Assessment of physicians’ and pharmacists’ knowledge,attitudes,perceptions,and barriers concerning generic medicine in Pakistan: A cross-sectional study

Abstract

Background

The rising costs of pharmaceuticals globally have increased the demand for generic medications as people seek more affordable alternatives to costly branded drugs. Generic medications are a beneficial approach to reducing pharmaceutical expenses without compromising healthcare quality. Yet, the prescribing of generic medications is still nil to date due to various factors not explored well. Therefore, we aimed to assess the knowledge, attitudes, perceptions, and challenges physicians and pharmacists face in Pakistan regarding implementing generic medicines.

Methods

A cross-sectional observational survey was conducted among conveniently available physicians and pharmacists from February to July 2024. Data was collected using a structured validated questionnaire. Participants were invited from randomly selected public and private sector hospitals and pharmacies in Pakistan’s twin cities (Rawalpindi and Islamabad). Data from this study was analyzed using descriptive statistics, Mann–Whitney and Kruskal–Wallis tests, and multivariate binary logistic regression in SPSS version 25.

Results

Out of 515 distributed surveys, 415 individuals responded, and 400 surveys were analysed, resulting in an 80.5% response rate. Of the 400 participants, 214 (53.5%) participants were pharmacists, and 186 (46.5%) were physicians. More than half of the participants demonstrated high knowledge, 215 (53.8%), and the majority of them had positive attitudes, 323 (80.7%), as well as perceptions, 249 (62.3%), toward generic medicines. A significant positive correlation existed between participants’ attitudes and perceptions (r = 0.504, p < .05). In multivariate binary logistic regression analysis, age, practice setting, and negative attitude had statistically significant associations with positive attitude.

Conclusion

Health care professionals possess considerable knowledge and exhibit a positive attitude towards generic medications, demonstrating strong support for generic substitution. Educational interventions are necessary to enhance generic drug prescribing and dispensing practices among healthcare professionals.

Keywords

knowledge brand medicines healthcare professional generic substitutions quantitative study Pakistan

Introduction

A generic medicine (GM) is described as a pharmaceutical product often meant to be interchangeable with the branded medication. It can only be produced after the expiration of the patent protection for the branded medication. Generic pharmaceuticals are regarded as therapeutically equal to their branded counterparts.¹ Generic medications are accessible once the patent protection for branded pharmaceuticals ends. Upon the expiration of patent protection, generic pharmaceuticals may be produced by entities other than the original innovator business.² Innovator products are reference items whose efficacy, safety, and quality have been established after rigorous clinical trials and are sold under patent cover by their innovators.³ Utilizing GM to replace branded medicines (BM) constitutes a cost-effective approach, as BM is significantly more expensive than GM for treating the same clinical problems.⁴ GM is sold at a far lower cost. They are generally 20 to 90% less expensive than their brand counterparts.^3,5 Most patients have had out-of-pocket expenses for both GM and BM medicine purchases.^6–8

The rise in healthcare expenditure may pose a global issue, with pharmaceutical costs constituting a substantial portion of this spending. Consequently, generic alternatives have widespread appeal globally, particularly in developing nations where poverty significantly limits purchasing power.^9,10 Governments in numerous nations have implemented continuous cost-containment measures to ensure equitable access to healthcare. However, the practice of substituting GM has been controversial among healthcare professionals, mainly due to quality, safety, and efficacy issues.¹¹ GM is lower in quality, efficacy, and safety than branded ones.^11,12 To advance GM substitution, it is essential to rectify misconceptions regarding GM quality, efficacy, and safety.^2,13 Inaccurate or inadequate understanding and perception of generics restrict a more thorough generic medication.¹⁴ The knowledge and attitudes of healthcare professionals are crucial in eliminating the rejection of generic medication utilization and promoting its implementation. The heightened prescription of lower-cost generic medications may decrease healthcare expenses and reduce out-of-pocket patient costs.

However, evidence around Pakistani physicians’ and pharmacists’ knowledge, attitudes, and perspectives of generic drugs is insufficient. Moreover, no adequate generic medication or brand substitute prescribing strategies have been developed in Pakistan. Numerous studies have been undertaken in many nations globally, examining the expertise of physicians and pharmacists concerning generic medications.^{3,15,16,17,18,19,20} Over time, the confidence and understanding of patients and prescribers about generic medications have boosted,²¹ especially in developed nations; despite all, further efforts are required in low- and middle-income countries (LMICs) including Pakistan.²¹ The unacceptability of generics may lead to non-concordance, non-affordability resulting in treatment failure.²² Therefore, it is essential to investigate changing physicians’ and pharmacists’ knowledge, attitudes, and perspectives regarding generic substitution. This study will assist policymakers in establishing effective medication substitution policy regulations to optimize patient benefits, address potential disinformation and misconceptions regarding generic medicines, and improve the prescribing of generics.

