Knowledge and perception differences towards generic medicines consumption among consumers

Abstract

The objective of this study was to evaluate the population behavioural influence towards generic medicines use in a Klang Valley. A self-administered questionnaire in the Klang Valley, Malaysia, was distributed conveniently. A total of 222 respondents have participated in the study (response rate 57.8%). The majority of the respondents (87.7%) have reported considerable amount of knowledge on the generic medicine availability in the market. In comparison of sociodemographic influence, only household size was found to influence the respondent’s knowledge and curiosity. For the perception, there was a statistically significant difference in attitude scores for respondents who had good level of knowledge (M = 3.322, SD = 0.516) and poor level of knowledge (M = 3.011, SD = 0.591) towards generic medicines; t(220) = –4.180, p < 0.05. In terms of subjective norms, data findings indicate a statistically significant difference in scores for respondents who had good level of knowledge (M = 3.456, SD = 0.704) and poor level of knowledge (M = 3.057, SD = 0.616) towards generic medicines; t(220) = –4.393, p < 0.05. Similarly, this study found a statistically significant difference in perceived behavioural control scores for respondents who had good level of knowledge (M = 3.605, SD = 0.548) and poor level of knowledge (M = 3.121, SD = 0.577) towards generic medicines; t(220) = –6.350, p < 0.05. Therefore, these results reveal that good level of knowledge really influence the level of perceptions among consumers of generic medicines. It is imperative that more initiatives to be introduced by the government to promote the practice to prescribe generic drugs to the population. The need to educate both health professionals and patients on the availability of the cheaper and bioequivalence medicine should be put into formality, thus increasing the awareness of the patient of the generic medicine and next reduce the dependency of the costlier innovator brand medicine in the prescription at both public and private healthcare settings.

Keywords

Generic medicine behavioral intention knowledge differences attitude subjective norms

Introduction

The use of generic medicines in Malaysia was relatively low as compared to any other developing countries in the Southeast Asia. This is due to the lack of considerable knowledge among the general population on the availability of the generic medicine as substitute to the innovator brand drugs. Generic medicine is defined as the drugs that is created to provide an alternative to the innovator brand drugs that has expired of its patent at cheaper cost.¹ The cost of medicines is one of the worrying facts in ever rising healthcare costs. Among the main aims of its creation is to provide a substantial amount of cost saving to the ever increasing cost of pharmaceutical to the healthcare industry. The notion of the move to shift to generic drugs in drugs prescription to save cost in pharmaceuticals was recognised by many. As the generic drugs were lower up to 80% from the innovator brand drugs, the cost-saving measure was said to be immense especially to the developing country such Malaysia.² Apart from that, the cost of pharmaceuticals in Malaysia has been strained over the years especially to the private healthcare centre. Although the government through Ministry of Health has enacted the use of generic drugs in the public healthcare facilities, the private setting is left without any regulation of the affordable and appropriate drugs policy that can be prescribed to the patient.³ While the creation of the generic drugs in the market is absolutely equivalent in safety and efficacy of the medicine with the innovator brand medicine, the selling cost might not always be cheaper than its predecessor. In a study by Ahmad and Islahudin⁴ on the affordability level of medicine consumption has revealed that the price of generic medicine has gone up to more than 100% than the innovator brand drugs in the private sector. This is further supported by the comparison analysis of the study on the drug prices among emerging economies such China, India as well as our own country, Malaysia, which found the drugs prices in Malaysia is considerably high as compared to its counterparts especially to the generic drugs.⁵ As a result, though generic drugs existence is to provide an alternative for cheaper prices to the innovator’s drugs that is expensive (due to the innovation, research and development costs), the price of generic drugs inclines to be no different or lesser in price as compared to the innovator’s brand drugs that yield out little significant to the cost containment efforts.

