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Table 1 Summary of studies (sorted by reference number)

From: What do people really think of generic medicines? A systematic review and critical appraisal of literature on stakeholder perceptions of generic drugs

Location Subject(s) n Type Focus Main findings Reference
Nigeria Pharmacists 154 Questionnaire Perceptions Many respondents lacked confidence in the quality of the generics available on the Nigerian market, but a majority supported generic substitution practices. [13]
Czech Republic Pharmacists 615 Questionnaire Opinions, attitudes, experiences A majority of respondents considered generic drugs as bioequivalent and therapeutically equivalent. [14]
A small number of pharmacists believed that generic products were of lower quality than branded drugs and expected generics to cause more adverse drug reactions.
South Africa Consumers and healthcare professionals 73 consumers Focus group discussions with consumers Comparison of healthcare professionals’ and consumers’ opinions, along with testing of generic formulations All formulations passed in vitro tests for quality. Therefore, the study showed clear differences between perceptions of quality and actual quality of medicines, suggesting that implementation of generic medicine policy requires information gaps to be addressed. [15]
15 healthcare professionals Semi-structured interviews with healthcare professionals
USA Physicians 506 Questionnaire Perceptions A meaningful proportion of physicians expressed negative perceptions about generic medications, representing a potential barrier to generic use. Payers and policymakers trying to encourage generic use may consider educational campaigns targeting older physicians. [16]
Ireland Patients 42 Interviews Perceptions Variable knowledge about generic medicines among patients. Although patients were supportive of their more widespread use, concerns regarding safety, clinical effectiveness and manufacturing quality of generic medicines were identified. [17]
Denmark Patients 2,476 Questionnaire Attitudes, beliefs, experiences Patients who had once experienced a generic switch were more likely to accept a future generic switch. [18]
Negative views on generic medicines were negatively associated with switching, while beliefs about medicine and confidence in the healthcare system had no influence.
USA Female patients 50 Focus groups Perceptions Generally favourable perceptions regarding generic drug discount programs. [19]
Study participants believed that generic medicines were generally effective and similar to their brand equivalents; however, there was an association between severity of illness and willingness to utilise generic prescription drugs.
Australia Patients 47 Postal survey Attitudes and perceptions to generic substitution with AEDs Considerable concern was found among patients with epilepsy about generic substitution of antiepileptic drugs. [20]
More clinical data and research on bioequivalence of generic antiepileptic medicines may help to address these concerns.
Canada Patients and physicians 81 patients Questionnaire Interchangeability of warfarin While most patients and physicians appeared to have accepted the principle of therapeutic equivalence of generic and brand name warfarin, a sizable minority had concerns that could influence prescribing and compliance, believing that generic warfarin was neither as safe nor as effective as brand name warfarin. [31]
110 physicians
Slovenia GPs 117 Postal survey Attitudes, generic prescribing The majority of GPs perceived generics to have the same effectiveness as branded drugs. [32]
Slovene GPs were aware of the cost of prescribed drugs. They were willing to accept independent academic detailing to improve their prescribing and were willing to increase prescribing generic drugs under certain conditions.
Saudi Arabia Physicians 772 Questionnaire Perceptions and attitudes, generic prescribing Most physicians supported generic substitution, but they indicated that there were certain clinical situations where they preferred to use brand name drugs. [33]
Greece Physicians 1,204 Postal questionnaire Perceptions Physicians seemed to be open to prescribing generic medicines, despite the fact that they did not do so at the time the article was published. The expansion of the generics market should have a positive impact on patients’ access to cheaper drugs. [36]
USA Patients and physicians 550 patients, 606 physicians Online survey Perceptions in the context of treatment of epilepsy About half of physicians were extremely/very likely to request that brand AEDs not be substituted with a generic. [37]
Perceptions among physicians and patients did not align with the FDA position that generic AEDs have the same clinical effect and safety profile as branded AEDs.
More research is needed to determine if generic AEDs are bioequivalent in real-life situations.