Methodology

Study design and study setting

This research followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist to report the study²³ attached in Supplemental file. A cross-sectional observational study was conducted using a paper-based, self-administered questionnaire between February 2024 and July 2024. Data were collected from physicians and pharmacists working in public and private hospitals and community pharmacies across Rawalpindi and Islamabad, Pakistan (twin cities).

Study population

The study population comprised registered physicians and pharmacists. Inclusion criteria included all registered physicians and pharmacists working full-time or part-time, having at least 12 months of professional practice experience, and providing informed written consent. Exclusion criteria included intern physicians, pharmacists, and individuals who did not provide informed consent.

Sampling techniques and sample size

A convenience sampling technique was employed to collect the data from 400 participants. The sample size was calculated using the Rao Soft calculator²⁴ based on a 5% margin of error, a 95% confidence level, and an expected response rate of 50%, which indicated a minimum required sample size of 377 participants.

Data collection tool

A structured questionnaire was developed after extensive reviews of relevant literature on generic medicines.^{3,12,16,20,25,26} Face and content validity of the initial questionnaire items was done by a panel of six members, experts in clinical pharmacy, pharmacy practice, and physicians, to ensure the questionnaire’s relevance, specificity, and comprehensiveness, and final adjustments made based on their feedback. Subsequently, a pilot study was conducted on 20 physicians and pharmacists to validate the questionnaire and review structure, clarity, and comprehension. The overall Cronbach’s alpha value of the questionnaire was 0.895, with a subscale of 0.592 for knowledge, 0.890 for attitude, and 0.864 for perception. The participants involved in pilot testing were excluded from the final analysis.

The questionnaire was divided into five sections. The first section collected participants’ demographic characteristics; the second assessed participants’ knowledge about generic medicines; the third evaluated attitudes toward generic medicines; the fourth measured participants’ perceptions of generic medicines; and the fifth identified the challenges/barriers to the prescribing and dispensing of generic medicines.

The knowledge section was assessed using 10-item statements, with respondents indicating their responses as ‘yes,’ ‘no,’ or ‘don’t know’ answers. ‘Yes’ answers scored 1 point, while ‘No’ and ‘Don’t know’ responses were given 0. The total score ranges from 0 to 10; a higher score means high knowledge. The scores were divided into two groups based on the midpoint of the total score: low knowledge (scores of 0–5) and high knowledge (scores of 6–10). The attitude and perception sections were evaluated using 10 items each. A 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’ was employed to assess participants’ attitudes and perceptions. The total score for both sections range from 1 to 50; a higher score means a positive attitude and perception. The scores were divided into two groups based on the midpoint of the total score: negative attitudes and perceptions (scores of 1–25) and positive attitudes and perceptions (scores of 26–50). The fifth section examined the challenges and barriers faced by physicians and pharmacists in Pakistan when implementing generic medicines.

Data collection procedure

We respectfully approached physicians and pharmacists during their breaks and afternoons, when patient numbers were typically low. The researcher provided complete information to the study participants about the study’s objective, voluntary participation, data anonymity, and the estimated time required to complete the survey. The participants signed the informed written consent before filling out the questionnaire, which typically takes 15 to 20 min to complete.

Statistical analysis

The data obtained, coded, entered, and analyzed for this study was conducted using the Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics, including the median with interquartile range, were used for continuous variables, while frequency and percentage were employed for categorical variables. The association between groups was assessed using Mann-Whitney and Kruskal-Wallis tests and multivariate binary logistic regression. The study further analysed the participants’ knowledge of generic medicines based on their sociodemographic characteristics. Due to the non-normality of the data (i.e., the knowledge score), the Mann–Whitney U and Kruskal–Wallis non-parametric tests were used. Spearman correlation coefficient was used to identify the relationships between study variables. P values <0.05 were considered statistically significant.

Ethical considerations

The study adhered to the principles outlined in the Declaration of Helsinki²⁷ and received approval from the Research Ethics Committee of the Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan (Ref. No. REC/RIPS/2023/30). All participants were provided informed consent before participating and explaining the study’s objectives and procedures. Participants signed the consent form to confirm their voluntary participation before enrolling in the study.

