best alternative product for his health need. According to Lee (2005), who made a research about imported health food products in China, function and price are the most important criteria and brand, country of origin and packaging are following regarding the evaluation of alternatives. It is a frequent phenomenon that the first action of the consumer in this stage is to stay home and wait until he feels better (52%), only 14% takes the OTC drug and 12% visits the doctor according to IOBE (2017).  Purchase Decision. Purchasing a product about health is more complex and usually the final decision occurs, when the consumer is on the drug store (Global Self-Care Federation, 2020). According to IOBE (2017), the major factors that affect the Greek public to purchase OTC drugs are the drug safety (91%), its fast action and effectiveness (88%) and the pharmacist’s recommendation (76%).

Undergraduate Thesis / Postgraduate Dissertation 34 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Another study by Koslow (2015) in Australia suggests that 69.9% of people always seek a pharmacist’s advice prior to an initial purchase of a new medicine. In the case that there is a past experience the consumer selects and buys easier the OTC drug. According to Taylor et al. (2016), there is positive experience with a non- prescription therapy (81%) and only 4% of people had side effects after being suggested by their pharmacist.  Post purchase behavior. After the purchase the customers evaluate the product through experiencing it and in the case of OTC painkillers the outcome is pain relief or continuation of pain. If the patient is satisfied, it is a high possibility of repurchasing the OTC drug. Also, according Court et al. (2009), there are two types of loyalty: active loyalists who like the brand, but also recommend it and passive loyalists, who are just satisfied enough by the brand, but they are open to new solutions.

3.9 What is Self-Care?

Self-care is a trend that has already gained ground in modern society and more and more people try to find solution to their health problem or prevent a health situation by themselves. As William Shakespeare has told “Our bodies are our gardens to which our wills are gardeners”. The first definition of self-care came from the World Health Organization (WHO) in 1983 defining it as "activities individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health. These activities are derived from knowledge and skills from the pool of both professional and lay experience. They are undertaken by lay people on their own behalf, either separately or in participative collaboration with professionals." Self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a health worker as defined by World Health Organization today in 2020.

Undergraduate Thesis / Postgraduate Dissertation 35 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Self-care starts with the simple everyday habits, such as washing your hands, cleaning your teeth, eating fruit and dinking plenty water, taking exercise or using OTC drugs for minor illnesses. Also, self-care includes preventing infections or chronic diseases, improving your health and well being and finally learning to live with chronic pain or generally chronic health disorders (Australian Health Policy Collaboration AHPC, 2018). The Global Access Partners (GAP) 2015 report gives emphasis to “the importance of health literacy and the role pharmacies and non-prescription medicines can play in supporting responsible self-care and reducing government expenditure. As well as enabling a more efficient health system, these factors are consistent with a growing desire by health consumers to become more involved in their own health care.” According to the Association of European Self-care Industry (AESGP, 2020) self-care continuum involves health literacy, good hygiene, healthy lifestyle choices (physically health, healthy eating) and avoiding unhealthy habits (smoking or excessive alcohol consumption), responsible self-diagnosis (recognizing the symptoms), self-treatment (using responsibly prescription and non-prescription medicines), self-monitoring the progress of illness and supplementation. Self-medication is a part of self-care and includes the proper selection and use of OTC drugs with the aim to manage mild illnesses or minor symptoms, which are diagnosed by individual without the doctor intervention, but with the pharmacist recommendation as mentioned by the Foundation of Economic and Industrial Research in Greece (IOBE, 2017). An important part of self care continuum is self-care products. OTC drugs, food supplements, such as vitamins and minerals and self-care medical devices such as throat lozenges, nasal sprays, thermometers (AESGP, 2020). Self-care products can treat minor ailments that include colds and flu, cough, sore throat, allergies, mouth ulcers, incomplete or difficult digestion, infrequent and difficult stools, vomiting, diarrhea, sunburn, warts, headaches and muscular pain, cuts, insect bites, eczema and others. According to 400 persons research by Khan et al. (2016), the reasons that lead people to self-care were first mild illness (52.1%) and cost saving (50.3%), following convenience (45.1%), lack of time (36.4%), prior experience with illness (34.6%), reluctance to follow up (33.2%) and quick relief (31.5%) and finally unavailability of doctor (24.1%) and avoid crowd in visiting doctor (15.4%).

Undergraduate Thesis / Postgraduate Dissertation 36 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.9.1 Benefits of self-care

According to IOBE and EFEX the implementation of self-care can benefit people in many aspects of their life and the major of these pros are the following. Self-care:  Empowers people to take their health into their own hands and gives them an active role in the prevention and the treatment of minor ailments. As a result, time and cost from seeing a doctor are saved, more people even in remote areas are served, and people having chronic diseases find solution to their daily problems easier and faster.  Gives the pharmacist the role of the scientific consultant. The drug store is the first place of primary health care, where the citizen can find self-medication products and the pharmacist is here to recognize the problem, recommend the right OTC drugs, to give instructions for the right and safety use of them in the case of minor symptoms and to refer the patient to the doctor if necessary. Also, the promotion of self-care and self-medication has as a result the increase of profitability in the drugstores.  Decreases the waiting time in the doctor’s office and gives the doctor the opportunity to provide better services and give emphasis on more serious health issues.  Saves costs not only for households, but also for governments. The public pharmaceutical expenditure is lower and the government can allocate the resources more efficiently and effectively. The increase on purchase of OTC drugs has economic benefits for the pharmaceutical companies, the pharmacists and the government through the taxes. Also driving people to self-care reduces the amount of hospital and private pharmaceutical expenditure, thus the government becomes sufficient to cover the population needs. Dereck Wanless suggests in his report in 2002 that “for every £100 spent on encouraging self-care, around £150 worth of benefits can be delivered in return”.

Undergraduate Thesis / Postgraduate Dissertation 37 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.9.2 Problems arising from Self care

“Pan metron Ariston”, means “everything in moderation” said by Kleovoulos Lindios in the 6th century B.C. There should be balance between how I can take care of my health and when to ask help from a health professional. Sometimes the consumers cross over the line and in their effort to be self-treated, they end up with serious problems. This can happen in the following cases:  OTC drugs’ abuse can lead to major health problems, as the side effects of these drugs can affect vital functions of the human body resulting often to hospitalization (Lykoudis, 2019).  Recommendations from family members or friends. Sometimes people search for help to their familiar persons, who had a similar health issue and take the non- prescription drug without asking for the pharmacist’s advice. This is a wrong action, because we should not compare our situation with anyone.

3.9.3 Greek Responsible Health Self-care Campaign with focus on pharmacy

The Pan-Hellenic Pharmaceutical Association in co-operation with the Association of Greek self-medication industry (EFEX) implemented an interesting campaign for the promotion of Self-care practices with the necessary participation of the scientist - pharmacist. The message of the campaign was “Self-care: Take care of yourself, Ask your pharmacist.” and recommended the public to contact with the neighborhood pharmacist in the case of mild symptoms or a health disorder. The pharmacist as the major ambassador of the campaign is called to promote the proper self-care products or give the right instructions for the prevention or treatment of minor ailments and also to refer someone to the doctor if it is necessary. This campaign lasted from February until May 2020 in the territory of Greece and included publicity actions such as press conference, radio spots, articles and interviews and official page on Facebook. Also, informative posters, brochures and badges were sent to pharmacies trying to reinforce this effort.

Undergraduate Thesis / Postgraduate Dissertation 38 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

3.9.4 The role of pharmacist to Self-care

According to EFEX pharmacists have a multidimensional role on self-care and self- medication practices and they should guide people to manage better their health.  As an informant, pharmacist is the first person to ask for the medical history of the patient and guarantee his privacy. He should be properly prepared and equipped to check the patient and estimate his health issue. Also, he should provide objective information about OTC drugs and be sure that the patient understands and applies his instructions. In the case that he considers the health disorder serious, he should immediately contact with the doctor and refer the patient to him.  As a dug supplier pharmacist ensures the right selection, storage and trading of OTC drugs and the other pharmaceutical products.  As an instructor and supervisor pharmacist is responsible for the good practice of the working staff and additionally he should have motivation to lifelong learning.  As a co-partner with other pharmacists and health professionals, patients, citizens, mass media, insurance funds and health organizations in order to share data and experiences for the best self-care practice.  As a health promoter pharmacist should participate to health promotion campaigns and be part of the health system in general.

3.9.5 Self-care in the time of COVID-19

The last months after the coronovirus outbreak, self-care has become more important in our daily lives. First detected in Wuhan, China in December 2020 the new virus has expanded very fast all around the world sowing panic to the unprepared humanity. Until now there is not a real solution to slow down the epidemic, although health care measures and health literacy are of great importance. According to AESGP (2020), prevention is better than cure and some of the measures that help to minimize the spreading of infection are:

Undergraduate Thesis / Postgraduate Dissertation 39 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

 Boosting our immune system by healthy eating, being physically active and taking vitamins as supplementation.  Washing hands regularly and diligently and cover our nose and mouth when we cough and sneeze.  Give attention to reliable information of local health authorities about traveling, restrictions in our daily routine. Panic and misleading information are not helping.  If we feel unwell (fever, cough, difficulty breathing), we stay home, contact with our doctor and relieve our symptoms using OTC drugs, self-care devices and relaxation.

Undergraduate Thesis / Postgraduate Dissertation 40 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Chapter 4: Research Methodology

Research is a process, which includes data collection and analysis aiming to better understand an issue (Creswell, 2016). Generally, research is composed by three stages:  Posing a question  Data collection for answering this question  Presenting an answer to this question

The methodology of the research is used to explain the actions and methods used in order to investigate the research objectives allowing the readers to evaluate the reliability and validity of the research outcome.