Jamaica Physicians 60 Questionnaire Acceptance, perceptions There were doubts about whether bioequivalence of a generic was equitable to therapeutic equivalence to an innovator drug. A third of the physicians were able to identify at least one case in the past year of clinical problems with generic substitutes, which they perceived would not have occurred with the innovator. [38]
Pakistan Physicians 11 Semi-structured interviews Knowledge, attitudes, perceptions The major themes identified were knowledge of generic medicines, perceptions regarding generic medicines, attitude towards generic medicines and perception towards marketing strategies of pharmaceutical industry for brands and generics, as well as recommendations to further enhance generic utilisation. [40]
Pakistan GPs 206 Questionnaire Perceptions, attitudes Close to three-quarters of the respondents showed correct knowledge about generic medicines being a ‘copy of the brand name medicines’ and ‘interchangeable with brand name medicines’. The majority of respondents incorrectly understood that the generic medicines were less safe than brand name medicines. The majority of respondents believed that their prescribing decision was influenced by pharmaceutical company representatives. [42]
Knowledge gaps evident.
Italy Family paediatricians 303 Online questionnaire Perceptions, patterns of use Major issues related to scepticism about reliability of bioequivalence tests and safety of switchability from branded to generic equivalents. More information about generic drugs and more research in the field of paediatric pharmacology are needed to increase the generic medicine prescription rate. [43]
Malaysia GPs 87 Postal survey Knowledge, perceptions Although it appeared that GPs had largely accepted the use of generic medicines, they still had concerns regarding the reliability and quality of such products. GPs need to be educated and reassured about the generic product approval system in Malaysia concerning bioequivalence, quality and safety. [45]
Germany Physicians: psychiatrists 410 Survey Decision-making between generic and branded Psychiatrists were more likely to choose branded drugs when imagining choosing the drug for themselves (versus recommending a drug to a patient). [47]
Psychiatrists were more likely to choose generic antidepressants than generic antipsychotics.
Ireland GPs 34 Semi-structured interviews Perceptions, beliefs, behaviours Majority of participating GPs actively prescribed generic medicines. Predominantly, participants believed that generics worked as effectively, and were of the same quality, as originator medicines A minority of GPs were of the view that generics were manufactured to a poorer quality than originators and may be a risk to patient safety. [48]
USA, Australia, Finland, Malaysia, Slovenia, France, Ireland, UK and Jamaica Physicians 14 papers Review article Views Physicians lack knowledge of regulatory requirements imposed on generics. [49]
1980–2008 Being cheaper than their branded counterparts raised the concerns of the physicians about their quality, safety and effectiveness, especially in the presence of heavy and successful promotional activities from brand name industry.
Australia GPs 10 Semi-structured interview Perceptions Study suggested that GPs in Melbourne had mixed attitudes to generic prescribing. [50]
Also shows that misconceptions about safety and efficacy of generic medicines still persisted among some GPs and that unless they were sufficiently educated by interested parties, such as the government and the generic medicine industry, this will have a negative impact on utilisation of generic medicines in future.
Australia, Canada, France, Germany and UK Pharmacists 254 Web questionnaire Attitudes, interchangeability of dry powder inhalers Just 6 % of pharmacists considered that dry powder inhalers were interchangeable, with a high level of concern shown about interchangeable use and with patient confusion being the main concern expressed. [51]
Portugal Patients and pharmacists 95 pharmacists Questionnaire Perceptions, attitudes More information for patients is necessary. Greater levels of acceptance seen in patients with higher education levels or those who had discussed substitution with physician/pharmacist. [52]
417 patients A majority of patients were willing to accept generics on recommendation of healthcare professional.
Sweden Pharmacists 16 Interviews Experiences, attitudes Pharmacists found it positive that generic substitution decreased the costs for pharmaceuticals but also emphasised that the switch can confuse and worry patients, which could result in less benefit from treatment. [53]
To prevent known confusion and concern among patients, it is important that community pharmacists acquire the necessary tools and knowledge to manage this situation, and communicate effectively with patients.
