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Consumers' views on generic medicines: A reiew of the literature

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IJPP 2009, 17: 79–88
ß 2009 The Authors
Received November 7, 2007
Accepted January 6, 2009
DOI 10.1211/ijpp/17.02.0002
ISSN 0961-7671
Correspondence: Mohamed
Azmi Ahmad Hassali, Senior
Lecturer, Discipline of Social and
Administrative Pharmacy, School
of Pharmaceutical Science,
Universiti Sains Malaysia, 11800
Minden, Penang, Malaysia.
E-mail: azmihassali@usm.my;
jemik7@hotmail.com
Review Article
Consumers’ views on generic medicines:
a review of the literature
Mohamed A.A. Hassali, Asrul A. Shafie, Shazia Jamshed,
Mohamed I.M. Ibrahim and Ahmed Awaisu
School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
Abstract
Objectives To review the literature on consumers’ knowledge, attitudes and opinions of
the use of generic medicines.
Method A narrative review of studies conducted from 1970 to 2008 on consumers’
perceptions and views towards generic medicines was performed. An extensive literature
search was undertaken using indexing services available at the authors’ institution library.
The following keywords were used for the search: brand, generic, multisource,
medications, medicines, drugs, pharmaceuticals and consumers, customers, and patients.
Electronic databases searched were Medline, Inside Web, ISI Web of Knowledge, Science
Direct, Springer Link, JSTOR, Proquest, Ebsco Host and Google Scholar. These electronic
databases were searched for full text papers published in English from 1970 to October
2008.
Key findings Twenty studies were identified. Eleven were from the USA, four were from
Europe, two were from Canada and one each was from Australia, Brazil and Malaysia. In
general, consumers showed mixed reactions towards the use of generic medicines. This
was evident from the divergence of views observed by country development level,
consumers’ socioeconomic characteristics, drug product characteristics, pharmaceutical
reimbursement system, policy environment, contact with health care professionals, past
experience with medications, and knowledge of the seriousness of a medical condition.
Conclusions Patient confidence and knowledge pertaining to generic medicines use have
increased over the past four decades, especially in developed countries. Mass educational
efforts, financial incentives, and greater communication among patients and health care
professionals were seen as major drivers to the uptake of generic medicines among
consumers.
Keywords consumer; generic medicines; knowledge; perceptions; policy
Introduction
Timely and effective use of medicines can ensure effective treatment of many illnesses and
avoid or delay the need for costly hospital treatment for patients. Significantly, generic
medicines can effectively treat many of today’s illnesses and their use provides the
opportunity to substantially reduce costs to health care budgets and patients.[1–3] There is
no doubt that branded medicines have exercised tremendous influence in medicines
utilization, but generic drugs, being bioequivalent to their brand-name counterparts, are
considered safe as well as cost-effective.[4] Globally, the use of generic drugs has increased
steadily as a result of economic pressures on drug budgets. In this review, consumer refers
to a person who buys medicinal products for either personal use or the treatment of a
disease. Generic medicines provide the opportunity for major savings in health care
expenditure directly to the consumers as well as to the government, given that they are
generally lower in price than their brand-name equivalents.[5–7]
Savings made by using generic medicines for established therapeutic care would
provide leeway for health care systems and patients to finance the purchase of the generally
more expensive, innovative products required to treat illnesses that at present lack adequate
pharmaceutical treatment.[8,9] In the debate over the use of branded versus generic
medicines, consumers’ perceptions based on their concerns regarding the risks involved
and on their beliefs concerning the use of generic drug products have been neglected.[10]
79
80 International Journal of Pharmacy Practice 2009; 17: 79–88
In this article we provide a chronological review of the
literature on consumer and patient knowledge, attitudes and
opinions about the use of generic medications. This study
provides the views of consumers from various settings in a
narrative way. The review also offers several recommenda-
tions that health care professionals can implement in their
practice settings to improve their patients’ utilization of
generic medicines.
Methods
A literature search was performed from May to October 2008
to identify published studies related to the views of con-
sumers or patients on generic medicines. In this narrative
review, only studies which measured consumers’ views and
perceptions towards generic medicines were included.
Studies that utilized either qualitative or quantitative
approaches, or both, were included in the review. However,
we excluded quantitative survey studies with fewer than
50 respondents as their sample. The retrieved literature was
abstracted using a standardized data-abstraction form in a
table format containing most of the elements presented in
Table 1 and our selection criteria. Each study was reviewed
by all five authors and a consensus meeting was convened to
ensure quality assurance.
The search strategy involved using Boolean operators for
combinations of the following terms: brand, generic, multi-
source and medications, medicines, medications, drugs,
pharmaceuticals and consumers, customers, patients. Equiva-
lent terms in thesauruses or Medical Subject Heading
(MeSH) browsers were used whenever possible. The search
was limited to full paper articles published in English
between 1970 and October 2008. However, our search was
not limited to prescription-only medicines, but also covered
studies involving consumers’ perceptions of non-prescription
medicines. Electronic databases searched included Medline,
Inside Web, ISI Web of Knowledge, Science Direct, Springer
Link, JSTOR, Proquest, Ebsco Host and Google Scholar.
These searches were supplemented by a hand search of the
reference lists in the reports identified. To determine whether
or not reports met the required criteria, the lists of titles and
abstracts from the searches were examined and where doubt
remained, the whole paper was examined. Reports that were
identified were arranged chronologically starting from the
1970s and ending in the 2000s.
Results
Three hundred and eighty two titles and abstracts were
identified by three authors from electronic searches of the
nine databases and, wherever possible, a review of the
reference lists. Of these, 313 titles and abstracts not related to
consumers’ views on generic drugs and duplicated citations
were examined and excluded. The full text of 69 articles was
retrieved and distributed among the five authors for further
assessment. All authors agreed that 41 of the 69 manuscripts
did not really assess consumers’ or patients’ knowledge of
and views towards generic medicines and therefore were not
suitable for inclusion in the review. The majority of these
were largely looking at the clinical effectiveness of generic
medicines or other clinical perspectives. Thus, 28 studies
were potentially appropriate for possible inclusion in the
review. However, eight observational quantitative studies
with a relatively small sample size (less than 50) were also
eliminated. In the final review, 20 studies which satisfied the
selection criteria were included in the analysis. The quorum
flow chart for this review is shown in Figure 1.
Here we provide a narrative review of the studies
conducted during the last four decades in a chronological
order.
The 1970s
Early studies on generic drugs examined attitudes, percep-
tions of risk and knowledge of and satisfaction with generic
medications, and compared the views of consumers,
physicians and pharmacists. Most of these studies were
conducted in the United States.
The first study retrieved and included in the review was
by Lambert et al.[11] This study was done in Florida to assess
the predisposition of 510 consumers to acceptance of generic
drugs. In this study, it was observed that approximately 66%
of the respondents rejected lower-cost generic alternatives,
regardless of the amount of savings suggested. Those
rejecting generic drugs were older and had higher incomes,
and they perceived generic medicines as less effective than
did those accepting the drugs. The researchers examined the
effect of 18 variables on the predisposition towards generic
drugs and found only two variables to have significant effect.
The first was age, which showed that older respondents were
more reluctant to switch to generic alternatives. The second
was perceptions of effectiveness, with rejecters perceiving
low-priced drugs to be less effective in relieving an illness.
Bearden and Mason,[10] in a study published in 1978,
surveyed 105 consumers regarding their attitudes towards the
risks involved with the use of generic medications. As a
framework for this study, the investigators used Fishbein and
Ajzen’s theory of reasoned action, which postulated that an
individual’s attitude towards an action is based on the
summation of his or her beliefs about the consequences or
risks of the behaviour and weighted by the perceived value
of these consequences. Risks were represented by the
probability and importance of loss across six dimensions:
financial, social, drug performance, psychological, physical
and convenience. The investigators examined consumers’
beliefs about and evaluations of the quality, price, safety,
adverse effects and efficacy of generic medications, as well
as the reputations of generic drug manufacturers.
Approximately one-third of the consumers surveyed were
negatively inclined towards the use of generic drugs, one-third
were positively inclined and the remainder were neutral.
Those opposed to generic substitution perceived higher risk
levels for each of the six dimensions and considered those
risks to be more important than did those favouring generic
substitution practices. The latter believed that generic drug
products were high in quality, safe and produced by reputable
manufacturers, and that they would have the intended results.
Further analyses indicated that consumer preferences (nega-
tive, positive and neutral) regarding the purchase of generic
drugs were influenced by their concerns about drug perfor-
mance, potential financial loss and safety.
Table 1 A summary of the studies included in the review investigating consumers’ perception of generic drugs