4.1 Methodological approach

Through this study it was attempted to be investigated the effect of OTC painkillers advertising on consumers purchase choices. It was analyzed the tendencies of consumers towards the OTCA, the factors that lead to OTC painkillers selection and the involvement of consumers with OTC painkillers, as well as whether these variables change in relation with gender, age, educational level, occupation and residence. Also, it was measured the exposure to mass media and the attention of the respondents to OTCA. Finally, this study tried to describe the general opinion of the public about OTC painkillers. It was considered appropriate for this reason the application of a quantitative research, as it can be used to find patterns and averages expressed in numbers and additionally it can be used to explain how a variable affects another variable. More specifically, the survey research design (Creswell, 2016) was selected, which includes the following stages:  quantitative and numeric data collection through the administration of a questionnaire to the population  statistical analysis of the data so as to be explained the tendencies, opinions, behavior and the characteristics of this population  interpretation of the data by correlating the statistics results with previous researches.

Undergraduate Thesis / Postgraduate Dissertation 41 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

In the case of the survey method, data are collected from the original source for a specific problem (primary data) (Kavussanos, 2005) and the researcher gathers them through the questionnaire or interviews. Also, there is no control over the way the data are generated (descriptive method) (Kavussanos, 2005). Concerning the timescale and location of the research design, this survey was cross- sectional, in which the researcher gathers data in a single point of time, so as to study the current tendencies of the population (Creswell, 2016). This field survey took place in the real world, as it aimed to find out how something occurs.

4.2 The sampling method

The target population selected in the present study was the OTC painkillers consumers in the regional unit of Florina. This selection was made in order to investigate how the citizens of Florina and the rest regional unit are affected by the OTC painkillers advertising. As it was not feasible to examine the whole target population, it was conducted non- probability convenience sampling, in which the researcher selects persons, who are available and convenient and have a representative characteristic that is examined (Creswell, 2016). In this case, the sample may be not representative of the target population, but it can be used in order to provide helpful information for answering the research objectives. In this study the sample was consisted of 130 participants, of whom 66.2% live in the city of Florina and 33.8% live in the rest regional unit of Florina. It was very important to take the permission of the participants in order to be studied and used in this research (Creswell, 2016). Ethical considerations should be taken into account as there are sensitive issues that are examined. So, the participants were first informed for the research aim and that their personal data are safe before they become part of the survey.

Undergraduate Thesis / Postgraduate Dissertation 42 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

4.3 Data collection

The collection of primary data was conducted through a questionnaire and Google Drive form application was used in order to be gathered electronically. According to Kavussanos (2005), questionnaires provide a cost effective way to gather information, but the design of this is very important for reliable and sufficient data collection. Another advantage of the questionnaire is that it is easy enough and a quick way of data collection. Also, the fact that it is anonymous gives participants the chance to be sincere (Robson, 2007). The questionnaire though has disadvantages such as the misunderstanding of the questions, not taking serious the completion of the questionnaire or not having enough time and giving non objective answers. The participants were asked to complete the questionnaire in person with the use of a tablet either alone or with the help of the researcher in the cases of older people or people unable to use the tablet. The questionnaire was online administered, too, targeting only people who live in the regional unit of Florina. Data collection had duration 2 months, from February until April 2020.

4.4 Questionnaire design

Designing a measurement device such as a questionnaire is not an easy process and there is not a standard method to do it. According to Silver et al (2013), some useful characteristics that a questionnaire should have are the following:  include questions that express the study objectives, collect meaningful information or measure the behavior of the respondents  be appealing to the respondent, easy and able to understand and have the appropriate context targeted to the right sample of population  provide the right amount of information, no more no less  classify the questions for better presentation

In the present study, first the research objectives and the literature findings were taken into consideration, then we found similar surveys, from which the questions were taken and

Undergraduate Thesis / Postgraduate Dissertation 43 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

finally we designed the questionnaire with closed-ended questions. This type of questions is easier for the respondents to understand and faster to answer. Before the administration of the questionnaire, it was tested pilotly with three volunteers from the family environment in order to evaluate its structure, the question understanding and the time needed to be completed. After some corrections, the final questionnaire was ready, 10 minutes to be completed and administered to the sample.

4.5 The questionnaire structure

In the first page of the questionnaire it was noted that the questions concern non- prescription painkillers, which are administered by mouth and crèmes or gels are not included. Five parts of questions were followed. The first part concerned the exposure to the mass media and the attention that the respondents gave to OTCA. The second part had the aim to understand the opinion of the respondents towards the OTC painkillers advertising. The third part examined which factors influence more the consumer to the buying decision and the fourth part included questions about OTC painkillers generally. The fifth part had the demographic characteristics of the sample.

Part 1 The first two questions are related to the frequency that the consumers are exposed to mass media (TV, radio, newspaper, Internet) and the frequency that they give emphasis on an OTC painkiller advertisement. These frequencies were measured on a scale of 1=never, 2=1-2 times a month, 3=once a week, 4=3-4 times a week and 5=every day. The next two questions concern brands of OTC painkillers that respondents see most on advertisements and purchase most, aiming to understand whether the most seen brand is the most purchased or not.

Part 2 The following questions 5-14 refer to the tendencies of consumers towards the OTC painkillers advertising.

Undergraduate Thesis / Postgraduate Dissertation 44 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

 Questions 5, 6 and 12 are based to the study of Tiwari (2016) and refer to the awareness and buying OTC painkillers through the advertisement.  Questions 7, 9 and 10 have to do with the humor of the advertisement, best self- medication choice and not mentioning the side effects on the advertisement and are based on the study of Czerw et al. (2015).  Questions 8 and 11 examine the opinion of the consumers about the advertising effectiveness and the power of advertising to make an OTC painkiller popular to the public and are used in the research dissertation of Papadaki (2012).  Questions 13 and 14 refer to the positive and negative emotions respectively that the advertisements create to the consumers.

Part 3 In this part the questions are formed so as to find out the main factors that influence consumers to purchase an OTC painkiller. Questions 15-22 are inspired by the quantitative research of IOBE (2017) about OTC drugs, which concerned the whole population of Greece. The factors examined are advertising, recommendation by pharmacist, doctor or family and friends, price, trust on the OTC painkiller and popular brand. Questions 16 and 17 referring to pharmacist’s advice are based on the study of Kapedanovska-Nestorovska et al (2016).

Part 4 Questions 23-30 are used in order to understand the general opinion about OTC painkillers including the frequency of use, the safety, the increase of price and the debate whether selling OTC painkillers outside the pharmacy or not. These questions are based on the study of IOBE (2017).

In questions 5-30 the Likert scale was used to measure the consumers’ behavior. Likert scale is a five level psychometric scale, where 1=strongly disagree, 2=disagreed, 3=neither agree nor disagree, 4=agree and 5=strongly agree.

Undergraduate Thesis / Postgraduate Dissertation 45 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Part 5 In this part, the demographics were placed:  gender (male, female)  age (18-34, 35-44, 45-54, 55-64, 65-74, 75+)  educational level (primary, secondary/high, vocational, bachelor, master/PhD)  occupation (state/private employee, self-employer, farmer/stockman, retired, unemployed, university student, domestic)  residence (city of Florina, rest regional unit of Florina)

4.6 Data analysis

The data gathered from the questionnaire in Google Drive form application were entered to SPSS (Statistical Package for the Social Sciences). In this quantitative research, which was based on numbers, the data were analyzed statistically. More specifically the statistical analysis included:  The demographic characteristics of the sample.  The frequencies, the means and the standard deviations of each question.  Cronbach’s alpha (a) as reliability analysis that measures the consistency of the responses of the sample at each category.  Non parametric tests and more specifically 2 and K Independent Samples in order to test the significant differences between the sub-groups of the sample having same demographic characteristics in relation with the mean scores. The ad attitude mean score was created from the questions of Part 2 in order to estimate how OTC painkillers advertising influences consumers and thus affects them in their decision buying process. The mean score of buying OTC painkillers tendency arouse from Part 3 aimed to explain if demographics play role to the degree that the examined factors influence the respondents. Finally, the OTC painkillers involvement mean score from Part 4 used to find out whether the different demographic characteristics were related to how much the sample is involved with OTC

Undergraduate Thesis / Postgraduate Dissertation 46 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

analgesics. In each case, demographics were the categorical independent variable (factor), whereas the mean score was the continuous dependent variable. It should be noted that we conducted non parametric tests, because the assumption of normality has been violated in most cases. Mann-Whitney test (2 Independent Samples) was used for the demographic characteristics gender and place of residence, whereas Kruskal-Wallis test (K Independent Samples) was used for age, educational level and occupation. These non parametric tests control if the population distributions are different or not through the Null and the Alternative hypothesis.

We stated the Null Hypothesis (H0), where the mean score is not different between

the sub-groups and the Alternative Hypothesis (H1), where the mean score is different between the sub-groups. So, having setted α=0.05, if p-value > 0.05 we retain null hypothesis, if p-value < 0.05 we reject null hypothesis, where α is the significance level (the probability that the Null Hypothesis is rejected). This means that if p-value > 0.05 there is not statistically significant difference between the mean score of different sub-groups, whereas if p-value < 0.05 there is statistically significant difference between the mean score of different sub-groups. In the first case demographics play role to the mean score and in the latter case demographics do not affect the mean score.  Friedman test (K related samples), a non parametric test, aiming to control if there are differences between the responses for the factors that influence the consumers

to purchase an OTC painkiller. We stated the Null Hypothesis (H0), where there are not statistically significant differences among the responses and the Alternative

Hypothesis (H1), where there are statistically significant differences among the responses. So, if p-value > 0.05 we retain Null Hypothesis and there is no statistically significant difference among the factors leading the consumers to buy OTC painkillers, whereas if p-value < 0.05 we reject Null Hypothesis and there is statistically significant difference among these different factors.

Undergraduate Thesis / Postgraduate Dissertation 47 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Chapter 5: Research analysis and Results

5.1 Demographics

In this study 130 residents of the regional unit of Florina took part, from who 42 were men (32.3%) and 88 were women (67.7%) (Table 1). The percentage of women was higher than men for two reasons; a) women visited the pharmacy more often than men as it is noted by the bibliography and b) in the case of the online survey, women were more willing to complete the questionnaire.

