Generic medicine: Boston University students’ perceptions and surprising lack of knowledge

Abstract

This project aims to compare knowledge, perceptions, and attitudes regarding generic medicines in an effort to illuminate the reasons for widely discrepant rates of generic utilization in different countries. While the United States has high rates of generic uptake (around 86%), and generic medicine utilization has saved the US healthcare system over $1 trillion in the past decade (2003–2014), similar figures are not seen in many other countries despite the opportunities for substantial cost savings. Therefore, it is in the interest of global policy makers and public health professionals to be aware of public perception of generic medicines. Using quantitative and qualitative methods, our study illuminated five major themes among Boston University students of various nationalities: origin, knowledge, important decision-making factors, perceptions of self/others, and information sources. The key finding of our study was that only 24% of participants reported accurate knowledge of generic medicines. This figure is alarming given the high rates of use in the United States and carries implications for generic promotion and uptake rates.

Keywords

Generic medicines perception knowledge undergraduate students mixed methods

Introduction

Health expenditures are an ever-present budgetary concern for countries around the world, and efforts to reduce these costs are nearly constant. One area of health systems that has been proven to provide huge savings is the use of generic medicines.¹ After the patent on the originator medicine expires (comes off patent), the medicine can be produced and sold by another manufacturer as a branded generic or as an unbranded generic, while the company responsible for its initial development can continue to sell its originator version of the product. Using the originator brand Lipitor as an example, this drug would then be widely sold under the international nonproprietary name (INN) of atorvastatin. The unbranded generic is sold under the INN, whereas a branded generic would have a unique trademarked brand name sold at a higher price, though usually less than the originator. Lipitor still exists, but the generic is offered as a bioequivalent alternative at a substantially reduced price. Knowing this, it would seem intuitive that most people would simply switch to the generic brand when possible. The reality can be quite the contrary. In many countries of varying income levels and healthcare structures, generic medicines are not widely used. Studies to examine the perceptions of physicians and prescribers have gained insight into the potential reasons for the discrepancy.^2–4 However, studies on consumer perceptions are less common. The United States leads the world in generic use with generic medicines accounting for 86% of all prescriptions, but most countries pale in comparison.⁵ To highlight a few, this measurement (in 2010) was 24%, 41%, 50%, and 52% in Japan, Spain, Australia, and France, respectively.⁶

Health policy makers and other industry experts typically operate under the notion that these numbers vary due to policy differences within each country. To an extent, this may be true. In 1984, the United States passed the Hatch-Waxman Act, formally known as the Drug Price Competition and Patent Term Restoration Act of 1984. This legislation set forth what are today’s generic drug regulation policies, and encouraged more generic drugs to enter the market.⁷ Since the ratification of this act, the United States’ generic drug market has vastly changed. But can that be the only reason for the drastic differences between generic use here and abroad? This paper will propose an alternate hypothesis to explain this conundrum: perception. In other words, can the difference in generic uptake rates be attributed to national and personal differences in perception of generic medicines? These differing perceptions convert into a willingness to pay more for branded generic or originator products.

Literature review of prior studies on perceptions of generic medicines

This literature review aims to explore the recent studies (since 2000) that have attempted to examine consumer perception of generic medicines. Because our project used a questionnaire and in-depth interviews (IDI), this review discusses previously tested approaches that used these two methods. Google Scholar and PubMed were the primary databases that were used to find material for this review. In total, eight studies and one literature review on this topic were found. The publication dates range from 2000 to 2013, but only one study was published prior to 2009.⁸ The eight studies were completed in Australia, Iraq, Jordan, Malaysia, New Zealand, South Africa, United Arab Emirates (UAE), and the United States. The smallest study had a sample size of 14 participants, while the largest study had 500 participants. All publications analyzed perception of generic medicines in some manner, with slight variations in the exact objective of each study. Overall, most studies (five out of eight) used a questionnaire, while two used a semi-structured interview guide, and the last used focus groups.