Results

A total of 415 individuals responded to the 515 distributed questionnaires, yielding a response rate of 80.5%. Of them, 400 completed questionnaires were chosen for analysis. Among the responses, 203 (50.7%) were females. A majority of participants, 301 (75.3%), possessed a bachelor’s degree, and 162 (40.5%) were aged between 31 and 45 years. Of the participants, 214 (53.5%) were pharmacists, whereas 186 (46.5%) were physicians. A majority of participants, 252 (63.0%), indicated had 1 to 5 years of professional experience (Table 1).

Table 1.

Sociodemographic characteristics of the participants.

Characteristics	Frequency (%)
Gender
Male	197 (49.3)
Female	203 (50.7)
Age
18–30	127 (31.8)
31–45	162 (40.5)
≥46	111 (27.8)
Qualification
Bachelors	301 (75.3)
Masters	82 (20.5)
PhD	17 (4.3)
Profession
Physician	186 (46.5)
Pharmacist	214 (53.5)
Experience
≤1	107 (26.8)
1–5	252 (63.0)
≥6	17 (4.3)
Practice city
Rawalpindi	177 (44.3)
Islamabad	223 (55.8)
Practice setting
Public	157 (39.3)
Private	243 (60.8)

Knowledge of the participants about generic medicine

The knowledge of generic medicines among the study participants in Pakistan is presented in Table 2. The overall mean ± SD knowledge score for participants was 5.46 ± 1.42 with a median (IQR) of 6 (5–7). Of the participants, 215 (53.8%) demonstrated good knowledge, with a mean ± SD of 6.53 ± 0.58 and a median (IQR) of 6 (6–7). Most respondents, 348 (87.0%) correctly identified that generic and branded medicines are bioequivalent. Regarding side effects, 346 (86.5%) correctly believed that generic medicines do not cause more side effects than branded counterparts. Furthermore, 342 (85.5%) of respondents knew that generic and branded medicines contain the exact dosage. In terms of efficacy, 313 (78.3%) of respondents correctly believed that generic medicines are not less effective than their branded medicines. However, only 132 (33.0%) of respondents accurately recognized that branded medicines do not necessarily have higher safety standards than generics. Regarding interchangeable products 181 (45.3%) knew that an interchangeable product is therapeutically equivalent to a reference product. Meanwhile, only 170 (42.5%) understood that generic substitution involves dispensing a brand or unbranded drug instead of a prescribed product.

Table 2.

Knowledge of the participants about generic medicine.

Knowledge questions	Correct answern (%)
Generic and branded medicines are bioequivalent? [T]	348 (87.0)
Generic and branded medicines contain the same amount of active ingredients. [T]	342 (85.5)
Are generic medicines less effective than their branded counterparts? [F]	53 (13.3)
Generic medicines must be in the same dose and dosage form as their branded counterparts. [T]	294 (73.5)
Generic medicines cause more side effects than branded medicines. [F]	35 (8.8)
Branded medicines have higher safety standards than generic medicines. [F]	226 (56.5)
Pharmaceutical substitution is dispensing a pharmaceutical alternative for a prescribed drug product. [T]	196 (49.0)
Therapeutic substitution is a process of dispensing a therapeutic alternative for a prescribed drug product. [T]	338 (84.5)
An interchangeable product is a drug product therapeutically equivalent to a reference or innovator product. [T]	181 (45.3)
Generic substitution is dispensing a different brand or unbranded drug product in place of a prescribed drug product. [T]	170 (42.5)

Note: T: True, F: False.

There were no statistically significant differences in knowledge ratings among the seven demographic and professional characteristics that were evaluated (Table 3). Additionally, multivariate binary logistic regression analysis indicated that gender, age, educational qualification, profession, years of experience, practice city, and practice setting were not significantly correlated with participants’ knowledge levels concerning generic medicine prescribing (Table 4).

Table 3.

Comparison between participants’ sociodemographic characteristics and their knowledge, attitude, and perception regarding generic medicines.