Table 1: Absolute and relative frequency of the gender. F %f Male 42 32.3% Female 88 67.7% Total 130 100.0%

The biggest part of the respondents (53.1%) were between 18 and 34 years old, following the 55-64 age group (16.9%) and the 35-44 age group (14.6%) (Table 2). Among the groups, the younger respondents are more frequent and this can be explained by their convenience to be part of the survey. Though, 11 out of 130 persons were 65 plus years old due to the participation of the researcher in the completion of the questionnaire.

Table 2: Absolute and relative frequency of the age. Age f %f 18-34 69 53.1% 35-44 19 14.6% 45-54 9 6.9% 55-64 22 16.9% 65-74 5 3.8% 75+ 6 4.6% Total 130 100.0%

Undergraduate Thesis / Postgraduate Dissertation 48 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Concerning the educational level of the sample, 43.1% of the respondents were university graduates, 26.2% of them have finished secondary/high school and 14.6% of them were Master/PhD holders (Table 3). So, the majority of the sample had a good level of education, while the rest of it was either primary (5.4%) or vocational school graduates (10.8%).

Table 3: Absolute and relative frequency of the educational level. Educational Level f %f Primary school 7 5.4% Secondary/High school 34 26.2% Vocational school 14 10.8% Bachelor 56 43.1% Master/PhD 19 14.6% Total 130 100.0%

The respondents were asked to complete their occupation and 45.4% of them checked the box as state/private employee, following the self-employers (17.7%) and retired (13.1%) (Table 4). 12 out of 130 people were unemployed, 8 persons were university students and 6 persons were housewives. Only, 3.8% of the sample worked at the primary sector of the economy and this can be logically explained that the people of this sector were busy and had not enough time to complete the online questionnaire or visit the pharmacy.

Table 4: Absolute and relative frequency of the occupation. Occupation f %f State/private employee 59 45.4% Self-employer 23 17.7% Farmer/stockman 5 3.8% Retired 17 13.1% Unemployed 12 9.2% University student 8 6.2% Domestic 6 4.6% Total 130 100.0%

Finally, the place of residence was questioned and among the respondents 86 (66.2%) stated that live in the city of Florina and 44 (33.8%) in the rest regional unit of Florina (Table 5). Most of the letters are probable to live in Sitaria village, where the pharmacy is located and where a part of the survey was conducted.

Undergraduate Thesis / Postgraduate Dissertation 49 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 5: Absolute and relative frequency of the residence. Residence f %f City of Florina 86 66.2% Rest regional unit of Florina 44 33.8% Total 130 100.0%

5.2 Exposure to mass media and attention to OTC painkillers advertisements

In this part, it was measured the exposure to advertising through the mass media, such as TV, radio, press and internet and the attention that the consumers give to OTC painkillers advertisements. Thus, it would be easier to understand the effect of OTC advertising on the purchase of OTC painkillers. Concerning the exposure to advertisements through mass media, the majority of the sample (81.5%) were exposed every day in the last six months (Figure 8), indicating a high exposure level (M=4.65, SD=0.87). Responses were reported on a 5-point scale ranging from 1 (never) to 5 (every day). So, it is probable that they were exposed to OTC painkillers advertisements every day. In the next question, it was measured the attention that the sample paid to OTC painkillers advertisements in the last six months and it was found a low level of attention (M=2.45, SD=1.33). More specifically, 33.8% of the respondents gave emphasis to OTCA 1-2 times a month (rarely) and 28.5% of them stated never (Figure 9). The results indicated a negative attitude towards OTC painkillers advertising. In the study of Lee et al. (2015), the level of attention to OTC advertising was found moderate (M=4, SD=1.36) having significant difference in comparison with the present study.

Undergraduate Thesis / Postgraduate Dissertation 50 Figure 8: Exposure to advertising through mass media. Figure 9: Attention to OTC painkillers advertisements. Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

5.2.1 Most advertised and most purchased OTC painkillers

It was attempted to find out if the most advertised OTC painkillers according to the respondents were the same that they finally purchased. Figures 10 and 11 provide us with the following conclusions:  In the first case, there was diversity among the advertising OTC painkillers, while in the second case, only three drugs were dominant (depon, panadol and algofren).  The most frequent advertised OTC painkiller was panadol (25.8%), following depon (19.6%), nurofen (19.3%), seractil (14.1%), algofren (12.1%), apotel (5.6%), aspirin (3.6%) and algon was in the last place, which had not been seen in any advertisement according with the sample. The most frequent purchased OTC painkiller was depon (41.5%), following panadol (26.1%), algofren (19.5%) and the others having percentage less than 5.5%. Although the respondents saw panadol most often in the mass media, they purchased depon, which was the major choice in Figure 11. This is a first indication that advertising does not influence the sample to buy OTC painkillers.  Another finding was that the active ingredient paracetamol (depon, panadol, apotel) was purchased by 68.4% of the respondents or 7 out of 10. According to www.healthmag.gr (2019), 9 out of 10 purchased OTC analgesics in Greece have paracetamol.

Figure 10: Frequencies of the advertised Figure 11: Frequencies of the purchased OTC painkillers. OTC painkillers.

Undergraduate Thesis / Postgraduate Dissertation 51 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

5.3 Reliability analysis

Cronbach’s alpha is a statistic commonly used by researchers to demonstrate that tests have been constructed or adopted properly and are reliable to be presented (Taber, 2016). This statistic measures the consistency of the responses of the sample at each group of questions. It can take values from 0 to 1 and the acceptable values are above 0.45. In the present study, the questions were spitted into 3 groups and Cronbach’s reliability test was conducted in each group:  Questions 5-14 (Attitude towards OTC painkillers advertising), where Cronbach’s alpha was 0.77.  Questions 15-22 (Factors that influence the purchase of OTC painkillers), where Cronbach’s alpha was 0.53.  Questions 23-30 (General opinion about OTC painkillers), where Cranach’s alpha was 0.45.

5.4 Attitude towards OTC painkillers advertising

In this part, the consumers’ tendencies towards OTC painkillers advertising were investigated and it was attempted to estimate the positive or negative emotions that this type of advertisements created to them. Likert scale was used ranging from 1 (strongly disagree) to 5 (strongly agree). According to Global Self Care Federation (2020), advertising plays an important role on the awareness of OTC drugs, whereas it affects less OTC drug purchases. In order to determine the general opinion of the consumers for OTC painkillers advertising, 8 statements were used (Cronbach’s a=0.771), which concerned the information provided by OTCA and the reliability of them. The results captured the general view of the respondents for OTC painkillers advertisements and the degree of their liking (Tables 6 and 7).

Undergraduate Thesis / Postgraduate Dissertation 52 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 6: Results from the analysis of the statements about the attitude towards OTC painkillers advertisements on percents. Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree Advertisements inform me about OTC painkillers in the 6.2 14.6 43.1 35.4 0.8 market. Advertisements inform me about new OTC painkillers in 3.1 16.2 31.5 46.2 3.1 the market.

OTCA is funny. 4.6 23.1 53.8 17.7 0.8

OTCA persuades me for OTC 15.4 29.2 37.7 17.7 0.0 painkillers effectiveness. OTCA helps me to choose the appropriate OTC painkiller 15.4 36.2 26.2 20.8 1.5 (self-treatment). OTCA does not mention the side effects of the OTC 2.3 3.1 6.9 48.5 39.2 painkillers. OTCA makes OTC painkillers 1.5 6.2 25.4 49.2 17.7 popular to the public.

OTCA influences me to 12.3 36.6 23.8 23.8 3.1 purchase an OTC painkiller.

Undergraduate Thesis / Postgraduate Dissertation 53 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 7: Results from the analysis of the statements about the attitude towards OTC painkillers advertisements, mean and standard deviation. M SD Advertisements inform me about OTC painkillers in the 3.10 0.879 market. Advertisements inform me about new OTC painkillers 3.30 0.886 in the market.

OTCA is funny. 2.87 0.781

OTCA persuades me for OTC painkillers 2.58 0.955 effectiveness. OTCA helps me to choose the appropriate OTC 2.57 1.034 painkiller (self-treatment). OTCA does not mention the side effects of the OTC 4.19 0.872 painkillers. OTCA makes OTC painkillers popular to the 3.75 0.872 public. OTCA influences me to 2.68 1.064 purchase an OTC painkiller.

The first two statements were mentioned in the awareness of OTC painkillers through the mass media. In the case of an already known OTC painkiller, 35.4% of the sample agreed and 43.1% of them remained neutral. In the case of new OTC painkillers releases, 46.2% of the respondents agreed and 31.5% remained neutral. It can be concluded that advertising is a great source for informing the public about OTC painkillers and this result was similar with bibliography. According to Tawari (2016), 41.2% of the sample agreed that they had been aware of the OTC drugs through the advertisements. The high percents of the neutral respondents of the present study could be explained by their negative attitude towards OTC painkillers advertising. When the consumers were asked if they find funny the OTC painkillers advertisements, almost half of them kept neutral position, whereas the remainders were spited between

Undergraduate Thesis / Postgraduate Dissertation 54 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

positive and negative attitude. The general conclusion was that the majority of the sample had not a good opinion about OTCA. The next three statements indicated, too, the general tendencies of the respondents towards OTCA. In the question “OTCA persuades me for OTC painkillers effectiveness”, 44.6% of the sample disagreed or strongly disagreed and 37.7% were neutral. In the question, which related the advertising with self-care, 77.8% of the respondents had negative (51.6%) or neutral (26.2%) position towards OTC painkillers advertisements. Same results came from the question “OTCA does not mention the side effects of the OTC painkillers”, where the majority of the sample were against OTCA and believed that these advertisements did not mention the side effects of OTC painkillers. The negative attitude of public towards OTC advertising was evident in the study of Stephens and Johnson (2000), where the respondents considered OTCA as unreliable source of information. Another statement was “OTCA makes OTC painkillers popular to the public” and 66.9% of the respondents agreed or strongly agreed. This result was expected according to bibliography, as it was mentioned by Wilson and Kollander (2011) that aggressive advertising increases the popularity of an OTC drug and sometimes marketers create awareness for products that may be not needed if there was not advertising. The final question was “OTCA influences me to purchase an OTC painkiller”, where M=2.68, which indicated a moderate level of agreement. The most respondents (49.2%) disagreed (36.9%) or strongly disagreed (12.3%), 23.8% of them neither agreed nor disagreed and 23.8% of them stated that OTCA influenced them to buy an OTC analgesic. The negative and neutral position or 73% could be interpreted as not been influenced by advertising and this is similar with the study of Tiwari (2016), where the majority of the sample was not been influenced by OTCA on the purchase of OTCs.