Methodologies

Only some of the reports gave great detail about their questionnaires, but the average number of questions per survey was between 20 and 30. All of the questionnaires were anonymous. All questionnaires included some demographic questions, such as gender and age, and some were more specific, including race, income level, education level, and general health status. One questionnaire from a study undertaken in Jordan consisted of three sections: background/definitions, evaluation of perceptions, and demographic information.⁹ This enabled participants to answer some of the questions even if they did not understand what generics were or had never heard of them. While awareness of generic medicines is typically higher in the United States than in Jordan, we think this format is valuable for the central purpose of our proposed research question

For the two papers in which investigators conducted interviews, the exact questions and probes of the semi-structured interview guides were not provided.^10,11 After those interviews were conducted, thematic analysis was performed to identify major themes within the respondent’s feedback. The thematic analysis seemed to yield underwhelming results: both studies reported almost identical results and conclusions. While this is sometimes a necessary first step in establishing a hypothesis for a certain under-researched area, we avoided this outcome by having interviews with pre-selected key informants, whom we already knew had varied experiences with generic medicines.

Findings

The published papers from South Africa and Auckland both found misconceptions about generics to be quite prevalent in their study population.^12,13 In Auckland, only 51.6% of participants had prior knowledge of generic medicines. In Malaysia, only 32.5% knew what generics were, but those who did, reported positive opinions about them.¹⁴ In Jordan, 78% of consumers did not mind the originator being substituted with a generic, but this is likely due to the high cost of medicines in Jordan, not necessarily the perceptions of generics alone.⁸ The study from the UAE found that willingness to accept generics rose with increasing patient education levels, but willingness to accept generics fell with increasing severity of illness.¹⁵

Summary of literature review

In general, our project differs from the existing literature in several ways. None of these studies attempted to draw comparisons among nationals of different countries. Additionally, none of the existing studies have exclusively surveyed students. This means that our recruitment methods were untested, as we sampled from within a differently defined population than the previous studies used. Our project has its limitations but will hopefully be replicated and refined elsewhere over time in order to produce more information about differing national knowledge and perceptions among various population groups.

Methods

This was a mixed-methods study utilizing a quantitative survey and qualitative methods of IDI and a focus group. The results of the different methods were triangulated during the analysis.

Survey

The survey was created based on the literature review and conversations with experts in the field. The hypothesis of the survey was that perception of generic medicines would vary based on country of origin among Boston University (BU) students. We first formulated a draft that was pilot-tested on a small group of students (seven people), analyzed, and then adjusted as necessary. The final version was then sent out to a targeted cohort of BU undergraduate students (Appendix 1). This cohort was recruited through purposive sampling by contacting as many of the cultural organizations on campus as possible. There are 41 official organizations at BU that are related to specific international cultures and/or religions. Several members of these organizations were born in or spent significant time in a foreign country. An email was sent to each organization and the survey was distributed based on which organizations responded. Thirteen of the 41 organizations responded confirming that they would distribute the survey to their members. All responses received by the deadline were analyzed. The survey resulted in a total of 164 responses.

The survey was created and distributed through the BU provided Qualtrics software for the sake of feasibility, ease of use, and affordability.¹⁶ The target populations for the survey were US-born and foreign-born students, undergraduate, and graduate. The term “foreign-born” was used because we tried to isolate country of origin rather than citizenship or nationality. In other words, an American student may have been born in China and vice versa. Since our project aimed to find a difference in perception between people from different countries, we essentially used foreign-born students as a proxy for the general perceptions of people from their birthplace. We also asked about place of residence prior to studying at BU to see if that affected perception.

IDI and focus group

Survey participants were given the option at the end of the survey to provide their email address, indicating an interest in participating in an IDI. Interviewees were chosen from this group based on interesting or salient survey responses and representation of demographic variables. The IDI followed a semi-structured interview format (Appendix 2) and were done with nine participants; this component was incentivized with an additional $10 gift card for each participant. Each interview lasted no more than 20 min and each participant was prompted with the same five questions and subsequent probes. The interviews were recorded, transcribed, and thematically analyzed for common themes.