Characteristics	Knowledge		Attitude		Perception
Characteristics	Median (IQR)	p- value	Median (IQR)	p- value	Median (IQR)	p- value
Gender		0.748		0.432		0.252
Male	6 (5–7)		28 (22-32)		23 (17-23)
Female	6 (5–7)		29 (24-32)		24 (18-32)
Age		0.449		0.115		0.942
18–30	6 (5–7)		28 (22-31)		24 (18-30)
31–45	5 (5–6)		29 (21-32)		25 (16-31.25)
≥46	6 (5–7)		30 (24-33)		23 (17-32)
Qualification		0.600		0.000		0.150
Bachelors	6 (5–7)		29 (24-32)		23 (18-30.50)
Masters	6 (5–7)		25 (17-30)		24.50 (15.50-32)
PhD	5 (5–6)		30 (27.50-32.50)		29 (22-33.50)
Profession		0.515		0.199		0.257
Physician	6 (5–7)		28 (21.75-32)		23 (16-31)
Pharmacist	6 (5–7)		29 (24-32.25)		24 (18-31.25)
Experience		0.403		0.020		0.020
≤1	6 (4–7)		30 (25–33)		25 (19–33)
1–5	6 (5–6)		29 (22–32)		24 (17–30.75)
≥6	6 (5–7)		25 (16.50–32)		20 (14.50–28)
Practice city		0.942		0.387		0.251
Rawalpindi	6 (5–7)		29 (23.50–32.50)		25 (18–33)
Islamabad	6 (5–7)		28 (23–32)		23 (17–30)
Practice setting		0.386		0.169		0.350
Public	6 (5–7)		29 (24–33)		24 (18–33)
Private	6 (5–6)		28 (22–32)		23 (17–30)

Table 4.

Multivariate binary logistic regression analysis of predictors for knowledge, attitude, and perception of the participants.

Characteristics	Knowledge		Attitude		Perception
Characteristics	OR (95%CI)	p-value	OR (95%CI)	p-value	OR (95%CI)	p-value
Gender
Male	1.084 (0.69–1.69)	0.721	0.850 (0.47–1.51)	0.581	0.961 (0.61–1.50)	0.861
Female	Reference	—	Reference	—	Reference	—
Age
18–30	1.296 (0.72–2.31)	0.380	0.369 (0.16–0.83)	0.017	1.246 (0.68–2.26)	0.472
31–45	1.220 (0.70–2.10)	0.475	0.400 (0.18–0.88)	0.024	1.021 (0.58–1.79)	0.943
≥46	Reference	—	Reference	—	Reference	—
Qualification
Bachelors	0.990 (0.32–3.03)	0.986	1.878 (0.31–11.05)	0.486	0.109 (0.01–0.65)	0.016
Masters	0.877 (0.26–2.88)	0.829	0.555 (0.09–3.31)	0.518	0.226 (0.03–1.39)	0.110
PhD	Reference	—	Reference	—	Reference	—
Profession
Physician	1.375 (0.87–2.15)	0.164	0.777 (0.43–1.38)	0.390	0.826 (0.52–1.30)	0.409
Pharmacist	Reference	—	Reference	—	Reference	—
Experience
≤1	0.925 (0.36–2.32)	0.868	2.338 (0.80–6.76)	0.117	4.111 (1.70–9.88)	0.002
1–5	0.671 (0.29–1.53)	0.345	1.187 (0.51–2.74)	0.688	2.911 (1.33–6.36)	0.007
≥6	Reference	—	Reference	—	Reference	—
Practice city
Rawalpindi	1.074 (0.38–3.00)	0.892	0.309 (0.09–1.01)	0.052	3.827 (1.12–13.02)	0.032
Islamabad	Reference	—	Reference	—	Reference	—
Practice setting
Public	1.121 (0.39–3.19)	0.831	4.771 (1.39–16.28)	0.013	0.254 (0.07–0.88)	0.031
Private	Reference	—	Reference	—	Reference	—
Knowledge
Poor	—	—	1.030 (0.53–1.99)	0.931	1.558 (0.92–2.61)	0.093
Good	—	—	Reference	—	Reference	—
Attitude
Negative	1.031 (0.53–1.97)	0.926	—	—	8.090 (4.30–15.21)	0.000
Positive	Reference	—	—	—	Reference	—
Perception
Negative	1.575 (0.94–2.63)	0.084	0.124 (0.06–0.23)	0.000	—	—
Positive	Reference	—	Reference	—	—	—

The attitude of the participants toward generic medicine

The overall mean ± SD attitude score for participants was 26.7 ± 8.32 with a median (IQR) of 29 (23–32). Of the participants, 323 (80.7%) demonstrated a positive attitude, with a mean ± SD of 30.0 ± 4.62 and a median (IQR) of 30 (27–33). A majority of participants, 333 (83.3%), believed that generic medicines would reduce drug costs, while 324 (81%) believed branded medicines were too expensive for patients. 320 (80%) felt patients’ preferences for branded medicines influenced their dispensing and prescribing decisions. Concern about therapeutic failures related to locally manufactured medicines was expressed by 302 (75.6%). Regarding preferences, 293 (73.3%) participants preferred generic medicines over branded ones (Table 5).