Moreover, lower awareness and knowledge among both the doctors and patients on the bioequivalence and safety of the generic drugs were said to add to the complexity and sporadic development of generic drugs usage and preferences among the population.⁶ This distorts the effort to contain the cost of pharmaceuticals in the healthcare sector especially to the patients that are categorised as self-paying patient in the private sector. In a study among the doctors in the private medical centre in Malaysia had found that most of the respondents were more likely to prescribe innovator brand drugs as compared to the generic drugs to the patient which also stated the cost factor as among the only factor that prevent them from prescribing none other than innovator brand drugs.⁷ This happened as the doctor and patient are having asymmetry information relationship, in which most of the patient would trust on the health professionals’ advices on the type of drugs that should be consumed for their illnesses. Although Malaysia has introduced a National Medicine Policy which enacted and put an effort to promote the usage of generic drugs among the population (by both health professionals and consumers), lacking in appropriate regulation and laws to ensure the implementation of the said policy has twisted the early effort to replace the expensive innovator medicine to the generic medicine that is proven to be lower in cost.⁸ Therefore, the study is intended to look into demographic views of the respondent that may affect the level of knowledge as well as projecting the difference of the knowledge possessed by the respondent in influencing the respondent’s perception towards generic medicine.

Overview of Malaysia healthcare system

Malaysia achieved its independence for more than 60 years since 1957 from the British Crown. The inheritance of the colonial system has caused the nation to follow most of the industrial practice from the Great Britain including healthcare system. Malaysia dual healthcare system has allowed the existence of both public and private healthcare sectors which offer healthcare diagnostic and medical services according to the population affordability level. Public healthcare sector is being subsidised almost 98% by the government through taxation revenue (with a very minimum fee of 1MYR for an access to the medical services and medications and 5MYR for the access to the tertiary care service with the medical specialist),⁹ while for the private healthcare system, the patient is paying by either using their own out-of-pocket money, insurance companies or third party payer as well as employer’s insurance benefit to the employees.¹⁰ The private healthcare sector is mushrooming since the 1997 recession that hit Malaysia economy by shifting the focus of the sector from providing medical services from general population to the foreigner through medical tourism initiative by the government.^11,12 This provides an option to the population of selecting the best medical services provider of their choice with most of the population preferred to render the medical consultation in public healthcare system which the government has subsidised for both medical fees and pharmaceuticals supply. However, it is worth noting that more than 50% of the population is using their out-of-pocket money to pay for their healthcare services.¹³ This has shown a considerable amount of the population that was seeking the medical services from the private healthcare provider for better quality of services and consultation.

Materials and methods

Study design and participants

A cross-sectional survey was carried out from October to December 2018. A convenience sampling approach was employed in this study.

Data collection and instrument

A 28-item questionnaire designed to discover demographic profile, assess the knowledge and preferences of consumers towards generic medicines were distributed to 384 consumers at various community areas in Selangor. The questionnaire was comprised of four sections: (a) the demographic characteristics of consumers, (b) accessing their knowledge towards generic medicines, (c) their perceptions of generic medicines usage and (d) the purchasing intention of generic medicines. A five-point Likert type scale ranging 1 (strongly disagree) to 5 (strongly agree) was used. Reliability analysis was performed to measure internal consistency using Cronbach’s alpha coefficient. Each of the dimensions was individually tested and the results are described in Table 1. According to rule of thumb, above 0.7 is considered as an acceptable value.¹⁴

Table 1.

Reliability analysis.

No.	Variables	Cronbach’s alpha	No. of items
1	Knowledge	0.725	7
2	Attitude	0.712	4
3	Subjective norm	0.793	5
4	Perceived behavioural control	0.781	5

Data analysis

All the obtained data were analysed using statistical package for social science (IBM SPSS version 23.0). Both descriptive and inferential statistics were applied. Simple frequencies and cross-tabulation were carried out to study characteristics of the respondents. Non-parametric chi-square test was performed for group comparisons at a significance level of 0.05. Furthermore, comparison analysis was conducted to test differences in the perceptions of generic medicines usage between respondents who had good level of knowledge and poor level of knowledge.

Results

Demographic profiles of consumers

A total of 222 consumers participated in this study (response rate of 57.8%). Majority of the consumers were female (63.1%) and below age of 30 years (69.8%). Nearly 70% of the respondents were single and 40% were Bachelor Degree holders. In terms of financial background, more than half (62.2%) of the respondents received less than RM2500 income in a month and 34% reported more than 3 for household size. In relation to the knowledge level on generic medicines, nearly 60% of the respondents can be considered as having good knowledge of generic medicines. Details on the demographic profiles of the consumers are described in Table 2.

Table 2.

Demographic profiles of consumers (N = 222).

