CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Broadly speaking a drug is any substance or product that is used or intended to be used to modify
or explore the physiological system or pathological state in the benefit of the recipient (World
Health Organization, 2006). These include pharmaceutical, recreational and psycoactive drugs
such as tobacco, caffeine and alcoholic beverages. One of the ways in which people get to know
about drugs is through advertising.

Advertisement is an informative or persuasive message carried by a non-personal medium and

paid for by an identified sponsor whose organization or product is identified in some way. It is a
form of communication used to persuade an audience being it viewers, readers or listeners to
take some action with respect to products, ideas, or services. Advertisement simply refers to the
public promotion of some product or service.

Effective advertisement is very costly if one wishes to attract more customers and this can be due
to the competition involved. There are two ways of advertising a product: direct – to – consumer
and through the media. Direct – to – consumer advertisement (DTCA) of prescription drugs are
perhaps today’s most present source of consumer drug information available especially in the
United States and New Zealand. In the US annual spending on DTCA surpasses two billion
dollar. This has raised numerous concerns about the potential effects of drug advertising on
health care leading to the questioning the educational value of drug advertising. (Young, J. H.,
1969)

Drug advertisement messages are usually viewed via various traditional media including mass
media such as newspaper, magazines, television commercial, radio advertisement, outdoor
advertising or direct mail; or new media such as websites and text messages.The first
advertisement for patent medicine was placed in an American newspaper in 1708 by Boston's
Nicholas Boone (Young, 1969).

According to Dr. Friedman, drug advertisement could help promote greater consumer awareness
about prescription drugs. But most doctors believe that these adverts lead to unnecessary use of

1
medical care and hence exposing patients to expensive brand names especially on the internet
and other media network. Most doctors also feel pressured to prescribe the most heavily
advertised products. Now these advertisements not only drive conversation between patients and
doctors but also remind those who already have been prescribed medicines to take them. (Avorn,
J., Chen, M., & Hartley, R. 2011)
Students are among the major groups that are are frequently exposed to drug advertising
messages by the media. It is known that young people view more than 40,000 adverts each year
on television alone and increasingly are being exposed to advertising on the Internet, in
magazines and in schools. The average young person views more than 3000 adverts everyday on
television, on the internet, on billboards and in magazines (Goodman, E., 1999).

In Ghana the commonest media in which people are reached with advertising messages is
through the radio, television commercials, billboards and public speaking.

Researchers have raised the question in the past if drug advertisement have adverse effect on
people and this has gained public attention.

A report by the Food and Drugs Board in Ghana suggests that recent drug advertisements by the
media in the country are misleading and threat to the safety of consumers in the country (Ghana
news agency, 2004).

Various people have different views about the effect of drug advertisements. In a study by
Mackowiak, E. D., O’Connor, T. W., Geller, H., Nguyen, J., & Wilkes, W. (1997), around half
the pharmacists and students surveyed regarded over-the-counter drug advertisements, they were
shown as misleading and not truthful.

Opponents of DTCA observe that the principles of DTCA are incompatible with patient
education. According to Bradley, L. R., &Zito, J. M. (1997), when consumers are faced with a
complex technology that is beyond their formal education, limited information may lead to
confusion and heightened expectations about medication which result in demands for a clinically
inappropriate treatment or an unnecessary risk. They believe that most consumers do not have
the necessary clinical and pharmacological expertise to evaluate accurately and hence agree that
drug advertisement should enhance customers understanding.

2
Again, others believe that consumers rather misinterpret promotional materials. These concerns
therefore reflect healthcare expertise’s opinions about the informational role of drug advertising
and consumers’ comprehension and the use of information. Hence advocate for direct interaction
with medical practitioners. (Young, 1969)

Several researches have been conducted on the effects of drug advertisements. These studies
were conducted among health professionals, consumers, the youth and school children. Most of
these countries in which these studies were done have different demographic setting and
technological advancement. Evidence from these searched is however not conclusive.
In this research work, we are going to find out if indeed drug advertisement educate consumers
or it rather confuse them creating more harm to their health.

1.2 PROBLEM STATEMENT

Drugs are meant to treat, mitigate or prevent disease, disorder or abnormal physical state, or
symptoms thereof or restore, correct or modify organic functions in man. However, if drugs are
inappropriately or irrationally used, they can have potentially toxic effects on the consumer.

One of the major ways in which people get informed about drugs is through advertisements.
Students are among the major group that are exposed to drug advertisements, considering the
fact that they are almost always in touch with the media; they spend most of their time either
reading, listening, watching or chatting to be either educated, informed or entertained.

Most of these drugs and other foreign drugs are advertise on the television, radio and internet
due to advancements in technology. As a result individuals who might not want to go to the
hospital for reasons known to them choose to go to the pharmacy to purchase drugs they assume
could make them well again.

We can never therefore undermine the effects that these adverts have on students in the country
who sooner or later become a significant part of the country's resource.

3
The question now is, does drug advertisement educate consumer? How are drug advertisements
really affecting our society? Does it give enough information to consumers? Is it a good idea to
purchase drugs not prescribed by a doctor?

1.3JUSTIFICATION OF THE STUDY.

Drug advertisements have become one of the areas of research interest since the emergence of
modern forms of advertising and its associated public health concerns. Politicians, social
scientists, health professionals, and health organizations make various comments about how drug
adverts can be of benefit to us and how it can adversely affect our society. This study seeks to
identify the effects drug advertisements have on students.

1.4 OBJECTIVES OF THE STUDY

1.4.1 Main Objective

To determine the impact of drug advertisement by the media on students of Garden City
University College.

1.4.2 Specific Objectives

1. To determine the effects of drug advertisements on the use of medication by students.
2. To determine the effects of increased drug advertisements on hospital attendance.
3. To determine whether drug advertisement has resulted in abuse of drugs.
4. Find out if drug advertisements educates or confuse students.

1.5 RESEARCH QUESTIONS

1. What are the effects of drug advertisement on the use of medication by students?
2. What are the effects of increased drug advertisements on hospital attendance?
3. Have drug advertisement resulted in abuse of drugs?
4. Does drug advertisement educates or confuse students?

4
1.6 LIMITATIONS OF THE STUDY

Various limitations were encountered in the course of the study. The study was impeded by time,
material and financial constraints.