Table 5.

An attitude of the participants toward generic medicine.

Attitude questions	Strongly disagree n (%)	Disagree n (%)	Neutral n (%)	Agree n (%)	Strongly agree n (%)
I am concerned about the therapeutic failures associated with some locally manufactured medicines	32 (8.0)	21 (5.3)	45 (11.3)	163 (40.8)	139 (34.8)
Branded medicines are too expensive for patients	14 (3.5)	23 (5.8)	39 (9.8)	180 (45.0)	144 (36.0)
I prefer generic medicines to branded medicines	20 (5.0)	17 (4.3)	70 (17.5)	185 (46.3)	108 (27.0)
Generic medicines are more available in the drug market than innovator brands	17 (4.3)	29 (7.2)	91 (22.8)	189 (47.3)	74 (18.5)
I feel that branded medicines are imported more than generic medicines	16 (4.0)	8 (2.0)	52 (13.0)	171 (42.8)	153 (38.3)
Medical representatives are good sources of information for me	19 (4.8)	78 (19.5)	99 (24.8)	159 (39.8)	45 (11.3)
I feel that patients’ demand for certain medicines influences my dispensing/prescribing decisions	15 (3.8)	18 (4.5)	47 (11.8)	196 (49.0)	124 (31.0)
I feel that patients should need more explanation when generic medicines are dispensed/prescribed to them	16 (4.0)	25 (6.3)	60 (15.0)	201 (50.2)	98 (24.5)
I am comfortable with prescribing/dispensing products from local manufacturers	15 (3.8)	17 (4.3)	56 (14.0)	219 (54.8)	93 (23.3)
I feel generic medicines will reduce drug costs	13 (3.3)	10 (2.5)	44 (11.0)	216 (54.0)	117 (29.3)

The study analysed the participants’ attitudes toward generic medicines based on their sociodemographic characteristics. Those participants with PhD qualifications had significantly higher attitude scores than those with bachelor’s and master’s degrees [median (IQR): 30 (27.5–32.5) versus 29 (24–32) and 25 (17–30)]. Similarly, participants with <1 year of practice experience had significantly higher attitude scores than those with 1–5 years and more than 6 years of practice experience [median (IQR): 30 (25–33) versus 29 (22–32) and 25 (16.50–32)] (Table 3).

In multivariate binary logistic regression analysis, age had statistically significant associations with attitude; those aged 18–30 (OR = 0.369, 95% CI: 0.16–0.83, p = .017) and 31–45 (OR = 0.400, 95% CI: 0.18–0.88, p = .024) were less likely to have a positive attitude compared to those aged 46 and above. Similarly, the practice setting of participants had statistically significant associations with attitude, with public sector participants being more likely to have a positive attitude (OR = 4.771, 95% CI: 1.39–16.28, p = .013) compared to those in the private sector. Additionally, attitude had significantly significant associations with perception, as those with a negative attitude were substantially more likely to have a negative perception (OR = 8.090, 95% CI: 4.30–15.21, p < .001) (Table 4).

Perception of the participants toward generic medicine

The overall mean ± SD perception score for participants was 23.8 ± 8.70 with a median (IQR) of 24 (17.2–31). Of the participants, 249 (62.3%) demonstrated a positive perception, with a mean ± SD of 29.3 ± 5.39 and a median (IQR) of 29 (25–34). A significant majority, 335 (83.3%), believed that generic medicines could help reduce drug costs and mitigate the market monopoly of branded product producers. Additionally, 322 (80.5%) participants indicated that generic medicines would foster healthy competition among drug manufacturers. However, concerns about the credibility of manufacturers and suppliers of generic medicines were raised by 278 (69.5%) participants. Furthermore, 258 (64.5%) respondents believed that collaboration among healthcare professionals would enhance the quality of generic medicines, and 263 (65.8%) supported the need for standardized guidelines for brand substitution (Table 6).

Table 6.

Perception of the participants toward generic medicine.