In total, 55 participants volunteered to be IDI participants. With questions regarding perceptions, it is especially necessary to add a qualitative element such as an IDI. For example, the interview could reveal that an exchange student from Europe, who may have previously been distrusting of generic drugs, responded to the survey with newly formed opinions that were acquired since living in the United States. On the survey, this would have seemed contradictory to our hypothesis that European-born students would have a more negative perception of generic drugs but in reality, would have supported our hypothesis.

The focus group discussion (FGD) was conducted prior to survey distribution because it was originally used for an additional class project (Appendix 3). Participants were recruited through snowball sampling in order to draw from the international student population at BU. Seven students were recruited and five participated in the focus group. The discussion followed a semi-structured interview format and lasted about 45 min. The FGD was recorded, transcribed, and thematically analyzed along with the IDI transcripts.

Survey results

Demographics

The survey resulted in an even age distribution across the expected ages for undergraduate students. Nearly even percentages of freshmen, sophomores, and juniors took the survey (31%, 30%, and 26%, respectively), while there were fewer seniors (12%) who participated. The overall female:male gender ratio at BU is 60:40, while for survey participants the gender ratio was 80:20. BU has nine undergraduate schools and colleges, and the survey resulted in a fairly accurate distribution of participants from each school compared to the overall BU distribution. For example, 41% of participants were in the College of Arts and Sciences (CAS) and 16% were in the School of Management (SMG), while 41% and 15% of BU students actually make up CAS and SMG, respectively. These are the two largest undergraduate schools or colleges by student enrollment. The most significant difference in terms of survey participants versus actual enrollment was for the College of Communication (COM). While this school makes up 14% of BU undergraduates, only 6% of survey participants were enrolled in that school. The distribution graphs for all demographic indicators are shown below.

Represented countries and regions

The aim of the survey was to gather enough responses per country/region to compare between them. Three questions were asked to explore the international presence among survey participants. The first question was “Where were you born?” the second question was “Have you ever lived in another country (besides the United States) prior to attending BU?” and the third (presented only to those who answered “Yes” to the second question) asked “Which country?” The majority of participants (73%) were born in the United States, with India (11%), China (6%), and Latin America (6%) making up the next three most common places of birth. For the second question, 28% of survey participants reported having lived in another country prior to attending BU. Out of these participants, India, Latin America, and China made up about a quarter each for places lived, followed by Europe (8%), Asia (8%), and Africa (5%).

Knowledge of generics

In the survey, participants were asked, “Do you know what generic medicines are?” after which they answered “Yes” or “No.” Participants who answered “Yes” were then asked to describe what they believe generic medicines to be in a short answer. These responses were graded correct or incorrect according to specific criteria (see Appendix 4) by two people separately, compared, and a third party grader settled any disagreements. Sixty-seven percent of participants answered “Yes” to Question 10 and explained their knowledge.

Participants who reported knowledge of generic medicines	Reported knowledge deemed correct by grading criteria	Correct participant knowledge of generic medicines
67%	39%	24%

After grading, only 39% of the given responses were deemed to be correct. Therefore, only 24% of participants actually knew what generic medicines were. After assessing participants’ knowledge of generics, a definition and example of generic medicines was shown regardless of how participants answered Question 10. In other words, all participants saw the definition and example of generic medicines.

Cross tabulations with knowledge of generics

Following the definition of generic medicines, participants were asked four questions about their perception of generic medicines, one question about future use, and one question about willingness to pay. The perception and future use questions were posed with answers on a 5-point Likert scale. These questions were then cross-tabulated with the graded answers to Question 10 and analyzed for any correlation.

Question 14 asked participants to rank their level of agreement or disagreement with the statement, “Generic medicines work as effectively as originator medicines.” While 83% of participants who knew what generic medicines were agreed with this statement in, 64% of those who did not know what generics were agreed. This shows that those who had knowledge of generics were more likely to agree with this true statement.

Question 14: Generic medicines work as effectively as originator medicines.
Accurate knowledge of generic medicine	Strongly disagree or disagree	Neither agree nor disagree	Strongly agree or agree*	Total	% correct
Yes	4	2	30	36	83%
No	14	25	69	108	64%
Total	18	27	99	144

Correct answer.

p-value = 0.0069.