5.4.1 Emotions that arise from OTC painkillers advertising

Next, the present study attempted to determine the emotions aroused after the respondents were exposed to OTC painkillers advertisements. The first statement had to do with discomfort (Figure 12), whereas the second statement estimated the hope for the future (Figure 13). More specifically, more than half of the sample (47.7% disagreed and 8.5%

Undergraduate Thesis / Postgraduate Dissertation 55 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

strongly disagreed), did not feel discomfort when they were exposed to an OTC painkiller advertisement. Also, 30.8% of the sample stated neutral and less than 13% of them felt bad, when they watched or heard the advertising message. In the case of hopeful feelings, the results were almost the same. The respondents, who disagreed, were 36.9% and those who strongly disagreed were 14.6%, which is almost half of the sample as in the first statement. The neutral were the same (30.8%) and the respondents, who felt hope were 17.7%, a little higher percent in comparison with the discomfort emotions. As a conclusion, the majority of respondents had not strong feelings neither discomfort nor hope after their exposure to OTCA. This result indicated that OTC painkillers advertising did not affect them emotionally, because they probably did not give much attention to OTCA. This was found above (Figure 9), where the level of attention to OTCA was found moderate. In addition, Huh et al. (2015) came up with the same conclusion, which was that consumers give emphasis to the information of an ad message and they are not affected emotionally.

Figure 12: Discomfort emotions due to OTC Figure 13: Hope emotions due to OTC painkillers painkillers advertisements. advertisements.

5.4.2 Advertising attitude mean score

Giving points from 1 (strongly disagree) to 5 (strongly agree) in the 10 questions (5-14) of this part, we took a score for the attitude towards OTC painkillers advertising. It should be noted that questions 10 and 13 were reversed, in order to give a meaningful score. The highest score could be 50 and the minimum score could be 10 for each respondent. As

Undergraduate Thesis / Postgraduate Dissertation 56 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

shown in Table 8, the mean is 28.69 and if it is divided by 10, the mean ad attitude summated score (Cronbach’s a=0.77) would be 2.9 (SD=5.26). The resulted mean score indicated a moderate attitude towards OTC painkillers advertisements. So, the sample was moderately affected by OTCA. The median (30) and the mode (30) provide the middle value and the most frequent value respectively and show a moderate opinion about OTCA. The most positive response was 45, whereas the most negative response was 16.

Table 8: Ad attitude mean score. Ad attitude Total 130 Mean 28.69 Median 30 Mode 30 Standard Deviation 5.26 Variance 27.63 Range 29 Minimum 16 Maximum 45

5.4.3 The effect of demographics on ad attitude mean score

After finding the general opinion of the respondents about the OTC painkillers advertising, it was investigated whether there are statistically significant differences between sub- groups of the sample formed by their demographics: gender, age, educational level, occupation and place of residence. Mann-Whitney tests and Kruskal-Wallis tests were conducted for evaluating statistically significant differences between the sub-groups. The purpose was to examine whether demographics play role on the degree that OTCA influences the respondents.

The first Man-Whitney test was conducted between the gender groups in order to evaluate if there are significant differences between male and female respondents. The results

Undergraduate Thesis / Postgraduate Dissertation 57 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

(Table 9) indicate that there is no significant difference between the two gender groups (p- value > 0.05).

Table 9: Gender based Man-Whitney test. Mean Sum of Man- N Z p-value Rank Ranks Whitney U male 42 67.05 2816.00 1783.000 -0.325 0.746 female 88 64.76 5699.00

The second test concerning the age groups was Kruskal-Wallis test (Table 10), where no statistically significant differences were found (p-value > 0.05).

Table 10: Age based Kruskal-Wallis test. N Mean Rank df p-value 18-34 69 62.04 35-44 19 61.05 45-54 9 68.83 5 0.150 55-64 22 64.11 65-74 5 86.90 75 + 6 101.58

The next test was Kruskal-Wallis test and was conducted for the education level. The results showed that there is not statistically significant difference between the sub-groups of respondents indicating that education level does not play important role on the attitude towards OTCA. The results are presented on Table 11 (p-value>0.05).

Table 11: Education level-based Kruskal-Wallis test. N Mean Rank df p-value Primary school 7 104.21 Secondary/High 34 67.13 school Vocational 4 0.060 14 56.25 school Bachelor 56 64.30 Master/PhD 19 58.66

In order to examine the occupation, another Kruskal-Wallis test was conducted and there was detected statistically significant difference as p-value < 0.05. As we can see in Table

Undergraduate Thesis / Postgraduate Dissertation 58 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

12, the sub-group “farmer/stockman” shows significantly higher mean rank from the others, so they seem to be more affected from OTCA.

Table 12: Occupation based Kruskal-Wallis test. N Mean Rank df p-value State/private 59 63.62 employee Self-employer 23 56.22 6 0.039 Farmer/stockman 5 100.20 Retired 17 87.71 unemployed 12 54.79 University 8 60.13 student domestic 6 56.33

The last Mann-Whitney test was conducted for the place of residence, where no statistically significant differences were found (p-value>0.05, Table 13). So, the respondents living in Florina and those living in the rest regional unit of Florina do not differ significantly about their OTCA opinion.

Table 13: Place of residence based Mann-Whitney test. Mean Sum of Mann- N Z p-value Rank Ranks Whitney U City of Florina 86 64.26 5526.50

Rest 1785.500 -0.525 0.599 regional 44 67.92 2988.50 unit of Florina

5.5 Factors that influence the purchase of OTC painkillers

In this part, the research was focused on the factors that affect the respondents when they decide to purchase an OTC painkiller. The factors, which were examined, were OTC painkillers advertising, the advice from the pharmacist and the doctor, friends/family recommendations, the price, trust and the popular brand name. The Cronbach’s alpha was 0.526 for this set of questions (15-22). Special emphasis was given to the role of the

Undergraduate Thesis / Postgraduate Dissertation 59 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

pharmacist in relation with the OTCA effect on the consumer decision making process. Likert scale was used ranging from 1 (strongly disagree) to 5 (strongly agree). So, higher mean values indicate more influencing factors. The results are presented on Tables 14 and 15.

Table 14: Percents of factors that influence the purchase of OTC painkillers. Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree

Advertising 11.5 31.5 33.1 23.1 0.8

Pharmacist 1.5 3.1 13.1 60.8 21.5

Doctor 0.0 0.0 6.9 43.8 49.2

Friends/Family 14.6 26.2 39.2 20.0 0.0

Price 26.2 46.9 19.2 6.9 0.8

Trust 0.0 0.8 6.2 56.9 36.2

Popular brand 1.5 13.1 32.3 46.2 6.9 name

Table 15: Median and standard deviation of factors that influence the purchase of OTC painkillers. M SD Advertising 2.70 0.978 Pharmacist 3.98 0.782 Doctor 4.42 0.621 Friends/Family 2.65 0.963 Price 2.09 0.893 Trust 4.28 0.613 Popular brand name 3.44 0.863

Undergraduate Thesis / Postgraduate Dissertation 60 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Advertising seemed to be a less important factor concerning the purchase of an OTC painkiller, as 56 out of 130 respondents disagreed (31.5%) or strongly disagreed (11.5%) that they buy an OTC painkiller seen in the advertisements. 33.1% of them neither agreed nor disagreed and only 23.9% stated that they were influenced by the OTCA. Similar results were found from IOBE research (2017), where the majority of the respondents were affected little or not at all by OTCA. Also, according to Hana and Hughes (2011) less than 30% of the sample was influenced by OTCA. The majority of the sample agreed (43.8%) or strongly agreed (49.2%) that they were influenced by the doctor’s recommendation in the decision making process of buying an OTC painkiller. This result was expected according to the research of Stephens and Johnson (2000), which indicated that people, especially the older, relied on health care providers’ advice in a great extent. In the case of friends and family, most of the respondents remained neutral and did not give a clear position (39.2% neither agreed nor disagreed). This could be explained by the fact that they did not want to admit that their buying behavior was influenced by their acquaintances. Only 20% of the sample agreed that were influenced by their family environment and this is similar to the result of Czerw's study (2015), where 17.24% of the respondents purchased OTC painkillers due to their beloved ones. Price was another examined factor and the results showed that the sample of consumers in Florina did not give emphasis to the low price of OTC painkiller, as 46.9% of them disagreed and 26.2% strongly disagreed that the low price is an incentive to buy the drug. Opposite results came from IOBE study (2017) concerning the whole Greek population and 49% of the sample were influenced by the price of OTCs on moderate and high level. Also, Hana and Hughes (2011) found, too, that about 55% of the sample was influenced by the cost of non-prescription drugs on their purchase. That result could be explained by the examined category of the OTC drugs, analgesics, where consumers give more emphasis on the effectiveness and safety, rather than the low price. With the statement “I buy an OTC painkiller, which I know and trust.” the present study was attempted to understand whether consumers buy the drug in accordance with its safety, effectiveness and good past experience. The vast majority of the respondents (93.1%) agreed or strongly agreed with the statement and thus, it was concluded that an OTC painkiller, which has earned the trust of the public, is differentiated among the