Time was a limiting factor due to demand from other academic activities. Due to financial
constraints, a smaller sample size was used which may also interfere with generalization of the
results to a larger group since it may not be a true reflection of characteristics of the larger group.

1.7 DEFINITION OF TERMS

Advertisement: is a form of communication used to persuade an audience being it viewers,

readers or listeners to take some action with respect to products, ideas or services.

Drug: a substance or mixture of substances manufactured, sold or presented for in vivo use in
the diagnosis, treatment, mitigation or prevention of a disease disorder, abnormal physical state
or the symptoms thereof, or in restoring, correcting or modifying organic function(s) in man, but
excluding mechanical devices and cosmetics.

Effect: the result of a particular influence.

5
 CHAPTER TWO

LITERATURE REVIEW

2.1 OVERVIEW

This chapter deals with the studies conducted by others on drug advertisement and the effects
they have on people. The literature review highlights findings and results of other studies on the
topic.

The current spectrum of drug advertisements is aimed at consumers on board. Such

advertisements fall into three categories according to Bradley and Zito (1997); Health-seeking
advertisements educate consumers about a disease or medical condition, reminder
advertisements that provide the name of the drug and other minimal information but say nothing
about the drug's use, effectiveness or safety and product-specific advertisements that mention a
drug therapy by name, describes its therapeutic use(s) and make representations about its safety
and effectiveness. The vast variety of advertisements fall within this latter category.

Advertising preconditions the consumer to buy, formulating the attitudes needed for considering
a purchase. An attitude about a brand has two parts; a cognitive or logical component that holds
beliefs about the benefit of the product, and an effective component in which emotions energize
behavior. Products project a psychological and social meaning to the consumer who buys them
(Kindra, G. S., Laroche, M., & Muller, T. E., 1994)

2.2 EFFECTS OF DRUG ADVERTISEMENT ON SELF-MEDICATION

Irrational use of medicines is an extremely serious global problem that is wasteful and harmful.
In developing and transitional countries, in primary case less than 40% of patients in the public
sector and 30% of patients in private sector are treated in accordance with standard treatment
guidelines. Moreover, it has been estimated that half of all patients fail to take their medication
as prescribed or dispensed (WHO, 2011).

6
World Health Organization (2011) reports that drug advertisements by the media has led to
increased patronage of drugs, some of which may contain insufficient quantities of active
ingredients or with the addition of toxic substances or even without active ingredients.

In other words, DTC advertising may cultivate the belief among the public that there is a pill for
illness and contribute to medicalization of trivial ailments, leading to an even more
'overmedicated' society (Nikelly, A. G., 1995)

2.3 EFFECTS OF DRUG ADVERTISEMENTS ON REQUEST FOR A PARTICULAR

PRESCRIPTION

These drug campaign are extremely altering the relationship between doctors and patients in a
negative way. “Prescription drug adverts pressures health professionals to prescribe particular
medications, and often the ones that may be less effective and more expensive and dangerous.
This intrudes in the relationship between medical professionals and patients and disrupts the
therapeutic process” (Ruskin, G., 2005).

A recent broadcast launched by a leading Republican law maker, Bill Frist, carried the message
that drug advertising leads patients to demand from their doctor drugs that may not need or even
worse, that might expose them to risks they didn't know about.

Indeed, a recent study by US Food and Drug Administration found ads increased awareness of
new treatments and that most doctors felt they helped discussions about health matters with
patients. But the study also found that adverts unnecessarily increase patients' anxieties about
their health, and that doctors felt under pressure to prescribe specific medicines.

Strand, R. D., (2005) writes that surveys reported in medical literature revealed that even when a
patient comes into a doctor's office and requests a specific drug that he has seen advertised in the
media, the doctor writes the exact prescription the patient requested more than 70 percent of the
times.

A recent survey of physicians found that 92% 0f patients had requested an advertised drug
(Thomaselli, R., 2003).

7
Everret, L. & Stephen, E. L., (1991) asked 238 people in Denver, USA to respond to a
hypothetical situation in which they had back pain and saw an advertisement for s prescription-
only muscle pain reliever. About one-third of the sample said they would ask their doctor for the
drug and 5% said they would change doctor if he/she did not prescribe it. Those who were very
less educated were more likely to say they will they will tell the doctor they had seen the
advertisement and ask him/her to prescribe the drug.

In a somewhat more realistic study, Perri, M., &Dickson, W. M. (1987) sent fake advertisements
for fictitious prescription medicines through mail to 200 patients who had scheduled
appointments with their doctors.

They used the advertisements developed by Morris, which he had found to produce the highest
knowledge and recall scores. The four doctors treating the patients in the study knew about the
advertisements, acted as if the medicines where real and recorded patient behavior. One hundred
and fifty-five patients were observed by doctors. Thirteen made general comments and asked
general questions about the medicines but none made requests for the medicine. Ninety-four
patients also completed questionnaires, which showed that those with chronic medical conditions
were more receptive to the advertisements and more favorable attitudes. The four doctors in the
study felt that the advertisement had had no negative effect on their relationships with patients
(Morris, L. A., & Millstein, L. G., 1989).

A group of researchers analyzed a sample of 1431 visits to primary care physicians in one
Canadian and one US city. They found patients requested prescriptions in 12% of visits and 42%
of these request were for products advertised to consumers. (Mintzes, B. B., Morris, L., Kravitz,
R. L.,Kazanjian, A. T., Bassett, K., Lexchin, J., Evans, R. G., Pan, R., & Marion, S. A., 2002 )

2.4 EFFECTS OF DRUG ADVERTISEMENTS ON HOSPITAL ATTENDANCE

According to a research conducted in US Department of health and human services, food and
drug administration, 4% of patients visited their doctors because of a drug advertisement seen
(Ruskin,2005).

8
2.5 EFFECTS OF DRUG ADVERTISEMENTS ON ABUSE OF DRUGS

In a study by WHO-Ghana, on tobacco involving 510 senior high school students in 6 schools,
65 (13%) had ever smoked cigarettes. Of these 13%, 15(23%) started at the age of 16, 26% of
the total sample were aware that smoking caused harm to the lungs. The habit is as a result of
peer pressure, parental smoking and advertising (Wellington et al 2000).

Ghana has never over the years made diligent efforts to control the drug menace among its
populace. Efforts have included the development of policies against drug trafficking through
national and internal ports of entry, confiscation of property of drug traffickers, banning cigarette
advertised on television.