Question 15 asked participants to rank their level of agreement or disagreement with the statement, “Generic medicines are cheaper because they do not have the same ingredients as the originator medicines.” A higher percentage (69%) of those who knew what generics were correctly disagreed with this statement compared with those who did not (38%). Therefore, this survey found that knowledge of generics is significantly correlated with the belief that generics do have the same ingredients as the originator medicine.

Question 15: Generic medicines are cheaper because they do not have the same ingredients as the originator medicines.
Accurate knowledge of generic medicine	Strongly disagree or disagree*	Neither agree nor disagree	Strongly agree or agree	Total	% correct
Yes	25	6	5	36	69%
No	41	33	34	108	38%
Total	66	39	39	144

Correct answer.

p-value = 0.0025.

Question 16 asked participants to rank their level of agreement or disagreement with the statement “I use generic medicines only for certain types of ailments.” Surprisingly, more participants with knowledge agreed with this statement compared to participants without knowledge.

Question 16: I use generic medicines only for certain types of ailments.
Accurate knowledge of generic medicine	Strongly disagree or disagree*	Neither agree nor disagree	Strongly agree or agree	Total	% disagree
Yes	7	7	22	36	19%
No	20	33	55	108	18.5%
Total	27	40	77	144

p-value not significant.

Question 17 asked participants to rank their level of agreement or disagreement with the statement, “I always use generic medicines when possible.” Little variation between the two groups was seen with this question, with 31% of those with knowledge agreeing and 24% of those without knowledge agreeing. In other words, the majority of participants in each knowledge group reported not always using generics when possible.

Question 17: I always use generic medicines when possible.
Accurate knowledge of generic medicine	Strongly disagree or disagree	Neither agree nor disagree	Strongly agree or agree*	Total	% agree
Yes	11	14	11	36	31%
No	44	38	26	108	24%
Total	55	52	37	144

p-value not significant.

Question 18 asked participants to rank their level of likelihood of using generic medicines in the future. Out of those with knowledge of generics, 69% reported probably or definitely using generics in the future, while this was at 59% for those without knowledge of generics. This discrepancy shows that most people in each knowledge group will at least probably use generics in the future.

Question 18: I will use generic medicines in the future.
Accurate knowledge of generic medicine	Probably/ definitely will not	Unsure	Probably/ definitely will	Total	% Prob/ def will
Yes	3	8	25	36	69%
No	15	29	64	108	59%
Total	18	37	89	144

p-value not significant.

IDI and FGD results

There were five major themes that resulted from nine individual IDI and one FGD with five participants. The themes were (1) knowledge, (2) origins, (3) important decision-making factors, (4) perceptions of self/others, and (5) information sources.

Knowledge

The first major theme from the qualitative data was knowledge, and how in most cases, participants were unsure about the definition of generic medicines even after the survey provided them with the correct information.

For example, when asked about the main information sources on generic medicines, one participant said, “Probably my parents, because we have all the medicine at home and usually I would just ask them. Because they usually know about basic [generic] medicines as opposed to prescription, which I would get from the doctor.”

This implies a belief held by many survey participants that “generic” is a term synonymous with over the counter medicines. The only participant who fully understood the definition of generic medicines had parents who both worked in the healthcare field as practitioners.

Origins

The major theme associated with origin was the utilization of home remedies or homeopathic medicine. Every participant (five in total) with parents from India mentioned the use of homeopathic or home remedies by their parents, as did the one participant with parents from Mexico and the participant born in Hong Kong.

One participant said their parents “Will look for other things instead of resorting to medicine.”

Another said, referring to her mother, “She thinks that holistic things, or things from nature, are the best way to go about it and that’s what she does for herself.”

Important decision-making factors

Participants were asked to list and rank factors they considered when buying or using medicine. Overwhelmingly, doctors’ recommendation was ranked as the most important factor when buying or using generic versus non-generic medicines in all origin and knowledge groups. When asked about future use of generics, one participant from Hong Kong replied “As long as my doctor recommends it to me,” indicating that she would only use generics if specifically recommended. The following quotes are two participants’ ranking of the factors they consider.