No.	Demographic variables		n (%)
1	Gender	Male	82 (36.9)
		Female	140 (63.1)
2	Age (years)	Below 30	155 (69.8)
		30–40	39 (17.6)
		41–50	25 (11.3)
		Above 50	3 (1.4)
3	Academic background	Certificate	38 (17.1)
		Diploma	79 (35.6)
		Degree	86 (38.7)
		Post degree	19 (8.6)
4	Monthly income (RM)	<2500	138 (62.2)
		2501–3500	50 (22.5)
		3501–4500	21 (9.5)
		>4501	13 (5.9)
5	Household size	1	66 (29.7)
		2	34 (15.3)
		3	46 (20.7)
		>3	76 (34.3)
6	Marital status	Single	152 (68.5)
		Married	65 (29.3)
		Others	5 (2.3)
7	Level of knowledge on generic medicines	Good	128 (57.7)
		Poor	94 (42.3)

Knowledge of generic medicines

Data results suggest that more than half of the respondents (57.7%) had a good knowledge of generic medicines. Table 3 shows the level of knowledge according to their demographic characteristics. Only size of household of the respondents influence the level of knowledge towards the use of generic medicines (p = 0.008). Nearly 40% of the respondents had poor knowledge and were from household size of more than 3, whereas those who were considered as good knowledge were from 1 person household (32.8%). Other demographic characteristics did not show any significant difference between respondents of good knowledge and poor knowledge levels toward generic medicines use.

Table 3.

Factors influencing knowledge level on generic medicines.

No.	Demographic characteristics	Level of knowledge
No.	Demographic characteristics	Good, n (%)	Poor, n (%)	p-Value
1	Gender
	Male	49 (38.3)	33 (35.1)	0.628
	Female	79 (61.7)	61 (64.9)
2	Age (in years)
	Below 30	94 (73.4)	61 (64.9)	0.228
	30–40	22 (17.2)	17 (18.1)
	41–50	12 (9.4)	13 (13.8)
	Above 50	0 (0.0)	3 (3.2)
3	Academic background
	Certificate	19 (50)	19 (20.2)	0.206
	Diploma	44 (34.4)	35 (37.2)
	Degree	50 (39.1)	36 (38.3)
	Post degree	15 (11.7)	4 (4.3)
4	Monthly income (RM)
	<2500	73 (57)	65 (69.1)	0.446
	2501–3500	34 (26.6)	16 (17)
	3501–4500	13 (10.2)	8 (8.5)
	>4501	8 (6.2)	5 (5.3)
5	Household size
	1	42 (32.8)	24 (25.5)	0.008*
	2	26 (20.3)	8 (8.5)
	3	21 (16.4)	25 (26.6)
	>3	39 (30.4)	37 (39.3)
6	Marital status
	Single	88 (68.8)	64(68.1)	0.353
	Married	39 (30.5)	26 (27.7)
	Others	1 (0.8)	4 (2.1)

*p < 0.05

Table 4 indicates the understanding of respondents relating to the knowledge of generic medicines. More half of the respondents (56.8%) believed that a generic medicine is a copy of brand name medicines (strongly agrees and agreed), whereas 11.8% believed otherwise (disagreed and strongly agreed). Approximately 60% of the respondents thought that a generic medicine was interchangeable with brand name medicines, while 14% did not thought so (disagreed and strongly agreed). Almost half of the respondents (46.8%) assumed that generic medicines were therapeutically equivalent to brand name medicines. Nearly one-third (32.4%) of the respondents were aware that generic medicines are manufactured after the patent expiry of innovator, while 12.2% did not know. In terms of quality, 55% of the respondents thought that brand medicines had good quality compared to generic brand (12.2%). About 62% of the respondents believed that brand medicines are required to meet higher safety standards when compared to generic medicines. More than half of the respondents (51.4%) thought that brand name medicines produced lesser side effects compared to generic medicines.

Table 4.

Knowledge of generic medicines.