Perception questions	Strongly disagree n (%)	Disagree n (%)	Neutral n (%)	Agree n (%)	Strongly agree n (%)
I believe generic medicines will reduce drug costs and the market monopoly of branded product producers	13 (3.3)	9 (2.3)	43 (10.8)	172 (43.0)	163 (40.8)
I believe generic medicines will encourage healthy competition among drug manufacturers	11 (2.8)	16 (4.0)	51 (12.8)	206 (51.5)	116 (29.0)
The credibility of manufacturers and suppliers is my concern when prescribing/dispensing generic medicines	26 (6.5)	86 (21.5)	96 (24.0)	135 (33.8)	57 (14.2)
I need more information about safety and efficacy issues with generic medicines	12 (3.0)	31 (7.8)	112 (28,0)	148 (37.0)	97 (24.3)
I believe the proliferation of generic medicines in different colors will lead to confusion in patients’ minds	10 (2.5)	30 (7.5)	82 (20.5)	174 (43.5)	104 (26.0)
In my opinion, collaboration among healthcare professionals will improve the quality of the use of generic medicines	10 (2.5)	31 (7.8)	101 (25.3)	145 (36.3)	113 (28.2)
The patient’s socio-economic factors will influence my choice of medicines prescribed/dispensed to them	21 (5.3)	38 (9.5)	145 (36.3)	137 (34.3)	59 (14.8)
Standard guidelines for all healthcare professionals are necessary for the brand substitution process	9 (2.3)	33 (8.3)	95 (23.8)	153 (38.3)	110 (27.5)
I think adequate information about generic medicines is necessary for patients to understand their medication better	15 (3.8)	58 (14.5)	98 (24.5)	145 (36.3)	84 (21.0)
I think generic medicines will improve access to medicines because they are cheaper and more affordable	16 (4.0)	58 (14.5)	103 (25.8)	132 (33.0)	91 (22.8)

The study analysed the participants’ perception of generic medicines based on their sociodemographic characteristics. Those participants with <1 year of practice experience had significantly higher perception scores than those with 1–5 years and more than 6 years of practice experience [median (IQR): 25 (19–33) versus 24 (17–30.75) and 20 (14.50–28)]. No other participants’ sociodemographic characteristics had a statistically significant effect on the perception score (Table 3). In multivariate binary logistic regression analysis, education had statistically significant associations with perception, with those holding a bachelor’s degree less likely to have a positive perception (OR = 0.109, 95% CI: 0.01–0.65, p = .016) compared to PhD holders. Moreover, experience also had statistically significant associations with perception, with participants having 1–5 years (OR = 2.911, 95% CI: 1.33–6.36, p = .007) and ≤1 year (OR = 4.111, 95% CI: 1.70–9.88, p = .002) of experience being more likely to have a negative perception compared to those with ≥6 years. Additionally, the practice city also had statistically significant associations with perception, with those practicing in Rawalpindi more likely to have a positive perception (OR = 3.827, 95% CI: 1.12–13.02, p = .032) than those practicing in Islamabad (Table 4).

Barriers faced by participants regarding generic medicine

The questionnaire comprised a total of 13 items assessing barriers to the prescribing of generic medications. Table 7 gathers the perspectives of physicians and pharmacists about various impediments in clinical practice. Among the 13 identified factors, participants ranked six as the most significant. The factors included inconsistent policy implementation (65.7%), lack of standard guidelines (62.7%), influence of pharmaceutical companies (58.5%), patient preference for branded medications (56.0%), limited access to reliable information (55.0%), and lack of confidence in the quality of generic medications (41.7%).

Table 7.

Barriers faced by participants regarding generic medicine.

What are the barriers physicians and pharmacists face regarding generic medicine prescribing/dispensing in clinical practice? (You may choose more than one answer)
Barrier	Percentage
Communication challenges	66.00%
Inconsistent policy implementation	65.75%
Regulatory challenges	64.50%
Inventory management	63.50%
Lack of standard guidelines	62.75%
Influence of pharmaceutical companies	58.50%
Patient demand for branded medicines	56.00%
Limited information	55.00%
Lack of confidence in quality	41.75%
Patient misconceptions	40.50%
Time constraints	34.75%
Perception of inferiority	33.00%
Economic incentives	26.50%

Correlation coefficient between variables

There was a significant, very strong positive correlation between attitude and perception scores with a coefficient of 0.504 (p < .001). This finding indicates that more positive attitudes toward generic medicines were associated with more favorable perceptions. In contrast, a very weak positive correlation existed between knowledge and attitude scores of 0.031, but the result was not statistically significant. This suggests that levels of knowledge about generic medicines do not significantly influence attitudes toward them. Furthermore, a very weak negative correlation existed between knowledge and perception scores of 0.076, and the result was not statistically significant (Table 8).