In a study in Ghana (Ghana Global Youth Tobacco Survey-GYTS) by Wellington et al (2000),

on tobacco involving 510 senior high school students in 6 school, 65 (13%) had ever smoked
cigarettes. It was found out that this habit is as a result peer pressure, parental smoking and
advertising.

Research suggests that exposure to tobacco advertising may be bigger risk factor than having
family members and peers who smoke (Evans, N., Farkas, A., Giplin, E., Berry, C., & Pierce, J.
P., 1995)

Two unique and large longitudinal studies have found that approximately one third of all
adolescent smoking can be attributed to tobacco advertising and promotions (Pierce, J. P., Choi,
W. S., Gilpin, E. A., Farkas, A. J., & Berry, C. C. 1998) and (Biener, L.& Siegel, M., 2000)

2.6 EFFECTS OF DRUG ADVERTISEMENT ON INFORMATION RECEIVED ABOUT

DRUGS

Steven Everett found that consumers were open to the idea of making use of DTC
advertisements as a source of drug information but were inclined to these advertisements to
supplement more traditional sources of information, including health care professionals (Everett,
1991)

Studies suggest that over-the-counter drug messages tend to confuse consumers regarding side
effect information and as a result, consumers attribute side effects to all products in the same
category (Sheffet, M. J.,& Kopp, S. W., 1990).
9
Few physician-directed print pharmaceutical advertisements adhere to all FDA guidelines; over
half fail to quantify serious risks. The FDA could better protect public health by creating new
more objective advertisement guidelines requiring transparent presentation of basic safety and
efficacy information (FDA, 1999).

In fact, mis-comprehension of drug advertisements has been documented (Morris et al, 1986). A
recent experiment found that the inclusion of both promotional and risk-related information in
the same broadcast advertisement adversely affected consumers' ability to understand each type
of information (Schommer, J. C., Doucette, W. R., & Mehta, B. H.,1998).Researchers like
Alperstein and Peyrot in their study came to a conclusion that approximately 70% of survey
respondents believed drug advertisements would educate them while less than one – third
believed that drug advertisements would confuse them. (Young, 1969)

Advertising drugs to the public often works by creating unhappiness or anxiety about symptoms
or normal experiences (such as occasional erectile difficulties), and by creating high expectations
of benefit from drugs. The combination of these can cause severe distress when a drug is
unaffordable or when its effects are disappointing: for example, a qualitative study of men who
used sildenafi l erectile dysfunction found that expectations raised by media hyperbole had an
adverse effect on the morale of those for whom it was ineffective. (Biener& Siegel, 2000)
Drug advertisement has been on the increase due to competition among drug makers.
Competitive pressures drive individual drug makers to advertise to make their products more
known and substitute medicines to treat conditions like asthma, diabetes etc.Studies also show
both positive and negative effects from drug advertisements. Many research organizations and
pharmaceutical industry support that drug advertisement provide consumers with important
information that may benefit their health (Mason, A.& Rubin, P. H., 1985) and (Hunt, M. 1998)

Other studies also oppose that drug advertisements manipulate, create false impressions and
mislead consumers instead of educating them about the drugs.

10
2.7 EFFORTS TO SOLVE THE PROBLEM

There are several evidence based recommendations made or suggested to solve this problem. The
guidance prepare by the intra-agency group on advertising and promotion clearly outlines
procedures to fulfill the requirements for disclosure of product information in connection with
consumer-directed broadcast advertisements for prescription human and animal drugs and human
biological products. It does not create or confer any rights for or on any person and does not
operate to bind FDA or the public (Mintzes et al, 2002).

One researcher (Sheetal Patel, 1999) also suggested that such problems of the effects of drug
advertisement on the youth can be solved by universal definitions of certain variables in the
study. She also suggested that research should include longitudinal studies so that variables such
as television viewing can be measured over a period of time as cultivation can take years to show
direct effects. Other variables outside of television should be measured on medication attitudes
to gauge strength of television media affects. Also, communication theories should be applied to
this area of research in order to guide method design and allow studies to be replicable. This
implies one action the government can take through a school, which is not only include
information on illicit drug health education classes but also provide messages about drug use
including advertising and regulations when needed. This may achieve some degree of media
literacy so that future generations are more equipped to handle messages.

11
 CHAPTER THREE

METHODOLOGY

3.1 Study Area

The study area will be conducted in Garden City University College (GCUC). The university is
located Kenyase which is in Kumasi, Ashanti region. The study was conducted at Garden City
University College which is affiliated to Kwame Nkrumah University of Science and
Technology. Garden City University College was established as the College of Information
Technology and Management Studies (CITMAS) in 2001. In January 2004, the Board of
Directors voted to convert the college into a university college and was granted permission to
operate as a university college.

Garden City University College is located at Kenyase which is in the Kwabre East district. It is
about 2 kilometers from the Kumasi airport roundabout on Antoa road. Kwabre East district
shares boundaries with Sekyere South district to the north, Kumasi Metropolitan Area to the
south, EjisuJuaben Municipal to the South East and Atwima District to the west.

The university college has three main schools; School of Nursing, School of Business, School of
Information and Communication Technology with medical laboratory, physician assistant and
midwifery introduced in 2013. The school’s population is about two thousand one hundred and
seventy eight (2,178).

The school has a fully equipped library with book stock of fourteen thousand (14,000) volumes
and internet connectivity with WI-FI accessibility. There are twenty four (24) full times
lecturers, thirty four (34) part time lecturers, ten (10) teaching assistance, three (3) technical
instructors, one (1) practical coordinator and one (1) senior administrative assistant and which
sum up to seventy three lecturers in the school.

3.2 Study Design

Cross-sectional, non-experimental study design was employed. Questionnaires were developed
with both close ended and open ended questions. The questionnaires contained questions that
enquired from respondents information about respondents' personal data, exposure to drug

12
advertisements, and whether or not the exposure has brought about effects like self-medication,
alcoholism, promiscuity, recommendation of prescription by patient, decreased hospital
attendance when sick and drug abuse.

3.3 Study Population

Students were the target population for this research and students from GCUC formed the study
population. They included students from the various departments within the University. The
school’s population is about two thousand, one hundred and seventy-eight (2,178). The school of
Business has the highest population which is one thousand and twenty (1020) students, School of
Nursing with seven hundred and forty-one (741) students, Midwifery, one hundred and seven
(107) students, Physician Assistant, one hundred and four (104) students, Medical Laboratory
Technology, forty-one (41) and Information Communication Technology with two hundred and
sixteen (216) students.