Undergraduate Thesis / Postgraduate Dissertation 61 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

competitors. Similar conclusions aroused from IOBE study (2017), where the respondents buy OTCs highly influenced by the safety (72%), the effectiveness (63%) and trust in the name of the OTC drug (33%). Additionally, Hana and Hughes (2011) concluded similarly that effectiveness (95.9%), familiarity with the name (79.1%) and safety (77.8%) were considered factors that influence the buying behavior in a great degree. The popular brand name was investigated in order to explain the effect of advertising and generally the importance of the marketing strategy applied by pharmaceutical companies for the promotion of their products. This study revealed that the respondents were positively affected by the brand name (53.1%), while a significant percent of them (32.3%) stated neutral. The letters did not probably want to admit that they consider important the popularity of the OTC painkiller. IOBE (2017) concluded that 68.4% of the sample was affected in moderate and high level by the popularity of the OTC drug. Concerning the pharmacist’s advice, 107 out of 130 respondents were positively influenced, from whom 60.8% stated that they agreed and 21.5% stated that they strongly agreed. Only 6 persons disagreed or strongly disagreed that they bought an OTC painkiller based on pharmacist (Figure 14). Residents of the area of Florina seemed to trust the pharmacists, when they have to make a decision for an OTC painkiller. This result is similar to IOBE results (2017), where most Greek respondents were influenced (21%) or strongly influenced (55%) by the pharmacist. Another research (Hanna and Hughes, 2011) supported the important role of the pharmacist, as 53.3% disagreed and 11.6% strongly disagreed to the statement “I buy OTC drug regardless of the pharmacist’s recommendation”. An additional statement was used in this part, so as to correlate pharmacist’s advice with OTC painkiller advertisements, “First I ask the pharmacist for an OTC painkiller, which I have seen on advertisements, before I buy it”. According to the results, 48.5% of the respondents agreed, 21.5% of them strongly agreed, whereas less than 10% of them disagreed or strongly disagreed (Figure 15). These findings indicated that consumers did not buy an advertised OTC painkiller, because they saw it on advertisements, but first they wanted to know what the pharmacist’s opinion is. Similar findings came from Kapedanoska et al (2016), where 77.7% of the pharmacists that took part in the survey stated that OTCA had not impact on pharmacist’s recommendations.

Undergraduate Thesis / Postgraduate Dissertation 62 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Figure 14: OTC painkiller purchase influenced by Figure 15: Asking for pharmacist’s advice prior pharmacist’s recommendation purchasing an advertised OTC painkiller.

5.5.1 Hierarchy of the factors that influence the purchase of OTC painkillers

In order to conclude which of the factors influenced most the consumers buying behavior, Friedman test, a non parametric test, was applied.

Null Hypothesis H0 = there are not statistically significant differences among the responses for the factor that influences the respondent to buy an OTC painkiller.

Alternative Hypothesis H1 = there are statistically significant differences among the responses for the factor that influences the respondent to buy an OTC painkiller.

Table 16 shows that at least two factors are statistically significant different (sig.0.000<

0.05). So, Hypothesis H0 is rejected.

Undergraduate Thesis / Postgraduate Dissertation 63 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 16: Hierarchy of factors that influence the purchase of OTC painkiller.

Mean Rank Advertising 2.78 Pharmacist 5.03 Doctor 5.86 Friends/Family 2.79 Price 1.95 Trust 5.57 Popular brand name 4.02

N 130

Chi-Square 469,174 Df 6

Asymp. Sig. ,000

Concluding, the factors that influence most the consumer’s buying behavior are the doctor’s advice, following trust on the OTC painkiller (safety, effectiveness, good past experience) and finally the pharmacist’s advice. The first place taken by doctor’s advice was unexpected, as according to bibliography drug effectiveness, familiarity with the name and safety are in the first places (Hana and Hughes, 2011). Also, according to Padisson and Olsen (2008), doctors are less trustworthy than pharmacists. This is opposite to the present study, as pharmacist’s advice takes the third place among the other factors. The finding that doctor is the most important factor that influences consumers to buy an OTC painkiller can be explained by the fact that residents of Florina are not familiar with self-care and self-treatment and so, they probably cannot deal with an emerging pain by themselves. This fact is confirmed by IOBE study (2017), where 6 out of 10 Greek citizens did not know the term “self-care”. An additional reason, which can explain the doctor’s trust, is that in Florina a visit to the doctor is affordable and also, the hospital of the city is available for anyone not having workload. Concerning the pharmacist’s opinion on the OTC analgesic purchase taking lower position than the doctor’s advice is justified by IOBE (2017) research, too, according to which 41% of Greek citizens did not ask for pharmacist advice due to the trust on doctor more.

Undergraduate Thesis / Postgraduate Dissertation 64 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

As concern the popular brand name, it is a factor of moderate importance and this is similar with the results of IOBE (2017). The factors having the lesser importance are family/friends, advertising and price and this finding is the same with the study of Paddison and Olsen (2008). Especially in the case of advertising, the researchers note that advertisements are more reinforcement rather than persuading.

5.5.2 Buying OTC painkillers tendency mean score

Giving points from 1 (strongly disagree) to 5 (strongly agree) in the 7 questions (15-22 except 16) of this part, we took a score for the extent that consumers were affected to buy an OTC analgesic due to the above mentioned factors : advertising, pharmacist, doctor, friends/family, price, trust, popular brand name. The highest score could be 35 and the minimum score could be 7 for each respondent. As shown in Table 17, the mean is 23.56 and if it is divided by 7, the mean summated score (Cronbach’s a=0.526) would be 3.37 (SD=2.745). This mean score shows moderately high degree of influence about OTC painkillers purchases. It is concluded that the respondents are affected strongly enough by the factors examined above, when they deal with pain and want to buy an OTC analgesic in order to be relieved. The less affected respondent had 16, whereas the most affected respondent had 30. The mode was 24 indicating that the sample tends to be affected on their buying decision process by the above mentioned factors.

Table 17: Mean score of buying OTC painkillers tendency.

Buying OTC painkillers tendency Total 130 Mean 23.56 Median 24.00 Mode 24 Standard Deviation 2.745 Variance 7.535 Range 14 Minimum 16 Maximum 30

Undergraduate Thesis / Postgraduate Dissertation 65 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

5.5.3 The effect of demographics on buying OTC painkillers tendency mean score

Like above (5.4.4), we examined the effect of demographics on the tendency to buy OTC analgesics affected by advertising, pharmacist, doctor, friends/family, price, trust, popular brand name. Mann-Whitney test and Kruskal-Wallis test were conducted for evaluating statistically significant differences between the sub-groups with same characteristics such as gender, age, educational level, occupation and place of residence.

Mann-Whitney was conducted between the gender groups so as to find out if there are significant differences between male and female respondents. The results (Table 18) indicate that there is no significant difference between the two gender groups (p-value> 0.05).

Table 18: Gender based Mann-Whitney. Mean Sum of Mann- N Z p-value Rank Ranks Whitney U male 42 67.42 2831.50 1767.500 -0.404 0.686 female 88 64.59 5683.50

The second Kruskal-Wallis test concerned the age groups (Table 19), where no statistically significant differences were found (p-value> 0.05).

Table 19: Age based Kruskal-Wallis test. N Mean Rank df p-value 18-34 69 69.53 35-44 19 64.71 45-54 9 54.11 5 0.385 55-64 22 63.09 65-74 5 76.30 75 + 6 38.58

The next Kruskal-Wallis test was about the education level. According to the results there is statistically significant difference between the sub-groups of respondents indicating that the extent to which the consumers are affected to buy an OTC analgesic is different among

Undergraduate Thesis / Postgraduate Dissertation 66 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

various age groups. The results are presented on Table 20 (p-value<0.05). The higher mean rank is for Master/PhD holders, who seem to be affected more.

Table 20: Education level based Kruskal-Wallis test. N Mean Rank df p-value Primary school 7 77.64 Secondary/High 34 54.40 school Vocational 4 0.028 14 70.32 school Bachelor 56 62.13 Master/PhD 19 87.29

In order to examine the occupation, another Kruskal-Wallis test was conducted and there was statistically significant difference as shown in table 21 (p-value = 0.05). So, occupation plays important role on the affection degree of the sample when buying OTC painkillers and the sub-group farmer/stockman present the higher mean rank.

Table 21: Occupation based Kruskal-Wallis test. N Mean Rank df p-value State/private 59 76.28 employee Self-employer 23 54.28 6 0.050 Farmer/stockman 5 76.30 Retired 17 56.85 unemployed 12 43.71 University 8 60.31 student domestic 6 68.50

The last Mann-Whitney test was conducted for the place of residence, where no statistically significant differences were found (p-value>0.05, Table 22). It can be concluded that the place of residence does not affect the examined mean score.

Undergraduate Thesis / Postgraduate Dissertation 67 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 22: Place of residence based Mann-Whitney test. Mean Sum of Mann- N Z p-value Rank Ranks Whitney U City of Florina 86 67.21 5780.00 Rest regional unit 1745.000 -0.729 0.466 44 62.16 2735.00 of Florina

5.6 General opinion about OTC painkillers

In this part of the study, the respondents were asked to tell their personal opinion about OTC painkillers issues completing 8 statements and Likert scale was used ranging from 1 (strongly disagree) to 5 (strongly agree), so as to estimate their answers (Cronbach's a =0.45). The results are presented on Tables 23 and 24.

Undergraduate Thesis / Postgraduate Dissertation 68 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 23: Results from the analysis of the statements about the general opinion about OTC painkillers on percents. Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree

I use OTC painkiller for daily 26.2 40.8 10.0 20.8 2.3 mild pains.