USA Patients, pharmacists 82 patients Postal survey Patient and pharmacist knowledge of, and attitudes toward, reporting adverse events due to using generic AEDs More than 92 % of patients and 85 % of pharmacists agreed that switching between forms of the same AEDs may cause an increase in seizures or adverse effects. [54]
112 community pharmacists
Malaysia Pharmacists 219 Postal questionnaire Views Only 50.2 % of the surveyed pharmacists agreed that all products that were approved as generic equivalents can be considered therapeutically equivalent with the innovator medicines. The Malaysian pharmacists had a lack of information and/or trust in generic manufacturing and/or approval system in Malaysia. [55]
New Zealand Pharmacists 360 Postal questionnaire Views, knowledge 70 % of pharmacists stated there was no difference in safety between original brand and generic medicines. [56]
65 % stated that original brand medicines were of higher quality than their generic counterparts, and half stated that generic medicines and original brand medicines were equally effective.
Concerns were raised regarding quality, safety and effectiveness; however, most of the pharmacists acknowledged the economic benefits to the healthcare system.
France Pharmacists 1,000 Postal survey Opinions, behaviours 90 % of the pharmacists were favourable to the implementation of generic substitution. 42.5 % declared they systematically offered patients the generic drug, whereas 55 % chose to target specific populations for substitution. [57]
Ireland Community pharmacists 44 Semi-structured interviews Perceptions, attitudes Only a small number demonstrated some reticence regarding generics. [58]
89 % of pharmacists reported receiving patient complaints regarding use of generic medicine, although 64 % suggested that this was due to a nocebo effect (that is, a result of patients’ preconceived notions that generics were inferior). Only a minority (21 %) reported that they had attempted to educate patients as to the equivalency of generics.
Germany Patients 804 Survey Perceptions GPs were in an ideal position to adequately inform their patients about the equivalence of brand name and generic drugs. Patients held views that inexpensive drugs must be inferior. [59]
Norway Patients 281 Written questionnaire Experiences, attitudes 36 % of the patients reported negative experiences after medication substitution. [60]
Generic drug substitution was not considered an equal alternative to branded drugs by a number of patients for whom additional information and support may be needed.
Norway Hypertensive patients 174 Interviews Challenges of generic substitution in adherence One in three said generic substitution made keeping track of their medications more demanding. [63]
A negative attitude towards generics was significantly associated with low educational attainment, an increasing number of drugs, having general concerns about medicine use and having received insufficient information regarding generic substitution.
Finland Patients 256 Questionnaire Preferences Approximately half of the respondents were strongly price-sensitive, while the others had other preferences such as brand or an opportunity to buy the medicine at a pharmacy, or to have a physician or a pharmacist as an information source. [64]
USA Patients 356 Postal survey Perception of generic AEDs A significant percentage of patients reported that generic AEDs were responsible for breakthrough seizures and increased side effects. A significant percentage of patients also reported switching back to a brand name AED and expressed concern over pharmacies switching to generic AEDs without a patient’s or physician’s consent. [65]
The Netherlands Patients 106 Interview Attitudes to substitution, oral atypical antipsychotics 3 % stated that they would be unlikely to take a generic antipsychotic if their pharmacist were to substitute it. [66]
Patients with psychoses/schizophrenia perceived generic versions of their antipsychotics as being significantly different. This perceived difference lowered their intention of continuing to take the medication, thus possibly jeopardising treatment outcome.
USA Patients 971 Postal survey Relationship between beliefs and generic usage Generic drug use was most closely associated with communication by providers about generics resulting in comfort with generic substitution. [67]
USA Patients 1,054 Postal survey Perceptions Patients agreed that generics were less expensive and better value than brand name drugs, and were just as safe. [68]
Findings may indicate that perceptions about generic essential medications have improved over time. Efforts to educate patients could positively influence usage of generics.
New Zealand Consumers 441 Questionnaire Knowledge, perceptions, attitudes Pharmacists were the main source of information regarding generic medicines followed by doctors and media. [69]
A higher level of education had a direct relationship with having correct knowledge of generics.
Many consumers have misconceptions regarding generic medicines.