3.4 Techniques, Instruments for Data Collection and Analysis

Data for this research were collected through questionnaire, which consisted of close ended and
open ended questions which was administered to each of the respondents after consent has been
given. Demographic data was first of the questionnaire of the respondents before the main
questions follow. English language was used for the questionnaires since all respondents were
students. The technique that was used to collect the data is self-administered questionnaires.

The data collected was analysed with the use of Statistical Package for the Social Science
(SPSS) version 21.

3.5 Sampling and Sampling technique

The sampling technique that was used in this study is quota and random sampling technique.
This ensured that a predetermined number of students are selected from each the departments in
the University based on the student population of that particular department. Students who

13
happened to be available at the time of data collection were selected for the sake of convenience.
The number of students that were selected from each department was directly proportional to the
student population of that particular department. More students were selected from the
department with larger student population and less number of students were selected from the
department with smaller student population.

3.6 Ethical Consideration

To deal with ethical associated with the study, permission was sought from the university's
administration. The research was ethical as much as possible by giving maximum respect to the
rights of the respondents. Information provided by respondents was handled with confidentiality
and anonymity. A thorough explanation of the processes were carried out to seek informed
consent from participants.

3.7 Validity and Reliability.

It was ensured that the information collected is relevant to the research questions. The
questionnaires were structured in a way that helped obtain results that are relevant to the research
question and ensure maximum validity. In the context of this study, the stability and consistency
of the data collecting tools was ensured to provide consistent results on repeated trials. This was
achieved by conducting a pretest of the questionnaire. The pretest was conducted at Kumasi
Polytechnic choosing five females and five males.

14
 CHAPTER FOUR
RESULTS
Figure 4.1 Age Distribution
50 47
45
40
34
35
30
25
19 Percent
20
15
10
5
0
18-22 23-27 28 and above

Age of respondents showed that 47% of them were aged from 23-27years, 34% of them were
aged from 18-22 years while 19% were aged 28 years or more.

Figure 4.2 Gender Distribution

53

52

51

50
Percent
49

48

47

46
Male Female

Among the respondents 41(48%) were males while 45(52%) being the majority were females.

15
Figure 4.3 Frequency of contact with media

80
72
70

60

50

40
Percent
30

20 14 13
10
1
0
Everyday Every other day Weekly Other

Majority of the respondents being 72% had contact with the media every day, 14% had this
contact every other day while 13% mentioned weekly.

Figure 4.4 Awareness of drugs advertisement

100 95
90
80
70
60
50
Percent
40
30
20
10 5
0
Yes No

Among the respondents 95% indicated that they were aware of drug advertisement while 5%
were not aware.
16
Figure 4.5 Type of media

60
54

50
42
40

30
Percent

20

10
4

0
Television Radio/FM stations Internet

The main type of media mentioned was radio/FM stations among 54%, 42% mentioned
television while 4% indicated the internet.

Figure 4.6 Common drugs advertisement

50 46
45
40
35
30
25
25
19 Percent
20
15
10
10
5
0
Pain relievers Cough mixtures Blood tonics Other

The study found that pain relievers were the common drugs advertised as mentioned by 46% of
the respondents, 19% indicated cough mixtures, 25% mentioned blood tonics while 10 of them
indicated other drugs such as anti-malaria and antibiotics.

17
Figure 4.7 Patronage of drugs

70
64

60

50

40 36
Percent
30

20

10

0
Yes No

Among the respondents, majority of them indicated they patronized drugs.

Figure 4.8 Length of time drug has been taken

35 32.8
29.7
30
25
25

20
Percent
15 12.5

10

0
Weeks Months Years Other

Length of time drugs were used among respondents was mostly weeks among 21(32.8%), usage
in months was indicated by 19(29.7%), 8(12.5%) mentioned they used the drugs for years while
16(25%) used it for other times.

18
Figure 4.9 Drugs taken whenever respondents suffer a disease

50
45 42.9

40
35
30
30 27.1
25
Percent
20
15
10
5
0
Yes No Sometimes

Among the respondents 30(42.9%) used drugs when they suffered diseases, 19(27.1%) did not
while 21(30%) mentioned that they used the drugs sometimes.

Figure 4.10 Visits to the hospital for every illness

90
79.1
80
69
70

60

50
Yes
40
No
30
19.8
20 17

10

0
Frequency Percent

Seventy (19.8%) of the respondents mentioned that they visited the hospital for every illness they
had while majority of them did not and were 69(79.1%).
19
Figure 4.11Means of treatment if the hospital is not visited

60
53.8

50

40

30
23.1 23.1 Percent

20

10

0
Borught a drug Used a medication Other

The means of alternative treatment for ailments were mostly by buying a drug by (42(53.8%),
18(23.1%) also mentioned using a medication or resorted to other interventions possibly spiritual
assistance.

Figure 4.12 Frequency at which used drugs are being advertised

50 47.4
45
40
35 32.9

30
25
19.7 Percent
20
15
10
5
0
Everyday Every other day Other

The frequency of advertisement of used drugs was mainly 36(47.4%), 25(32.9%) also used drugs
everyday while 15(19.7%) also indicated other forms of usage such as infrequent

20
Figure 4.13 Change in number of times drugs used are being advertised
70
59
60

50

40
Percent
30
24.1

20 16.9

10

0
Increased Decreased Remained the same

Respondent indicated mainly that the drugs advertisement had decreased after usage by majority
49(59%) of them, 30(16.9%) also added that it had remained the same and 14(16.9%) mentioned
that there has been an increase in the number of times.

Figure 4.14 Used a drug for its effect when not sick

90

80 75 76.5

70

60

50
Yes
40
No
30 23 23.5
20

10

0
Frequency Percent

Minority of the respondents being 23(23.5%) used drugs when they were not sick by desiring its
effect while 75(76.5%) did not indulged in this habit.

21
Figure 4.15 Frequency of drug usage
60
53.2
50

40

29.8
30
Percent

20 17

10

0
Every day Every other day Other

Frequency of drugs usage as recorded indicated that majority of the respondents being 25(53.2%)
used drugs inconsistently, 14(29.8%) used the drugs every other day, while 8(17%) reported of
using the drug every day.