I consider OTC painkillers safe. 4.6 16.9 43.1 33.8 1.5

I consult pharmacist for mild pains without visiting the 5.4 9.2 21.5 54.6 9.2 doctor.

OTC painkillers’ prices are 0.8 3.8 42.3 45.4 7.7 constantly rising.

The economic crisis led to decrease of OTC painkillers 1.5 26.9 36.9 27.7 6.9 purchases.

I consider right and logical to sell OTC painkillers outside 26.2 40.0 18.5 13.1 2.3 pharmacies.

I believe that the outside- pharmacies OTC painkillers’ 6.9 27.7 32.3 27.7 5.4 selling will lower their prices. I believe that the outside- pharmacies OTC painkillers’ 0.8 13.1 16.9 19.2 20.0 selling leads to their excessive consumption.

Undergraduate Thesis / Postgraduate Dissertation 69 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 24: Results from the analysis of the statements about the general opinion about OTC painkillers, mean and standard deviation. M SD I use OTC painkiller for 2.32 1.143 daily mild pains. I consider OTC painkillers 3.11 0.865 safe. I consult pharmacist for mild pains without visiting 3.53 0.974 the doctor. OTC painkillers’ prices are 3.55 0.727 constantly rising. The economic crisis led to decrease of OTC painkillers 3.12 0.937 purchases. I consider right and logical to sell OTC painkillers 2.25 1.059 outside pharmacies. I believe that the outside- pharmacies OTC 2.97 1.026 painkillers’ selling will lower their prices. I believe that the outside- pharmacies OTC painkillers’ selling leads to 3.75 0.951 their excessive consumption.

To begin with, it was examined the daily use of OTC painkillers for mild pains and the majority of the sample stated that they disagreed (40.8%) or strongly disagreed (26.2%). This result showed that when the respondents had to deal with pain, they did not use OTC analgesic as the first action. Same results came from IOBE (2017), where 54% of citizens waited to see if they would feel better, before they decided to take an OTC drug, whereas only 14% used an OTC to mild the symptoms. Concerning the safety of OTC analgesics, 35.3% of the sample considered them safe, whereas 21.5% of the sample had the opposite opinion. It was interesting that 43.1% of the respondents remained neutral, because they probably were negative towards OTC painkillers. The conclusion was that almost 4 out of 10 trust OTC analgesics, which is different from the results of IOBE (2017), where 7 out of 10 citizens considered OTCs trustworthy. This difference can be explained due to the fact that the present study

Undergraduate Thesis / Postgraduate Dissertation 70 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

examined OTC painkillers and not generally OTCs. The active ingredients of painkillers were not considered innocent in comparison to vitamins, products for skin care etc. The next statement was “I consult pharmacist for mild pains without visiting the doctor” and more than half of the respondents agreed (54.6%) or strongly agreed (9.2%). It can be explained as in most cases there is no time to visit a doctor and especially when there is mild illness and also, self-medication is costless and most times effective when there is a pharmacist to advice the patient for the right OTC products. The following statement was mentioned to the present increase of OTC painkillers price and according to the results 45.4% of the respondents agreed and 42.3% of them neither agreed nor disagreed. The letters did not probably want to admit this increase on price and so remained neutral. Statistical data presented on www.healthmag.gr confirm that the retail price had an 8.4% increase in 2019, so the citizens were aware of this increase. The respondents were asked to express their opinion if the economic crisis led to decrease of OTC painkillers purchases and the most of them remained neutral (36.9%) and did not want to take position. 34.6% of the sample agreed (27.7%) or strongly agreed (6.9%), whereas 28.4% of the sample disagreed (26.9%) or strongly disagreed (1.5%). The percent of the consumers that noticed decreased OTC purchases was close enough to the percent of those who did not notice change in the amount of purchases. In the study of IOBE (2017) these percents were even closer to each other and 1 out of 2 citizens stated that economic crisis affected the quantity and the kind of OTCs, which they would purchase. The following three statetements concerned the presence of OTC painkillers outside pharmacies and the consequences. More than half of the respondents (66.2%) were negative to OTC painkillers administration outside pharmacies and less than 15% of them were positive. In the first scenario of the decrease of OTC painkillers prices, both positive and negative positions were 27.7%. In the second scenario of the excessive OTC painkillers consumption, the majority of the respondents agreed (69.2%). As mentioned above in the bibliography, OTC selling outside the pharmacies has been already done and general purpose drugs can be now purchased in super markets and other stores. This legal regulation has been applied since 2016 against the pharmacist’s will, because government wanted to increase OTC drugs consumption and promote self-care and self-medication according to the European standards. The results of the present study indicated that most consumers understood the importance of purchasing an OTC painkiller in the pharmacy

Undergraduate Thesis / Postgraduate Dissertation 71 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

and after the recommendation of the pharmacist, as most of them considered that the outside-of-the-pharmacy OTC painkillers presence would lead to abuse of these drugs. Nevertheless, there was not unanimous opinion about the price changes, as 1 out of 2 respondents believed that the OTC painkillers price would fall as a result of moving out of pharmacies.

5.6.1 OTC painkillers involvement mean score

Giving points from 1 (strongly disagree) to 5 (strongly agree) in the 3 questions (23-25) of this part, we took a score for the involvement, which the respondents have with OTC analgesics. The highest score could be 15 and the minimum score could be 3 for each respondent. As shown in Table 25, the mean is 8.96 and if it is divided by 3, the OTC painkillers involvement summated mean score (Cronbach’s a=0.486) would be 2.99 (SD=2.107). The resulted mean score indicated a moderate involvement with OTC painkillers. The most frequent response was 9, which showed not high involvement with these drugs. The interesting part was the range (12), which depicted difference of opinions between the respondent with the highest involvement (15) and the respondent with the minimum involvement (3). This mean score showed that consumers do not use very often OTC analgesics and thus it can be concluded that residents of the area of Florina are not very familiar with self-medication in the case of self-managing pain.

Table 25: OTC painkillers involvement means score.

OTC

painkillers involvement Total 130 Mean 8.96 Median 9.00 Mode 9 Standard Deviation 2.107 Variance 4.440 Range 12 Minimum 3 Maximum 15

Undergraduate Thesis / Postgraduate Dissertation 72 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

5.6.2 The effect of demographics on OTC painkillers involvement mean score

The next step was to examine if the demographic characteristics (gender, age, educational level, occupation and place of residence) play role to the extent that the respondents are involved with OTC analgesics. Mann-Whitney test and Kruskal-Wallis test were conducted for evaluating statistically significant differences between the sub-groups.

First we conducted a Mann-Whitney test for evaluating differences between males and females and the results showed no significant deference between the two gender groups (p-value> 0.05, Table 26).

Table 26: Gender based Mann-Whitney test. Mean Sum of Mann- N Z p-value Rank Ranks Whitney U male 42 72.04 3025.50 1573.500 -1.384 0.166 female 88 62.38 5489.50

Concerning the age groups we conducted a Kruskal-Wallis test (p-value > 0.05) (Table 27), where no statistically significant differences were found. These results were different from the study of Lee et al. (2015), where the involvement with OTC was higher in higher ages.

Table 27: Age based Kruskal-Wallis test. N Mean Rank df p-value 18-34 69 59.99 35-44 19 61.16 45-54 9 69.17 5 0.169 55-64 22 77.32 65-74 5 97.40 75 + 6 67.17

The next Kruskal-Wallis test was conducted for the education level and the results showed that there is statistically significant difference between the sub-groups of respondents indicating that education level plays important role on the extent that the respondents use

Undergraduate Thesis / Postgraduate Dissertation 73 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

OTC analgesics. The results are presented on Table 28 (p-value<0.05). So, consumers with lower educational level presented higher involvement with OTC analgesics. The study of Lee et al. (2015) concluded to same results.

Table 28: Education level based Kruskal-Wallis test. N Mean Rank df p-value Primary school 7 99.00 Secondary/High 34 55.49 school Vocational 4 0.020 14 57.29 school Bachelor 56 64.59 Master/PhD 19 79.82

In order to examine the occupation, Kruskal-Wallis test was conducted and there was detected statistically significant difference as p-value < 0.05. Table 29 shows that the sub- group “farmer/stockman” has higher mean score from the others, so it is an indication that these respondents are more involved with OTC analgesics.

Table 29: Occupation based Kruskal-Wallis test. N Mean Rank df p-value State/private 59 71.62 employee Self-employer 23 51.61 6 0.017 Farmer/stockman 5 100.80 Retired 17 76.03 unemployed 12 49.50 University 8 45.63 student domestic 6 57.83

The last Mann-Whitney test was conducted for the place of residence, where no statistically significant differences were found (p-value>0.05, Table 30). So, the respondents living in Florina and those living in the rest regional unit of Florina do not differ significantly on the extent that they use OTC painkillers.

Undergraduate Thesis / Postgraduate Dissertation 74 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Table 30: Place of residence based Mann-Whitney test. Mean Sum of Mann- N Z p-value Rank Ranks Whitney U City of Florina 86 64.05 5508.50 Rest regional unit 1767.500 -0.621 0.535 44 68.33 3006.50 of Florina

Undergraduate Thesis / Postgraduate Dissertation 75 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Chapter 6: Discussion and further research

In this chapter, the main conclusions from the research analysis are presented and discussed. More specifically, the level of exposure to advertisements through mass media and the level of attention to OTC painkillers advertisements are estimated in order to understand how the respondents are related with the world of advertising. Also, it is explained why the most advertised OTC analgesic is different from the most purchased OTC analgesic. Next, the general attitude towards OTC painkillers advertising is presented and it is discussed whether demographics play role to this attitude. In addition, the main factors that influence consumers to buy an OTC painkiller are mentioned and the demographics effect is discussed, too. Conclusions about the general opinion about OTC analgesics follow and it is explained the extent of involvement with OTC painkillers in relation with demographics. Finally, it is discussed the issue about the presence of OTC analgesics outside pharmacies or not from the respondents’ point of view. Last but not least, suggestions for further research are presented.