Australia Patients: senior citizens 104 Focus groups Perceptions Demonstrated considerable mistrust of generic medicines. Participants highlighted their uncertainty about the extent of pharmaceutical companies’ influence on health professionals, the mistrust of foreign generic manufacturers and scepticism in their equivalence. [70]
South Africa Consumers 73 Focus groups Perceptions Irrespective of socioeconomic status, respondents described medicine quality in terms of the effect the medicine produced on felt symptoms. [71]
Generic medicines were considered to be poor quality and treated with suspicion.
Cost, avoidance of feeling ‘second class’, receiving individualised care and choice in drug selection were the main determinants influencing procurement behaviour.
Norway Patients: Pakistani immigrants 83 Interviews Challenges following generic substitution One-quarter of the participants were of the opinion that cheaper generic drugs were counterfeit drugs. Two-thirds had accepted generic substitution in the pharmacy, whereas the remaining participants had either opposed or were unaware of the substitution. [72]
Finland Public: consumers 1,844 Postal survey Opinions Finnish consumers considered generic substitution a good reform. They also had confidence in the effect of cheaper medicines. Savings were the main reason for accepting generic substitution. [73]
Substitution was not considered to cause any risk to drug safety.
Two main reasons for substituting were a desire to save money and recommendation by pharmacists.
Female gender, older age and use of prescription drugs were associated with refusing.
Japan Patients 1,215 Questionnaire Attitudes to generic substitution The public awareness program on generic drugs should be expanded to include more detailed information so that patients obtain the correct understanding of generic substitution. It is critical that physicians and pharmacists have the proper understanding of generic drug substitution and provide the correct information to patients. [74]
Iraq Consumers 14 Face-to-face interviews Perceptions Most of the participants understood that generics cost less compared with their branded counterparts, and their physicians and pharmacists had given them information on generics. [75]
However, knowledge of generic medicines was lacking among consumers in Iraq and their primary reason for using generic medicines was that they were less expensive.
Finland Public 1,844 Postal questionnaire Opinions on refusal of generic substitution Main reasons for generic substitution refusal were satisfaction with their current medicine and/or that a decision on a drug product had been made in co-operation with their physician. Most of these individuals indicated that they would be unwilling to accept generic substitution in the future. [76]
USA Patients 172 female patients of childbearing age Oral questionnaire Beliefs, perceptions Awareness of the benefits of generics did not equal preferences for personal use of generics. [77]
About a quarter believed that brand name medications were more effective than generics.
13.4 % believed that generics caused more side effects.
USA Patients 30 Focus groups Perceptions, barriers to use Barriers to generic medication use included: perceptions that generics are less potent than brand name medications, require higher doses and, therefore, result in more side effects; generics are not ‘real’ medicines; generics are for minor but not serious illnesses; the medical system cannot be trusted; and poor people are forced to ‘settle’ for generics. [78]
UAE Renal patients 188 Survey Views on generic substitution 70 % of patients were aware of the availability of generic medicines. [79]
31 % felt that generics were not equivalent or only sometimes equivalent to branded medicines. Nearly half the patients stated they would refuse generic substitution when it became available if this was just to save the health authority money.
Germany Patients 126 Questionnaire Perspectives to substitution in context of treatment of epilepsy 32 % of the patients who already experienced a switch to generic AEDs complained of problems with the switch. However, patients who had never switched were more concerned about generic substitution than those who had already switched. [81]
USA Consumers 183 Survey Factors influencing purchasing Single most influential factor was lower cost. [83]
Other factors, including advertisements, duration of the OTC drug effectiveness, severity of sickness, preferable form of OTC medication, safety of the OTC, relief of multiple symptoms and preferred company, would persuade consumers to pay more for brand name drugs.
USA, Europe, Canada, Australia, Brazil and Malaysia Consumers 20 studies Review article Views, chronological Mixed reactions, related to development level of country. [84]
However, reasonably positive attitude (40–60 %) stable across studies.
1970–October 2008 Positive attitudes not necessarily translated into increased use of generic products.
  1. AED antiepileptic drug, FDA US Food and Drug Administration, GP general practitioner, OTC over-the-counter