Figure 4.16 Frequency of hearing or seeing that drugs are being advertised on the media
45
40
40 36.9
35

30

25 23.1

20 Percent

15

10

0
Everyday Every other day Other

The study found that majority of the respondents (40%) hear or see drugs being advertised on the
media every day, 15(23.1%) hear or see the adverts every other day while 24 of them
representing (36.9%) hear or see the adverts inconsistently.

22
Figure 4.17 Frequency at which drugs are used for non-therapeutic purposes before
exposure to advert
60

50 47.8

40
33.3

30
Percent

20
14.5

10
4.3

0
Always Occasionally Rarely Other

The use of drugs for non-therapeutic purposes was rarely by 33(47.8%) of respondents,
23(33.3%) used it occasionally for this purpose while 3(4.3%) always indulged in this practice of
abusing the drugs. 10(14.5%) of them also indicate they abused drugs once in a while.

Figure 4.18 Frequency at which drugs are used for non-therapeutic purposes after
exposure to advert
60
50.8
50

40
33.8
30
Percent
20 15.4

10

0
Ocassionally Rarely Other

After exposure to adverts 22(33.8%) occasionally used drugs for non-therapeutic purposes,
majority of them which was 33(50.8%) rarely abused the drugs while 10(15.4%) used the drugs
at other times without any pattern.

23
Figure 4.19 Drugs used without prior knowledge for undesired effects
90
80.7
80

70 67

60

50
Yes
40
No
30
19.3
20 16

10

0
Frequency Percent

Among the respondents in this study, 16(19.3%) reported of using drugs without a prior
knowledge it having undesired effects while majority being 67(80.7%) of them indicated that
they did not use such drugs.

Figure 4.20 Initial source of information about drug

70
58.7
60

50

40
32.6
30 Percent

20
8.7
10

0
Someone told me From media Explained to me at
about the drug advertisement the hospital

The initial sources of information on drugs as indicated by respondents were by others telling
respondent about drugs among 27(58.7%) of the respondents, 15(32.6%) added that they were

24
informed by the media advertisement while 4(8.7%) mentioned they were informed at the
hospital.

Figure 4.21 Frequency of seeing or hearing the particular drug being advertised on the
media

50
45.6
45
40
35
30 26.3
25
Percent
20
15.8
15 12.3
10
5
0
Every day Ocassionally Rarely Other

Respondents upon being asked about the frequency of seeing or hearing the particular drugs
advert indicated mainly that it was seen or heard every day among 26(45.6%) of them,
15(26.3%) said it was heard or seen occasionally, 9(15.8%) indicated ‘rarely’ while 7(12.5%)
said it was inconsistent.

25
 CHAPTER FIVE

DISCUSSION, CONCLUSIONS AND RECOMMMENDATIONS

5.1 DISCUSSION

This discussion is aimed at; determining the effects of drug advertisements on the use of
medication by students, the effects of drug advertisements by the media on request for particular
prescriptions, the effects of increased drug advertisements on hospital attendance, find out
whether students contact a medical practitioner before purchasing or consuming drugs advertise
by the media determine whether drug advertisement has resulted in abuse of drugs an find out if
drug advertisements educates or confuse students. This discussion is follows the pattern of
question on the questionnaire and done by analyzing the results of the study and comparing them
with literature reviewed in an earlier chapter.

The demographic information of respondents identified that majority (47%) of the students
sampled in this study were aged from 23-27years. And females were dominant with a
representation of 45(52%). This finding on the demographic information was expected since
most individuals attended the tertiary institution around the ages of 20-30 and females were
normally majority in our population.

With regards to self-medication that is brought up by advertisement of drugs on the media, it was
found that majority (72%) of the students had access to the media every day. Since
advertisement of drug was nowadays mostly channeled through the media it was found that
almost all students (95%) sampled were aware of drugs advertisement on the media with the
most common form of media being the radio with a representation of 54% followed by the
television(42%). It can therefore be deduced that the electronic media had captured the times
since all the respondents had access to one form of electronic media or the other. According to
the World Health Organization (2011) reports which indicates that drug advertisements by the
media has led to increased patronage of drugs. In this study, this patronage is seen and even led
to self-medication. This study`s findings therefore agrees with the report by WHO (2011).

26
According to students of this study, majority of them highlighted the most common drugs
advertised to be pain relievers as evidence by 46% of them while others were cough mixtures,
antibiotics and hematinics. These result is certainly to have occurred since most pain killer drugs
were over the counter drugs and could be more often than not bought without strict prescription.
What is normally required of its users is that when the symptoms shown that prompted the use of
the particular pain relieve drug persist, proper medical care should be sought. These drugs were
therefore mostly patronized by majority of the students as they opined that they were safe for
use.

To determine the duration of self-medication among students they were quizzed on the duration
for which they had self-medicated. Responses that were attained pointed out that most of the
students had self-medication with the particular drugs for not long a period of time as 32% had
being in this habit for months while very few (12.5%) of them had being in this for years. Long
term use of a particular drug which is not under prescription could lead to effects such as serious
side effects and more seriously addiction. The instances when drugs were used among the
students was mostly when they suffered a disease by 42.9% of them while some of the students
used drugs for they were not sick and therefore desired the effects the drugs provided.

The patronage of the health facility during ailment was also affected with the high publicity of a
plethora of drugs on our electronic media. In general, it was identified that majority of the
students did not visit the health facility on all ailments as was indicated by majority of the
students (79.1%) mentioned this and was a predictor that it students either self-medicated or
sought treatments either than the health facility. The power of drug advertisement is becoming
stronger by the day as it has even prompted some individuals to particular visit their doctors as
indicated by Ruskin (2005) as a result a drug advertise by the media. There is therefore an
affirmation and an agreement between this study`s findings and that of Ruskin (2005).

This assertion above was proven in a follow up question that showed that majority of the
sampled students (53.8%) treated illnesses by buying drugs but not going to the hospital which
presented cases of self-medication.

The study also found that advertisement had an effect on the patronage of drugs that are self-
medicated. In this study, it was ascertained that the drugs that were mainly bought for the

27
management of illness were mainly advertised every other day as evidenced by majority of the
student (47.4%) while 32.9% mentioned those drugs bought were advertised every day. After
these heavily advertised drugs had been patronized, the students indicated that they were not
much advertised anymore since their frequency of advertisement decreased by majority of the
students being 59%. However, very few of the student indicated that the frequency of
advertisement stayed the same. Everret and Lay (1991) in their research asked 238 people in
Denver, USA to respond to a hypothetical situation in which they had back pain and saw an
advertisement for a prescription-only muscle pain reliever. Findings of their study points out that
the request for a particular prescription was very strong that some individuals even mentioned
they would change doctor if not prescription of the desired drugs was refused. There is therefore
agreement with this study`s findings since after exposure to drugs advertisement more and more
students liked to request for a prescription.