Table 8.

Spearman correlation coefficient between variables.

Variables	Knowledge	Attitude	Perception
Knowledge	—
Attitude	0.031 (0.532)	—
Perception	−0.076 (0.130)	0.504 (0.000)	—

Discussion

This study highlighted favorable results concerning the knowledge and acceptance of generic medications among healthcare professionals in Pakistan. Specifically, the majority of participants demonstrated a satisfactory level of knowledge in recognizing the therapeutic equivalence of generic and branded medications, as well as in understanding that generics are not contributing to increased side effects. Additionally, participants exhibited an overall favorable attitude, recognizing the capacity of generic medications to lower healthcare expenses. In terms of perception, a significant number of respondents supported the role of generics in promoting market competition and reducing the control of branded drug brands. Overall, the results indicate that medical professionals have a positive attitude regarding the increased utilization and acknowledgment of generic medications in healthcare settings.

Furthermore, a significant positive correlation was observed between participants’ attitudes and perceptions toward generic medicine. Despite variations in professionals’ knowledge, attitudes, and practices regarding generic drug replacement among countries due to cultural and policy differences, a strong understanding and positive attitude toward generic drugs could enhance the practice of generic prescribing.²⁸

This finding is higher than those of a comparable study conducted in New Zealand (70%),²⁹ and Qatar (38%),¹⁶ yet aligns closely with results from studies in Ethiopia (77.1%),^14,25 and Palestine (76.5%).³⁰ These comparable outcomes in the mentioned countries may be attributed to better educational qualifications and valuable work experience. The current study indicated that most participants (85.5%) reported that generic and brand medications contained equivalent quantities of active components. This result aligns with research conducted in Ethiopia (89%).^14,25 Additionally, 73.5% of participants claimed that generic medications should be in the same dose form as their brand-name counterparts. This corresponds with research conducted in Ethiopia (84.4%).^14,25

Participants exhibited a positive attitude towards generic drugs in the study area. This positive attitude could possibly be attributed to the cost-effectiveness of the generic medications. The majority of participants in this study expressed concerns regarding therapeutic failures related to some locally produced medicines. Consequently, the quality of both locally manufactured and imported generic medications must be rigorously inspected by regulatory authorities to guarantee compliance with established quality standards. This could improve the confidence of healthcare practitioners regarding the generic replacements available in Pakistan.³¹ The majority of participants in this study recognized that branded medications were excessively expensive for patients. This finding is comparable to the research conducted in India.³²

In this study, most respondents preferred generic drugs to branded ones. The interaction between pharmaceutical marketing presenters, physicians, and pharmacists has generated significant global discourse.²⁰ In our study, more than half of respondents believed medical representatives were trustworthy source of information regarding generic medicines. This is similar to the study by Joseph et al. among physicians conducted in Nigeria.²⁰ The majority of the study participants believed that patients should be given additional information when generic medicines are prescribed/dispensed to them. Physicians have a crucial role in prescribing generic medications. Pharmacists are at the forefront of delivering medications based on medical prescriptions and are the final healthcare experts determining medication selection. Therefore, establishing communication between physicians and pharmacists is essential in improving generic substitution.¹⁹

Sixty-nine percent of respondents believed that GM packaged in various colors could lead to confusion among patients. This finding is consistent with the research conducted in Nigeria.³³ This may be why more than half of the participants agreed with this study: it is necessary to educate patients on the medicines being administered to them or give them adequate information about generic medicines to better understand their medication. Replacing branded medications with their generic counterparts is regarded as a way to lower healthcare costs for patients.³ More than half of the participants in the present study concurred that generic medications enhance treatment access due to their widespread availability and reduced cost. This ratio is rather low when compared to findings from similar studies conducted in Nigeria, Qatar, Poland, and Saudi Arabia, where health professionals expressed more favorable views regarding the role of generics in improving access.^{16,20,33,34,35} However, the overall use of generics has greatly increased over the past two decades due to their reduced cost, offering an economical alternative to branded medications. Consequently, promoting the use of generic medications in developing countries may lead to considerable reductions in healthcare costs.^36,37

The implication of findings and future research

A clear and standardized generic substitution approach must be implemented immediately in clinical settings. Professional groups need to guide health authorities on a standardized approach for the utilization of generic medications. Overall, numerous laws and regulations concerning prescribing, dispensing, patients/consumers, and healthcare organizations should be considered to promote effective generic substitution. These findings possess significant implications for the continued development of generic replacement.