6.1 Discussion of the main results from the survey

To begin with, most consumers seem to be daily exposed to advertisements through television, radio, press and the internet, but it is detected a low level of attention to OTC painkillers advertisements. It can be concluded that they do not give emphasis to this type of advertisements. Also, according to the survey the most advertised OTC analgesic is Panadol, but the majority of consumers prefer to buy Depon. This is a first indication that advertising does not affect the citizens’ preferences among OTC painkillers and also, the trust to the brand name seems to be important. Concerning the consumers’ attitude towards OTC painkillers advertising, the research results show that people in Florina are not influenced by advertisements to purchase an OTC analgesic, as OTCA neither convince them for the effectiveness of these drugs nor mention their side effects. So, OTCA does not help them to choose the appropriate self- care product for the emerged pain. Nevertheless, OTC painkillers advertisements seem to achieve their primary goal of providing information to the public. In the cases of both new

Undergraduate Thesis / Postgraduate Dissertation 76 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

and already known OTC analgesics, advertising creates the awareness, so as to motivate the consumer to seek additional information about the drug. So, the informational content of the advertising message plays an important role and pharmaceutical companies should carefully design it. It is a fact that a good message can push the patient to search more for a “pain situation” that decreases his life quality or create a need to him that does not even exist. On the contrary, OTCA does not affect emotionally the consumers, as it does not cause to them neither negative nor positive emotions. Also, according to the survey, OTCA increases the drug popularity and this can be crucial in the decision making process. Generally, consumers have a moderate attitude about OTC painkillers advertising and this result reveals that they are not affected by OTCA in a great extent. This attitude is the same among sub-groups with different demographic characteristics (gender, age, educational level, residence) except from farmers/stockmen, who are more positive and thus more susceptible to OTCA. The general attitude towards OTCA in Florina is in accordance with past researches and people do not seem to be greatly affected by advertisements when they buy an OTC analgesic. Among the examined factors that influence the consumers to purchase an OTC analgesic, doctor’s recommendation, trust on the drug and pharmacist’s advice are found the most important. As concern the trust on the doctor, it is logical, as in Florina a visit to the doctor is considered affordable and patients have the general habit to ask their family doctor for everything. The global trend of self-care and self-medication is not so widespread in Greece and for this reason the Greek Responsible Health Self-care Campaign was conducted as mentioned above. The second factor, which is found to influence many respondents is the trust on the drug, which includes the safety, the effectiveness and the good past experience. This result was expected from the bibliography and in this study it is proved that patients want to deal with their pain using safe and effective OTC analgesics. Pharmacists cannot be missing from the top 3, because they are trustworthy persons, especially in provincial areas like Florina, where the citizens seek for their advice for mild pains. Additionally, the strong role of pharmacist is obvious, as the majority of consumers first ask for the pharmacist’s recommendation and then they buy an advertised analgesic. According to the results, brand name positively affects consumers on the OTC analgesic purchase, whereas family and friends have low impact. Advertising has more reinforcement role than persuading people to buy the drug. Finally, price is found to be the

Undergraduate Thesis / Postgraduate Dissertation 77 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

less important factor and this is opposite to past researches due to the nature of the investigated category of OTCs probably. Analgesics are drugs, which have the potential to be dangerous if they are not used on the proper time, for the proper purpose and in the proper dosage. For this reason, patients are more careful when purchasing these drugs and the cost affects little their final choice. Generally, the degree to which the respondents are affected by these factors does not present differences among sub-groups with different demographic characteristics, except from Mater/PhD holders and farmers/stockmen, who seem to be more influenced on the purchase of OTC painkillers. Involvement with OTC analgesics is also examined in the present study and moderate levels are revealed. More specifically, most respondents do not use OTC analgesics every day and they consider them not safe. The percent of consumers in Florina considering OTC analgesics safe is significantly lower than the corresponding percentage in the whole population in Greece (IOBE, 2017), but this can be explained as the present study concerns only OTC analgesics, while the other study has to do with OTCs in general. So, our examined category of OTC painkillers are not so innocents as other OTC drugs, such as vitamins or skin care products. In addition, the involvement with OTC analgesics seems to be higher on the lower education levels, whereas the other demographic characteristics do not play role. The results show that most consumers are informed about the increase of the retail price of OTC painkillers. Opposite opinions are noticed about the decreased OTC painkillers consumption due to economic crisis of the last years, where almost 1 out of 2 believes that economic crisis led to decreased purchases. In fact, the number of OTCs sold after crisis is lower, but the retail prices have increased and this has as a result higher turnover on pharmacies. Maybe this is the reason that confuses the public for the OTC analgesic consumption. The last issue examined in the survey was the consumers’ opinion about the presence of OTC analgesics outside the pharmacies, which has been already applied since 2016. The most respondents believe that the administration of OTC analgesics should be done in the pharmacies, where there is the responsible health care professional to give the right instructions and caution about the side effects. In the opposite case, this can lead to excessive consumption of OTC painkillers and abuse. Concerning the retail prices, the consumers have not a clear view. In fact, the government wanted to decrease the prices by

Undergraduate Thesis / Postgraduate Dissertation 78 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

releasing the Drugs of General Purpose outside pharmacies and promote the self-care. Though, the most retail prices have increased as mentioned above. This happened due to pricing change until the retail prices become equal to the mean of the two cheaper prices in Europe. Greece attempts to follow the modern trend of self-care and self-medication according to the European standards, but the legislation is not with the part of the public.

6.2 Suggestions for further research

The present study examined the attitude of consumers towards OTC painkillers advertising and their general buying behavior in the regional unit of Florina. It would be interesting to find out how OTC painkillers’ advertising affects the general population of Greece. Also, another research could be deal with the same research objectives, but for other OTC categories, such as cold and cough products, vitamins, skin care products etc. Among the conclusions of this study, it was noticed that health care professionals, such as doctors and pharmacists, have great impact on the decision making process of the patient concerning OTC analgesics. So, it is considered appropriate to study the way, by which doctors and pharmacists influence the public to purchase an OTC analgesic. The effect of advertising examined in the present study included generally the mass media, television, radio, press and the internet. According to bibliography, today the internet and the social media are a large field of communication, where a big amount of information is provided by pharmaceutical companies and also, people exchange opinions and past experiences with each other. So, the online OTC advertising is expected to play crucial role in the future. Further research about OTCA through the internet would help the pharmaceutical marketers to understand how to take advantage of this means of communication. Finally, the experiment method would be an interesting idea for further investigation of the impact of OTCA painkillers advertisements. More specifically, after the consumers’ direct exposure to OTCA, it will be estimated their attitude and emotions about these advertisements. This would be maybe a more accurate way to understand how OTCA affects the consumers’ buying behavior.

Undergraduate Thesis / Postgraduate Dissertation 79 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

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Undergraduate Thesis / Postgraduate Dissertation 90 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Appendix A: Ερωτηματολόγιο

Το ερωτηματολόγιο αυτό δημιουργήθηκε στα πλαίσια της διπλωματικής μου εργασίας με τίτλο « Η επίδραση της διαφήμισης στην κατανάλωση των Μη Συνταγογραφούμενων παυσίπονων Φαρμάκων (OTC) στην περιοχή της Φλώρινας: Μια ποσοτική μελέτη » για την απόκτηση μεταπτυχιακού τίτλου σπουδών στη Διοίκηση Επιχειρήσεων (MBA) του Ελληνικού Ανοιχτού Πανεπιστημίου. Όλες οι απαντήσεις είναι ανώνυμες και εμπιστευτικές και θα χρησιμοποιηθούν αποκλειστικά και μόνο για ακαδημαϊκούς σκοπούς. Παρακαλώ σημειώστε την επιλογή που εκφράζει πλησιέστερα την άποψή σας.

Να σημειωθεί ότι οι ερωτήσεις του ερωτηματολογίου αφορούν παυσίπονα φάρμακα που χορηγούνται από το στόμα (ταμπλέτες ή κάψουλες) και δεν συμπεριλαμβάνονται κρέμες ή τζελ που προορίζονται για τοπική χρήση. Επιπλέον, αυτά τα παυσίπονα φάρμακα χορηγούνται χωρίς ιατρική συνταγή και αναφέρονται παρακάτω ως παυσίπονα OTC δηλαδή Μη Συνταγογραφούμενα Παυσίπονα Φάρμακα.

ΜΕΡΟΣ 1Ο

Επαφή του καταναλωτή με τα μέσα ενημέρωσης.

1-2 3-4 φορές 1 φορά την Κάθε Ποτέ φορές την εβδομάδα μέρα το μήνα εβδομάδα Πόσο συχνά ήρθατε σε επαφή με κάποιο διαφημιστικό μέσο 1 (τηλεόραση, ραδιόφωνο, έντυπος τύπος, Διαδίκτυο) τους τελευταίους 6 μήνες; Πόσο συχνά δώσατε έμφαση σε διαφημιστικό μήνυμα που 2 αφορούσε παυσίπονο OTC τους τελευταίους 6 μήνες;

Undergraduate Thesis / Postgraduate Dissertation 91 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Επαφή του καταναλωτή με τα Μη Συνταγογραφούμενα παυσίπονα (OTC painkillers).

Depon panadol apotel algon aspirin seractil nurofen Algofren Ποιό από τα παρακάτω παυσίπονα OTC 3 παρακολουθείτε σε διαφήμιση πιο συχνά ; Ποιό από τα παρακάτω παυσίπονα OTC αγοράζετε πιο 4 συχνά ανεξάρτητα αν το είδατε σε διαφήμιση ή όχι;

ΜΕΡΟΣ 2Ο

Διαφήμιση και Μη Συνταγογραφούμενα παυσίπονα (OTC painkillers).