The level of drug abuse was determined in the study when students were asked the particular
times or instances where advertised drugs were used, the frequency of usage and intensity of
advertisement on the media concerning the drugs. the study identified that a considerable
percentage (23.5%) of the students did not use the drugs when they were sick despite majority of
the students (76.5%) did not indulge in this act of abusing drugs. it was rather unfortunate that
17% of the students use these drugs everyday probably due to the effect it gives them but not for
any therapeutic purpose notwithstanding the fact that majority of the students (53.2%) reporting
they used the drugs inconsistently. The effect of advertisement was affirmed from the results that
presented that majority of the students as evidenced by 40% haven heard or seen the
advertisement of drugs on the media while fewer of them did not always hear or see the adverts.
In a study by WHO-Ghana, on tobacco involving 510 senior high school students in 6 schools,
65 (13%) had ever smoked cigarettes. It was identified that this habit is as a result of peer
pressure, parental smoking and advertising, according to Wellington et al (2000). Advertising is
not really considered to have any effect but in actual fact it really makes an impact in the
patronage of drugs and even more seriously it abuse and addiction. In this study it is seen that
drugs that are abuse mostly are those intensively advertised on the media.

In a more clearer indication to determine the occurrence of drugs abuse among students, it was
found that before the advertisement of drugs on the media, drugs used for non-therapeutic
purposes was not pronounced since majority of the student (47.8%) rarely used the drugs for
28
non-therapeutic purposes. However this trend did not change after the exposure to drugs through
adverts on the media where majority of the students (50.8%) still rarely used the drugs for non-
therapeutic purposes. According to Evans et al (1995) the exposure to tobacco advertisement
makes immense impact in it use among the youth. Research suggests that exposure to tobacco
advertising may be bigger risk factor than having family members and peers who smoke as
indicated by Evans et al (1995), Pierce et al (1998) and Biener& Siegel, (2000). This also agrees
with the findings of this study.

Students were finally evaluated on their knowledge on side effects of the drugs that they used,
they were quizzed on their use of drugs that they had no prior knowledge on their undesired
effects, their initial sources of information on the drugs and the frequency of these drugs being
advertised. The study found that majority of the students (89.7%) did not use drugs that they
were not aware of their undesired effects. It was also found that majority of students (58.7%) had
used drugs recommended to them by others while very few of them (8.7%) mentioned the health
center as the initial source of information on the drugs used. In a study by Sheffet& Kopp (1990)
mentioned in their study that over-the-counter drug messages tend to confuse consumers
concerning side effect information and as a result, consumers relate side effects to all products in
the same category. This finding is in line with this study`s since the knowledge on side effect
was not good enough indicating that drugs advertisement did not highlight side effects of the
drugs.

Once again it was found that adverts on drugs whose side effects were not known by their users
was seen or heard every day among majority of them being 45.6% while very few of them
indicated it was rarely seen or heard. This indicates that the advertisement of drugs was still on-
going among the drugs sellers but did not meet the needed education for its users. In the delivery
by Elizabeth, Almasi, Randall, Stafford, Kravitz, & Mansfield (2006) it was indicated that the
media exaggerated the potency of some drugs just for patronage and when these drugs buyers are
not able to achieve the desired effect their morale could be diminished. Despite the unmet needs
of the users the media still run adverts for drugs.

29
5.2 CONCLUSION

The study concludes that;

 Self –medication was on the increase as majority of the students self-medicated when
they had ailments and was mostly due to advertisement on the drugs on the media.
 The students had a negative health seeking behavior.
 Abuse of drugs was not noted to be that high but there was an increase with increase in
drugs advertisement
 Finally, knowledge on side effects of the drugs used was low since most of the students
did not get information on the drug from the health facility and hence might have not had
the right information on side effects.

30
5.3 RECOMMENDATIONS

 The study recommends that the Ghana Food and Drugs Board and Standard Board should
run the needed tests for efficacy and safety of drugs before they are authorized to be sold
on the market.
 People should not abusedrugs under any situation but proper advice should be sought
from medical personnel before they are used.
 Pharmacies should not sell over-the-counter drugs to people should not be sold without
prescription from a certified medical practitioner or a pharmacist.

31
 REFERENCES

Avorn, J., Chen, M., & Hartley, R. (2011). Scientific versus commercial sources of influence on
the prescribing behavior of physicians. American Journal of Medicine, 73, 4-8.

Biener, L., &Siegal, M. (2000). Tobacco marketing and adolescent smoking: More support for a
casual inference. Am J. Public Health, 90, 407-411.

Bradley, L. R.,&Zito J. M. (1997). Direct-to-consumer prescription drug advertising. Medical

care, 35(1), 86-92.

Evans, N., Farkas, A., Giplin, E., Berry, C., & Pierce, J. P. (1995). Influence of tobbaco
marketing and exposure to smokers on adolescent susceptibility to smoking. J. Natl
Cancer Institution, 87, 1538-1545.

Everret, L.& Stephen, E. L. (1991). Audience response to prescription drug advertising. Journal
of advertising Research, 31, 43-49.

Food and Drugs Board. (2006). FDB to publish list of approved adverts. Modern Ghana Media
Group, Available at http//www.modernghana.com. Retrieved on September 11,2006.

Ghana News Agency. (2004, April 13). FDB cautions media on unapproved adverts. Accra,
GNA.

Goodman, E. (1999, June 27). Ads pollute most everything in sight. Albuquerque Journal, C3.

Hunt, M. (April 1998). Direct-to-consumer-advertising of prescription drugs. Unpublished

manuscript, National Health Policy Forum.

Kindra, G. S., Laroche, M., & Muller, T. E. (1994). Consumer behavior: the Canadian
perspective (2nd edition). Scarborough, Nelson Canada.

Mackowiak, E. D., O'Connor, T. W., Geller, H., Nguyen. J., & Wilkes, W. (1997). A survey of
pharmacists' and pharmacy students' attitudes toward OTC advertising. Journal of
Pharmaceutical Marketing & Management, 12.33-49.