One participant said, “The doctor, then the brand, then the price.”

Another participant said, “I guess doctor’s recommendation first, then the dosage then the price.”

Another important factor was price, but this was often dependent on severity of illness. Participants often explained they care more about a cheaper price when buying medicines for less severe ailments.

One participant said, “If it’s not going to impact my health that much, I think I would consider price more.”

Similarly, another participant said, “And just seeing the generic, yes they’re cheaper, but, at least the way my family is, you don’t want to compromise your health for something that’s a little bit cheaper.”

Lastly, the importance of family tradition was a factor in using generics versus name brand. Many participants explained that their views, for the most part, align with what their parents’ habits are.

Perceptions of self and others

Themes about perceptions of participants and others close to them revealed a few interesting points. First, the lower price of generics is often associated with a perceived lower quality.

One participant said, “I think just like the suspicion of why is it cheaper. You could feel that there are some other effects they’re not telling you about.”

Another said, “I would associate the higher price with higher quality.”

Another participant mentioned that the term generic “is kind of like a different connotation than what it means … just a simple medicine or something.”

These quotes reveal that the lower price can at times decrease an individual’s likelihood of purchasing generics, and that merely the name used to describe this category of medicine is not one that people associate with quality.

Several participants cited pharmaceutical advertising as one of the main reasons for their perception of generics being of lower quality.

“Well I think it [misconceptions] definitely stems from how pharmaceuticals market themselves.”

“I tend to pick the brand name even though I know it’s pretty much the same active ingredient. But I think because it’s advertised on television and they give the stats saying that it’s helpful, that’s why I do tend to pick the brand name.”

“Just because you know that name, you kind of feel like it’s going to work.”

In contrast to these views, the participant from Denmark mentioned his distrust of pharmaceutical companies contributing to his distrust of advertising. He said: “No, like, the advertising of branded medicines diminished my perception of all medicines here, because I don’t know what is true anymore, because I don’t assume advertising is true.”

Information sources and recommendations

When asked how misconceptions about how generic medicines should be addressed, participants most commonly answered that information should be transmitted through doctors. “Doctors’ opinions matter a lot, so if they were to say, this is what I prescribe, this is the best thing, and explain the ingredients and the cause and effect. I think that would be most effective.”

This makes sense given the nearly universal reliance on doctor recommendation regarding choosing which prescription medicines to take. The next most common answer was increased advertising through television and the Internet. Two participants also thought a component on generic medicines should be added to health education curricula. “Or in schools, when you’re teaching health classes, you can say generic medicines are the same in that way.”

Discussion

This study employed a mixed-methods approach, using a survey, IDI, and one focus group to collect quantitative and qualitative data. The survey collected both types of data and the IDI and focus group collected only qualitative data. Subject recruitment followed a purposive sampling approach and this resulted in representation of the key population groups of students attending BU. However, we do have recommendations for further research if these methods are to be repeated. First, it is important that the relevant student groups are contacted as early as possible and between exam periods, if possible. Second, recruitment methods should be more tailored to recruiting international students. In this study, the snowball recruitment method used for the focus group was more successful than the approach used for the survey. This is most likely due to the simultaneous isolation and closeness of the international community at BU. In other words, many of the international students know each other, and recruiting a few will quickly spread the word to the rest of their social circle.

Our findings aligned with previously published literature on perceptions of generic medicines. For example, the UAE study found higher severity of illness made people less willing to take generic medicines. This finding was seen again in almost all qualitative interviews as well as the survey. Participants’ perception of generics’ lower quality made them less willing to choose generics for more serious ailments. Additionally, multiple participants in the survey and interviews emphasized the reliance on doctor recommendation when choosing medicine. This finding was discussed in a study from Melbourne that found that one major barrier to generic medicine use was the influence of the provider on the patient. Finally, many participants cited familiarity with advertising as reasons for using branded medicines instead of generics. This theme was also found in a study done in South Africa, in which more participants identified with the originator brand Panado than with the generic paracetemol.