Ούτε Διαφωνώ συμφωνώ Συμφωνώ Διαφωνώ Συμφωνώ απόλυτα ούτε απόλυτα διαφωνώ Οι διαφημίσεις με ενημερώνουν για τα 5 παυσίπονα OTC που κυκλοφορούν στην αγορά. Οι διαφημίσεις με ενημερώνουν για τα νέα 6 παυσίπονα OTC που κυκλοφορούν στην αγορά.

Undergraduate Thesis / Postgraduate Dissertation 92 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Οι διαφημίσεις 7 παυσίπονων OTC είναι διασκεδαστικές. Οι διαφημίσεις με πείθουν για την 8 αποτελεσματικότητα των παυσίπονων OTC. Οι διαφημίσεις με βοηθούν να επιλέξω παυσίπονο OTC 9 κατάλληλο για την περίπτωση μου (αυτο- θεραπεία). Οι διαφημίσεις δεν αναφέρουν τις 10 παρενέργειες των παυσίπονων OTC. Οι διαφημίσεις κάνουν ένα παυσίπονο OTC πιο 11 γνωστό και αγαπητό στο κοινό. Οι διαφημίσεις με 12 ωθούν στο να αγοράσω ένα παυσίπονο OTC. Οι διαφημίσεις παυσίπονων OTC μου δημιουργούν δυσφορία, 13 καθώς μου θυμίζουν μια άσχημη κατάσταση που αντιμετώπισα στο παρελθόν. Οι διαφημίσεις παυσίπονων OTC μου 14 δίνουν ελπίδα ότι θα καταφέρω να βρω λύση στο πρόβλημά μου.

Undergraduate Thesis / Postgraduate Dissertation 93 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

ΜΕΡΟΣ 3Ο

Παράγοντες που οδηγούν στην επιλογή του Μη Συνταγογραφούμενου παυσίπονου (OTC painkiller).

Ούτε Διαφωνώ συμφωνώ Συμφωνώ Διαφωνώ Συμφωνώ απόλυτα ούτε απόλυτα διαφωνώ Αγοράζω παυσίπονο 15 OTC που είδα στην διαφήμιση. Ρωτάω τον φαρμακοποιό για 16 παυσίπονο OTC που είδα στην διαφήμιση πριν το αγοράσω. Αγοράζω παυσίπονο OTC που μου προτείνει ο φαρμακοποιός ακόμα 17 και αν είναι διαφορετικό από αυτό που είδα στην διαφήμιση. Αγοράζω παυσίπονο 18 OTC που μου προτείνει ο γιατρός. Αγοράζω παυσίπονο OTC που μου 19 προτείνουν οι φίλοι ή οι συγγενείς μου. Αγοράζω παυσίπονο 20 OTC που είναι πιο φθηνό. Αγοράζω παυσίπονο 21 OTC που ξέρω και εμπιστεύομαι. Αγοράζω παυσίπονο 22 OTC με γνωστό όνομα.

Undergraduate Thesis / Postgraduate Dissertation 94 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

ΜΕΡΟΣ 4Ο

Το Μη Συνταγογραφούμενο παυσίπονο (OTC painkiller) στην καθημερινή ζωή μας.

Ούτε Διαφωνώ συμφωνώ Συμφωνώ Διαφωνώ Συμφωνώ απόλυτα ούτε απόλυτα διαφωνώ Χρησιμοποιώ παυσίπονο OTC για 23 καθημερινούς ήπιους πόνους. Θεωρώ τα παυσίπονα 24 OTC ασφαλή. Συμβουλεύομαι τον φαρμακοποιό όταν έχω 25 ήπιο πόνο χωρίς να πάω στον γιατρό. Οι τιμές των 26 παυσίπονων OTC συνεχώς αυξάνονται. Η κρίση οδήγησε στην 27 μείωση αγοράς παυσίπονων OTC. Θεωρώ σωστό και λογικό να πωλούνται 28 παυσίπονα OTC εκτός φαρμακείου. Πιστεύω ότι η πώληση παυσίπονων OTC 29 εκτός φαρμακείου θα μειώσει τις τιμές τους. Θεωρώ ότι η πώληση παυσίπονων OTC εκτός φαρμακείου 30 οδηγεί στον κίνδυνο της υπέρμετρης κατανάλωσής τους.

Undergraduate Thesis / Postgraduate Dissertation 95 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

ΜΕΡΟΣ 5Ο

ΔΗΜΟΓΡΑΦΙΚΑ ΣΤΟΙΧΕΙΑ

Επιλέξτε το φύλο σας: ☐ Άνδρας ☐ Γυναίκα

Η ηλικία σας : ☐ 18-34 ☐ 35-44 ☐ 45-54 ☐ 55-64 ☐ 65-74 ☐ 75 και άνω

Το μορφωτικό επίπεδο σας:

☐ Απόφοιτος Δημοτικού ☐ Απόφοιτος Γυμνασίου/Λυκείου ☐ Απόφοιτος Επαγγελματικής Σχολής ☐ Απόφοιτος ΑΕΙ/ΑΤΕΙ ☐ Κάτοχος Μεταπτυχιακού/Διδακτορικού

Η απασχόλησή σας: ☐ Δημόσιος / Ιδιωτικός Υπάλληλος ☐ Ελεύθερος Επαγγελματίας ☐ Αγρότης / Κτηνοτρόφος ☐ Συνταξιούχος ☐ Άνεργος ☐ Φοιτητής ☐ Οικιακά

Τόπος κατοικίας σας : ☐ Φλώρινα ☐ Νομός Φλώρινας πλην της πόλης

Undergraduate Thesis / Postgraduate Dissertation 96 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Appendix Β: Questionnaire

This questionnaire was created in the context of my dissertation entitled "The effect of advertising on over-the-counter painkillers (OTC) consumption in the regional unit of Florina: a quantitative study" to obtain the degree in Master of Business Administration (MBA) of the Hellenic Open University. All answers are anonymous and confidential and will be used for academic purposes only. Please note the option that most closely reflects your views.

It is noted that the questions in the questionnaire refer to oral painkillers (tablets or capsules) and do not include topical creams or gels. In addition, these over-the-counter painkillers are administered without doctor’s prescription and referred as OTC painkillers or non prescription painkillers.

Part 1

Consumer contact with the mass media.

1-2 Once a 3-4 times a Every Never times a week week day month How often have you come in contact with an advertising 1 medium (TV, radio, press, Internet) in the last 6 months? How often have you given 2 emphasis on an OTC painkiller in the last 6 months?

Undergraduate Thesis / Postgraduate Dissertation 97 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Consumer contact with OTC painkillers.

Depon panadol apotel algon aspirin seractil nurofen Algofren Which of the following OTC 3 painkillers do you see most in advertising? Which of the following OTC painkillers do you buy most 4 often regardless of whether you saw it in an ad or not?

Part 2

Advertising and OTC painkillers.

Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree Advertisements inform me 5 about OTC painkillers in the market. Advertisements inform me 6 about new OTC painkillers in the market. 7 OTCA is funny. OTCA persuades me for 8 OTC painkillers

Undergraduate Thesis / Postgraduate Dissertation 98 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

effectiveness. OTCA helps me to choose 9 the appropriate OTC painkiller (self-treatment). OTCA does not mention 10 the side effects of the OTC painkillers. OTCA makes OTC 11 painkillers popular to the public. OTCA influences me to 12 purchase an OTC painkiller. OTCA causes discomfort 13 to me as it reminds me a bad past situation. OTCA gives me hope that I 14 will find a solution to my problem.

Part 3

Factors that lead to the purchase of OTC painkiller.

Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree I buy an OTC painkiller that 15 I saw in the ad. I ask the pharmacist about 16 the OTC painkiller I saw in the ad before I buy it. I buy an OTC painkiller suggested by my pharmacist 17 even if it is different from what I saw in the ad. I buy an OTC painkiller 18 recommended by my doctor. I buy an OTC painkiller 19 recommended by my friends or family. I buy an OTC painkiller 20 which is cheaper.

Undergraduate Thesis / Postgraduate Dissertation 99 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

I buy an OTC painkiller that 21 I know and trust. I buy an OTC painkiller 22 with a popular brand name.

Part 4

The OTC painkiller in our daily life.

Neither Strongly Strongly Disagree agree nor Agree disagree agree disagree I use OTC painkiller for 23 daily mild pains. I consider OTC painkillers 24 safe. I consult pharmacist for 25 mild pains without visiting the doctor. OTC painkillers’ prices are 26 constantly rising. The economic crisis led to 27 decrease of OTC painkillers purchases. I consider right and logical 28 to sell OTC painkillers outside pharmacies. I believe that the outside- pharmacies OTC 29 painkillers’ selling will lower their prices. I believe that the outside- pharmacies OTC 30 painkillers’ selling leads to their excessive consumption.

Undergraduate Thesis / Postgraduate Dissertation 100 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Part 5

DEMOGRAPHICS

Choose your gender: ☐ Male ☐ Female

Your age : ☐ 18-34 ☐ 35-44 ☐ 45-54 ☐ 55-64 ☐ 65-74 ☐ 75 +

Your educational level:

☐Primary school ☐Secondary/High school ☐Vocational school ☐Bachelor ☐Master/PhD

Your occupation: ☐State/private employee ☐Self-employer ☐Farmer/stockman

Undergraduate Thesis / Postgraduate Dissertation 101 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

☐Retired ☐unemployed ☐University student ☐domestic

Your place of residence : ☐ city of Florina ☐Rest regional unit of Florina

Undergraduate Thesis / Postgraduate Dissertation 102 Vasiliki Kipourou, The effect of advertising on OTC painkillers consumption in the regional unit of Florina: a quantitative study

Author’s Statement: I hereby declare that, in accordance with article 8 of Law 1599/1986 and article 2.4.6 par. 3 of Law 1256/1982, this thesis/dissertation is solely a product of personal work and does not infringe any intellectual property rights of third parties and is not the product of a partial or total plagiarism, and the sources used are strictly limited to the bibliographic references.

Undergraduate Thesis / Postgraduate Dissertation 103