32
Masson, A., & Rubin, P.H. (1985). Matching prescription drugs and consumers. New England
Journal of Medicine, 313(8), 513-515.

Mintzes, B. B., Morris, L., Kravitz, R. L., Kazanjian, A. T., Bassett, K., Lexchin, J., Evans, R.
G., Pan, R., & Marion. S. A. (2002). Influence of direct-to-consumer pharmaceutical
advertising and patients' request on prescribing decisions: two-site cross sectional
survey. British Medical Journal, 324, 278-279.

Morris, L. A., & Millstein, L. G. (1984). Drug advertising to consumers: effects of formats for
magazine and television advertisements. Food Drug Cosmetic Law Journal, 39, 497-503.

Morris,L. A., Mazis, M. B., &Brinberg, D. (1989). Risk disclosures in televised prescription
drug advertised to consumers.Journal of Public Policy & Marketing, 8, 64-80.

Nikelly, A. G. (1995). Drug advertisement and medicalization of unipolar depression in women.

Health Care for Women International,16(2), 229-242.

Perri, M., & Dickson, W. M.(1987). Direct-to-consumer prescription drug advertising:

consumer attitudes and physician reaction. Journal of Pharmaceutical Marketing &
Management, 2, 3-25.

Pierce, J. P., Choi, W. S., Gilpin, E. A., Farkas, A. J., & Berry, C. C. (1998). Industry promotion
of cigarettes and adolescent smoking. JAMA, 279, 511-515.

Ruskin, G. (2005, November 2). Hearings on direct-to-consumer prescription drug advertising.

Testimony of Gary Ruskin, Director of Commercial Alert before the U. S. Food and
Drugs Administration.

Schommer, J. C., Doucette, W. R., &Mehta, B. H. (1998).Rote learning after exposure to a

direct-to-consumer television advertisement for a prescription drug, Clinical
Therapeutics, 20 (3), 617-632.

Sheffet, M, J.,&Kopp, S. W. (1990). Advertising prescription drugs to the public: headache or

relief? Journal of public policy & Marketing,9, 42-61.

Strand, R. D.(2005). Death by prescription, pp 49

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Thomaselli, R. (January 14, 2003). Advertising Age. Paediatrics in Review, 13(4), 144.

Veracity, D. (2005). The great direct-to-consumer prescription advertising: how patients and
dootors alike are easily influenced to demand dangerous drugs. Natural News Network,
retrieved on October 11, 2011 from http//www.naturalnews.com/z010315_direct-to-
consumer_advertising_drug_ads.html.

World Health Organization (2011). WHO expert committee on drug dependence, sixteenth
report. (Technical report series. no. 407). Geneva: World Health Organization.

Young, J. H. (1969). The Medical Messiahs: A social history of health quackery in twentieth
century America.Princeton, N. J. : Princeton University Press.

34
 APPENDIX I

QUESTIONNAIRE

Dear Respondent,
I am a student of Garden City University College Kumasi, conducting a research on effect of
drug advertisement on Garden City University student at Kenyase. The study is for academic
purposes. You can either choose to participate or not. However, you are assured of
confidentiality and anonymity if you participate. I will be grateful if you cooperate with me by
giving your honest options.
Thank you.

SECTION A. Personal Data

1. Age

a.18-22 [ ] b. 23-27 [ ] c. 28 and above [ ]

2. Sex

a. Male [ ] b. Female [ ]

SECTION B. Self-Medication

3. How often do you get in touch with the media?

a. Everyday [ ] b. Every other day [ ]c. Weekly [ ]d. Other..................

4a. Have you ever seen or heard a drug advertisement on the media?

a. Yes [ ] b. No [ ]

4b. If yes, on what type of media do you commonly see or hear drug advertisements?

a. Television [ ] b. Radio/FM stations [ ] c. Internet [ ] d. Other ….............................

5. What are some of the common drugs you see or hear being advertised?

35
a. Pain relievers [ ] b. Cough mixtures [ ] c. Blood tonics [ ] d. Other ….........................

(Answers could be more than one of the options provided)

6. Have you ever patronized a drug which you know is being advertised by on media?

a. Yes [ ] b. No [ ]

7. Can you state the drug (s)?

…....................................................................................................................................................

8. What are the reason(s) for taking the drugs?

…........................................................................................................................................................
............................................................................................................................................................

9. How long have you been taking that drug?

a. Weeks b. Months [ ] c. Years [ ] d. Other

…...........................................

10. Do you take that drug whenever you suffer from a particular sickness?

a. Yes [ ] b. No [ ] c. Sometimes [ ]

SECTION C. Hospital attendance

11. If yes, do you always go to the hospital for every illness?

a. Yes [ ] b. No [ ]

11b. If no, how do you get yourself treated?

a. Bought a drug [ ] b. Used no medication c. Other …...........................................

12. If you used a drug, how often do you see or hear that drug being advertised by the media?

a. Everyday [ ] b. Every other day [ ] c. Other …........................................

36
13. How has the number of times you report at the hospital when sick changed after your
exposure to that drug advert?

a. increased [ ] b. decreased [ ] c. remained the same [ ]

SECTION D. Abuse of drugs

14. Have you ever used a drug when you were not sick but only desired a certain effect of the
drug?

a. Yes [ ] b. No [ ]

15. How often do you use such drugs?

a. Everyday [ ] b. Every other day [ ] c. Other …........................................

16. How often do you see or hear that drug being advertised by the media?

a. Everyday [ ] b. Every other day [ ] c. Other …........................................

17. How often did you use the drug for non-therapeutic purpose before your exposure to that
advert?

a. Always [ ] b. occasionally c. rarely [ ] d. Other …...............................

18. How often did you use the drug for non-therapeutic purpose after your exposure to that
advert?

a. Always [ ] b. occasionally c. rarely [ ] d. Other …...............................

SECTION E. Knowledge on side effects of drug

19. Have you ever used a drug and later got to know that it possessed certain undesirable effects
which you did not know before?

a. Yes [ ] b. No [ ]

20. What was your initial source of information about that drug?

37
a. Someone told me about the drug [ ] b. From media advertisements [ ] c. Explained to
me at the hospital d. Other.......................................................

21. How often do you see or hear that drug being advertised by the media?

a. Everyday [ ] b. occasionally [ ] c. rarely [ ] d. Other ….............................