Limitations of the study

This research is exposed to numerous limitations. First, respondents were given sufficient time to complete the survey in order to reduce the possibility of response bias induced by the self-administered nature of the questionnaire and self-reporting tendencies. Secondly, by limiting participation to individuals in proximity, convenience sampling introduced survey bias, excluding senior physicians. Third, the involvement of many healthcare experts from the same institution may have led to inconsistency in responses; however, this was minimized by thoroughly training data collectors to ensure consistency across facilities.

Conclusion

The survey indicated that considerably over half of the participants exhibited a strong understanding of generic medications, with significant awareness of bioequivalence, efficacy, and adverse effects. Nonetheless, there were still unanswered questions about safety regulations and the idea of generic replacement. However, their responses revealed a positive attitude and perception toward them. Despite this, several barriers were identified, including inconsistent policy implementation, regulatory challenges, inventory management, lack of standard guidelines, influence of pharmaceutical companies, communication challenges, patient demand for branded medicines, limited information, and lack of confidence in quality. These misconceptions may restrict the utilization of generic medications in Pakistan and, thus, must be rectified. It is imperative to equip healthcare professionals with comprehensive information regarding the efficacy, safety, and quality of generic medicine and the benefits of their utilization, through training programs and educational initiatives in various clinical environments and to encourage generic medication substitution. Moreover, physicians and pharmacists must engage proactively in patient counselling and education, adopting a distinctly favourable perspective on generics.

Supplemental Material

Supplemental Material - Assessment of physicians’ and pharmacists’ knowledge, attitudes, perceptions, and barriers concerning generic medicine in Pakistan: A cross-sectional study

Supplemental Material for Assessment of physicians’ and pharmacists’ knowledge, attitudes, perceptions, and barriers concerning generic medicine in Pakistan: A cross-sectional study by Ayesha Azam, Muhammad Amir Hamza, Rehana Sarwat, Abdullah Abdul Latif Akhter, Bushra Batool Zahra, Bilal Awan, Ali Ahmed in Journal of Generic Medicines

Footnotes

Acknowledgment

The authors express gratitude to all the physicians and pharmacists who contributed to the study.

ORCID iD

Ali Ahmed

Ethical considerations

The research was authorized by the Riphah Institute of Pharmaceutical Sciences’ Research Ethics Committee at Riphah International University in Islamabad, Pakistan (Ref. No. REC/RIPS/2023/30).

Consent to participate

All participants were provided with written consent prior to their involvement, which included an explanation of the study’s objectives and procedures. Prior to enrolling in the study, participants confirmed their voluntary involvement by signing the consent form.

Author contributions

Conceptualization: Ali Ahmed, Ayesha Azam.

Data curation: Ayesha Azam.

Formal analysis: Muhammad Amir Hamza, Ayesha Azam.

Investigation: Abdullah Abdul Latif Akhter, Bilal Awan, Ayesha Azam.

Methodology: Ayesha Azam.

Project administration: Rehana Sarwat, Bushra Batool Zahra.

Resources: Bilal Awan, Ayesha Azam, Abdullah Abdul Latif Akhter.

Software: Muhammad Amir Hamza, Ayesha Azam.

Supervision: Ali Ahmed.

Validation: Ali Ahmed, Ayesha Azam.

Visualization: Ayesha Azam, Rehana Sarwat, Muhammad Amir Hamza.

Writing-original draft: Ayesha Azam.

Writing-review & editing: Ayesha Azam, Muhammad Amir Hamza, Rehana Sarwat, Abdullah Abdul Latif Akhter, Bushra Batool Zahra, Bilal Awan, Ali Ahmed.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are accessible upon reasonable request. The data collected and/or examined in this study are not publicly accessible; however, they can be obtained from the corresponding author upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

Author biographies

Ayesha Azam, MPhil, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan.

Muhammad Amir Hamza, MPhil, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan.

Rehana Sarwat, MPhil, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan.

Abdullah Abdul Latif Akhter, Pharm.D, Department of Pharmaceutical Sciences, University of Lahore, Islamabad Campus, Pakistan.

Bushra Batool Zahra, MPhil, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan.

Bilal Awan, FCPS Cardiology, Department of Cardiology, Khyber Medical University, Peshawar, Pakistan.

Ali Ahmed, PhD, Division of Infectious Diseases and Global Public Health, School of Medicine, University of California, San Deigo (UCSD), La Jolla, CA, USA, Postdoctoral Fellow at UC San Deigo School of Medicine.

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Supplementary Material

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