No.	Variable	n (%)					M	SD
No.	Variable	Strongly agree	Agree	Neutral	Disagree	Strong disagree	M	SD
1	Generic medicines are copy of brand name medicine	19 (8.6)	107 (48.2)	70 (31.5)	21 (9.5)	5 (2.3)	3.51	0.87
2	Generic medicines are interchangeable with brand name medicines	18 (8.1)	114 (51.4)	59 (26.6)	29 (13.1)	2 (0.9)	3.53	0.85
3	Generic medicines are therapeutically equivalent to brand name medicine	16 (7.2)	88 (39.6)	83 (37.4)	32 (14.4)	3 (1.4)	3.37	0.87
4	Generic medicines are manufactured after the patent expiry of innovator	14 (6.3)	58 (26.1)	123 (55.5)	25 (11.3)	2 (0.9)	3.26	0.77
5	Brand medicines are good quality than generic medicines	40 (18)	82 (36.9)	73 (32.9)	23 (10.4)	4 (1.8)	3.59	0.96
6	Brand medicines are required to meet higher safety standards than generic medicines	37 (16.7)	100 (45)	69 (31.1)	13 (5.9)	3 (1.4)	3.70	0.86
7	Brand name medicines produce lesser side effects than generic medicines	27 (12.2)	87 (39.2)	83 (37.4)	21 (9.5)	4 (1.8)	3.50	0.89

Comparison of perceptions towards generic medicines

Table 5 shows the differences in perceptions, including attitude, subjective norms and perceived behavioural control, between respondents who had good level of knowledge and poor level of knowledge towards generic medicines. An independent-samples t-test was conducted to compare attitude, subjective norm and perceived behavioural control between the two groups of respondents: good knowledge and poor knowledge.

Table 5.

Comparison of perceptions towards generic medicines use.

Variables	Good knowledge (n = 128)		Poor knowledge (n = 94)		t-Test
Variables	M	SD	M	SD	t-Value	p-Value
Attitude	3.3223	.51565	3.0106	.59106	–4.180	.000
Subjective norm	3.0106	.59106	3.0574	.61635	–4.393	.000
Perceived behavioural control	3.6047	.54785	3.1213	.57714	–6.350	.000

This study results found that there was a statistically significant difference in attitude scores for respondents who had good level of knowledge (M = 3.322, SD = 0.516) and poor level of knowledge (M = 3.011, SD = 0.591) towards generic medicines; t(220) = –4.180, p < 0.05. The magnitude of the differences in the means (mean difference = –0.312, 95% CI: –0.458 to –0.165) has large effect (eta squared = 0.562). In terms of subjective norms, data findings indicate a statistically significant difference in scores for respondents who had good level of knowledge (M = 3.456, SD = 0.704) and poor level of knowledge (M = 3.057, SD = 0.616) towards generic medicines; t(220) = –4.393, p < 0.05. The magnitude of the differences in the means (mean difference = –0.399, 95% CI: –0.578 to –0.219) has large effect (eta squared = 0.647). Similarly, this study found a statistically significant difference in perceived behavioural control scores for respondents who had good level of knowledge (M = 3.605, SD = 0.548) and poor level of knowledge (M = 3.121, SD = 0.577) towards generic medicines; t(220) = –6.350, p < 0.05. The magnitude of the differences in the means (mean difference = –0.483, 95% CI: –0.633 to –0.333) has large effect (eta squared = 0.859). Therefore, these results reveal that good level of knowledge really influence the level of perceptions among consumers of generic medicines. On average, when consumers have better knowledge, their perceptions towards generic medicines use tend to be increased.

Discussion

Demographic characteristics

The study explore few demographic characteristics such gender, age, education, income and household size of the respective respondent. Of all the characteristics, only household size was noted to influence the level of knowledge among the respondents. This finding was in accordance with similar study on health insurance consumption among Penangites that was done by Shafie and Hassali¹⁵ which explain how the household size of the respondent affect the tendency to purchase health insurance to prevent unseen catastrophic healthcare expenditure. Surprisingly, the respondent’s income and education level did not contribute to influence the level of knowledge among respondent which then contradicted the previous literature.¹⁶

Knowledge of generic medicines

There is a significance difference of the respondent’s perception towards the use of generic medicines to treat medical illnesses. From the result above, it showed that the appropriate amount of knowledge is sufficed to influence the respondent to shift to the use of generic medicines in treating their illnesses. The finding is consistent with the study by Al-Gedadi et al.¹⁷ which suggested that further education by the healthcare provider to the patient might enhance the patient uptake of the generic medicine in their prescription. However, it is worth noted that the sociodemographic of the respondent did not influence the knowledge on generic medicine. This is in consistent with the previous study by Shraim et al.¹⁸ which found that the knowledge score is not associated with the sociodemographic data of the respondents. Nevertheless, the increase in the household size of the family did increase or change the respondents thought of generic medicines use among the family members.