In other instances, our findings were more extreme or did not align with previously published literature. The biggest surprise, which also acted as a confounding variable, in our results came from the question about prior knowledge of generics. While 67% of participants in our survey reported knowing what generics were, when asked to define what they were only 39% of those participants who claimed to know gave an accurate answer. This means that only 24% of participants reported accurate knowledge of generic medicines, while studies in Auckland and Malaysia found that 51.6% and 32.5% of participants knew what generics were. However, if respondents in these studies had been asked in an open-ended question to define generic medicines, it is possible that their results would have been more similar to ours. The study done in the UAE found that 60% of participants understood “generic” and “branded” in relation to medicines. Given the fact that the United States has an 86% generic utilization, this lack of knowledge about what generics are is alarming. Another implication of our finding is that researchers of future studies of perception of generic medicines should always ask respondents to define generic medicines with an open-ended question to assess the level of knowledge.

Another common finding in our study that was not mentioned in the literature on perception of generic medicines was the frequency of utilization of alternative medicines in households of students with immigrant parents, and how that might affect their knowledge, attitudes to, and use of generics. This theme was of interest because instead of choosing between generics and non-generics, participants or parents of participants would often choose between allopathic and alternative medicine. If they chose the allopathic route, the difference in medicine choices becomes less relevant because they may perceive these medicines as a less desirable option to begin with. Therefore, the cost-saving benefit of choosing generic medicines may not be considered and the branded version has an equal chance of being used.

To improve knowledge of and positive perceptions of generic medicines, the following actions are needed. First, doctors and other practitioners must explain generic medicines to patients in addition to prescribing them. There is a lack of understanding about why generics are cheaper, and this leads people to be suspicious of their ingredients and/or effects. This approach is most likely to be effective due to the amount of weight given by patients to their doctors’ recommendation. This finding was seen in both American and foreign-born participants. Another mechanism for generic promotion should be advertising, because participants emphasized the effect of familiarity on what medicines they choose to use. Obviously, if generic medicines were advertised as heavily as branded medicines, they would not be as cheap, but simple packaging design changes or print advertisements could potentially be effective and are probably worth exploring.

Limitations

The limitations of this study mainly include logistical challenges in contacting student organizations. This made it difficult to contact as many groups as was originally planned. Additionally, student groups often did not respond or were unwilling to help distribute the survey. Poor timing of survey distribution near final exam period also inhibited the response rate of student groups and survey participants. Finally, motivating students to participate in the IDI was a challenge despite the gift card incentive. Relying on student participation for data collection can be a risk and participant recruitment should be carefully planned with this in mind.

If this method is used for further research, more time should be allotted for subject recruitment. That would allow more contact with student groups or potentially time to visit their meetings in person to explain the research. If possible, more incentive should be provided for the IDI component as well. All of these recommendations address the main obstacle of subject recruitment for this study.

Conclusion

Promoting the use of generic medicines is important to control healthcare costs. While it is not clear if these survey results reflect more broadly on the general population, the low rate of correct knowledge about generic medicines is disturbing in this educated student population. Repeated studies in other student populations are needed in the United States and internationally to determine whether this lack of knowledge is widespread. If it is, efforts should be made to change the group knowledge and perception of this distinct population.

Footnotes

Conflict of interest

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

Funding

Funding support for this project was provided by Kilachand Honors College at Boston University.

Author biographies

Molly R Tobin graduated cum laude from Sargent College and the Kilachand Honors College of Boston University in 2015. This study was done for her senior keystone project for the Kilachand Honors College. She is now working in healthcare consulting in San Francisco and plans to attend graduate school to pursue an MBA/MPH after working for a few years.

Richard Laing is a professor in the Department of Global Health at Boston University School of Public Health. He is interested in all aspects of Access to Medicines globally. He has previously worked for WHO, Management Sciences for Health and the Ministry of Health, Zimbabwe.

Appendix 1: Survey questionnaire

Appendix 2: In-depth interview guide

Appendix 3: Focus group discussion guide

Appendix 4: Grading criteria for question 10

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