38
 APPENDIX II

Frequency Table

Age

Valid Cumulative
Frequency Percent Percent Percent

Valid 18-22 34 34.0 34.0 34.0

23-27 47 47.0 47.0 81.0

28 and above 19 19.0 19.0 100.0

Total 100 100.0 100.0

Sex

Valid Cumulative
Frequency Percent Percent Percent

Valid Male 41 41.0 47.7 47.7

Female 45 45.0 52.3 100.0

Total 86 86.0 100.0

Missing System 14 14.0

Total 100 100.0

39
Frequency of contact with media

Valid Cumulative
Frequency Percent Percent Percent

Valid Everyday 72 72.0 72.0 72.0

Every other
14 14.0 14.0 86.0
day

Weekly 13 13.0 13.0 99.0

Other 1 1.0 1.0 100.0

Total 100 100.0 100.0

Awareness of drugs advertisement

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 95 95.0 95.0 95.0

No 5 5.0 5.0 100.0

Total 100 100.0 100.0

40
Type of media

Valid Cumulative
Frequency Percent Percent Percent

Valid Television 41 41.0 41.8 41.8

Radio/FM
53 53.0 54.1 95.9
stations

Internet 4 4.0 4.1 100.0

Total 98 98.0 100.0

Missing System 2 2.0

Total 100 100.0

Common drugs adverstised

Valid Cumulative
Frequency Percent Percent Percent

Valid Pain relievers 46 46.0 46.0 46.0

Cough
19 19.0 19.0 65.0
mixtures

Blood tonics 25 25.0 25.0 90.0

Other 10 10.0 10.0 100.0

Total 100 100.0 100.0

41
Patronage of drugs

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 64 64.0 64.0 64.0

No 36 36.0 36.0 100.0

Total 100 100.0 100.0

Length of time drugs has been taken

Valid Cumulative
Frequency Percent Percent Percent

Valid Weeks 21 21.0 32.8 32.8

Months 19 19.0 29.7 62.5

Years 8 8.0 12.5 75.0

Other 16 16.0 25.0 100.0

Total 64 64.0 100.0

Missing System 36 36.0

Total 100 100.0

42
Drugs taken whenever respodnents suffers a disease

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 30 30.0 42.9 42.9

No 19 19.0 27.1 70.0

Sometimes 21 21.0 30.0 100.0

Total 70 70.0 100.0

Missing System 30 30.0

Total 100 100.0

Visits to the hospital for every illness

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 17 17.0 19.8 19.8

No 68 68.0 79.1 98.8

3 1 1.0 1.2 100.0

Total 86 86.0 100.0

Missing System 14 14.0

Total 100 100.0

43
Means of treatment if the hospital is not

Valid Cumulative
Frequency Percent Percent Percent

Valid Borught a drug 42 42.0 53.8 53.8

Used a
18 18.0 23.1 76.9
medication

Other 18 18.0 23.1 100.0

Total 78 78.0 100.0

Missing System 22 22.0

Total 100 100.0

Frequency at which used drugs are being adverstised

Valid Cumulative
Frequency Percent Percent Percent

Valid Everyday 25 25.0 32.9 32.9

Every other
36 36.0 47.4 80.3
day

Other 15 15.0 19.7 100.0

Total 76 76.0 100.0

Missing System 24 24.0
Total 100 100.0

44
Change in number of times

Valid Cumulative
Frequency Percent Percent Percent

Valid Increased 14 14.0 16.9 16.9

Decreased 49 49.0 59.0 75.9

Remained the same 20 20.0 24.1 100.0

Total 83 83.0 100.0

Missing System 17 17.0

Total 100 100.0

Used a drugs for its effect when not sick

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 23 23.0 23.5 23.5

No 75 75.0 76.5 100.0

Total 98 98.0 100.0

Missing System 2 2.0

Total 100 100.0

45
Frequency of drug usage

Valid Cumulative
Frequency Percent Percent Percent

Valid Every day 8 8.0 17.0 17.0

Every other
14 14.0 29.8 46.8
day

Other 25 25.0 53.2 100.0

Total 47 47.0 100.0

Missing System 53 53.0

Total 100 100.0

Frequency of hearing or seeing that drugs are being adverstised on the

media

Valid Cumulative
Frequency Percent Percent Percent

Valid Everyday 26 26.0 40.0 40.0

Every other
15 15.0 23.1 63.1
day

Other 24 24.0 36.9 100.0

Total 65 65.0 100.0

Missing System 35 35.0
Total 100 100.0

46
Frequency of drugs are used for non-therapeutic purposes before
exposure to advert

Valid Cumulative
Frequency Percent Percent Percent

Valid Always 3 3.0 4.3 4.3

Occasionally 23 23.0 33.3 37.7

Rarely 33 33.0 47.8 85.5

Other 10 10.0 14.5 100.0

Total 69 69.0 100.0

Missing System 31 31.0

Total 100 100.0

Frequency of drugs are used for non-therapeutic purposes after

exposure to advert

Valid Cumulative
Frequency Percent Percent Percent

Valid Ocassionally 22 22.0 33.8 33.8

Rarely 33 33.0 50.8 84.6

Other 10 10.0 15.4 100.0

Total 65 65.0 100.0

Missing System 35 35.0
Total 100 100.0

47
Usage of a drugs to later find out it had undesirable effects which
was not known

Valid Cumulative
Frequency Percent Percent Percent

Valid Yes 16 16.0 19.3 19.3

No 67 67.0 80.7 100.0

Total 83 83.0 100.0

Missing System 17 17.0

Total 100 100.0

Initial source of information about drug

Valid Cumulative
Frequency Percent Percent Percent

Vall;id Someone told me about

27 27.0 58.7 58.7
the drug

From media
15 15.0 32.6 91.3
advertisement

Explained to me at the
4 4.0 8.7 100.0
hospital

Total 46 46.0 100.0

Missing System 54 54.0
Total 100 100.0

48
Frequency of seeing or hearing the particular drug being advertised
on the media

Valid Cumulative
Frequency Percent Percent Percent

Valid Every day 26 26.0 45.6 45.6

Ocassionally 15 15.0 26.3 71.9

Rarely 9 9.0 15.8 87.7

Other 7 7.0 12.3 100.0

Total 57 57.0 100.0

Missing System 43 43.0

Total 100 100.0

49