Differences in perceptions towards generic medicines usage

Regarding the differences of perception towards generic medicine usage among the respondents, the researchers have employed the Theory of Planned Behaviour to measure the perception elements. From the findings, it was found that there is a significant difference between those that have good knowledge and otherwise in determining the respondent’s attitude of the generic medicine usage, the influence and experience from the next of kin in the generic medicine as well as the motivation and ability to use the generic medicine. This shows that as more knowledge were found among the respondent about generic medicine, it will increase the respondent’s readiness and perception to consume generic medicine in their treatment regime. In the heavily dictated healthcare system such as Malaysia, the level of knowledge of the individual determines their opinion towards certain medical procedures and treatment. Apart from that, the finding is important especially to the attitude of both doctors and patients towards generic medicine usage. As growing literature blamed on the negative perception of generic medicine to the patient’s well-being, none of them (healthcare practitioners) were able to provide robust evidence on the bioequivalence, safety and quality of the generic medicine to the innovator brand medicine.^7,19 The negative perception that lay on this healthcare system players has further distorted the development of more generic medicine usage among the patient especially in Malaysia. To combat this, the need to have sufficient amount of knowledge about generic medicine among the population is essential and supported by several studies that note on the knowledge and perception elements towards generic medicine usage among patients and the doctors that prescribe the medicines.^20,21 This is believed to be able to provide re-modification of the individual’s attitude and perception towards healthcare services especially towards generic medicine usage among the population in Malaysia. In addition to that, special extension was made to educate the first line of healthcare service which is the doctor of the need to prescribe more of generic medicines to the patient and proper policy be enacted to regulate the generic medicine prescription among the healthcare practitioners.²² To a certain extent, performance evaluation was also suggested to further improve the usage of generic medicine among the key stakeholders, healthcare practitioners in prescribing more of generic medicine to the patient.²³ This is among other efforts to increase the usage of generic medicine among the stakeholders in the healthcare system.

Conclusion

As Malaysia healthcare system is offering dual healthcare system to the population. It is important for both sectors to mimic each other in terms of its operation, technology and healthcare services including generic medicine prescribing act. As part of the cost containment measure by the public healthcare sector, the public healthcare facilities have been prescribing the generic medicines for quite some time. It is imperative that the same practice to be expanded and more initiatives to be introduced by the government to promote the prescription of generic drugs nationwide especially to the private healthcare setting. This may reduce the medicine cost that is paid out-of-pocket money by most of the paying patients in the private setting. Furthermore, the need to educate both health professionals and patients on the availability of the cheaper and bioequivalence medicine should be put into action, thus increasing the awareness of the patient of the generic medicine which then reduce the dependency of the costlier innovator brand medicine in the prescription at both public and private healthcare settings. These efforts are believed to be able to increase knowledge and awareness of the population of generic medicine usage by both patients and healthcare providers in Malaysia, thus increasing the availability of the generic medicine to the healthcare system as a whole.

Footnotes

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Mohd Redhuan Dzulkipli

Author biographies

Mohd Redhuan Dzulkipli is a senior lecturer at the Faculty of Business and Management, Universiti Teknologi Mara Selangor, Puncak Alam Campus. He holds Master of Health Services Management from Curtin University, Western Australia. Since then, he has authored and co-authored various academic publications. His area of interest includes willingness to pay, healthcare and pharmaceutical financing and generic medicine.

Siti Noorsuriani Maon is an associate professor at the Faculty of Business and Management, Universiti Teknologi Mara Selangor, Puncak Alam Campus. She received a PhD from the University of Queensland, Australia, in 2012. Her research interest includes healthcare behavior, health informatics and technological intervention in health improvement.

Mohamed Azmi Hassali is a professor at the Social and Administrative Pharmacy Department, School of Pharmaceutical Sciences, Universiti Sains Malaysia. He received a PhD from the Monash University, Australia, in Social Pharmacy. His research interests, among others, are qualitative and quantitative aspects of medication usage, clinical pharmacoeconomic, evaluation and analysis of pharmaceutical policy as well as pharmacy education.

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