Study Country Method Setting Number of Outcomes Limitations highlighted

participants

Lambert USA Questionnaire survey Household 510 Only two variables, i.e. age and perceptions of effectiveness, have Findings were based on expressed
et al. 1980[11] significant effects on the predisposition towards generics. intentions and not the actual purchase
behaviour.
Mason and USA Questionnaire survey Household 105 One-third of the consumers were negatively inclined toward the Generalizability was limited as
Bearden use of generic drugs; one-third were positively inclined probability sampling was not
1980[12] (remainder were neutral). employed.
Consumer’ preferences about purchase influenced by their concerns
about drug performance, potential financial loss and safety.
Bearden and USA Questionnaire survey Household 105 Overall consumers seemed supportive of generic prescribing and Generalizability was limited due
Mason substitution because they believed savings will result to them. to lack of probability sampling.
1978[10]
Shepherd USA Interview-adminis- Community 621 Frequent purchasers perceived generics as high quality, safe and Limitations not mentioned by authors.
1988 [13] tered survey pharmacies effective.
Tootelian USA Questionnaire survey College 389 Brand drugs were viewed as being more effective, having less Limitations not mentioned by authors.
et al. 1988[14] potential for adverse effects and providing greater value than
their generic counterparts.
The greater the perceived risk of the prescription drug, the greater
the respondent’s inclination to view the brand medication more
favourably.
Podulka USA Questionnaire survey Community- 100 Generic drugs were seen as equal in quality to their brand-name Limitations not mentioned by authors.
et al. 1989[15] based counterparts.
Consumers felt confident if a physician or a pharmacist
recommended a generic drug.
People were less likely to take them for chronic and serious conditions.
Perceptions of the illness was the influential variable in consumer
attitudes, not the perception of generic products.
Kendall Canada Field experiment Chain drug 295 80% of the patients accepted the offered generic substitute Limitations not mentioned by authors..
et al. 1991 [16] using prescription store prescription drug.
analysis Older patients were less likely to accept a substitute.
Rosendahl USA Questionnaire survey Community- 736 33% aged 45–65 years asked their physician and pharmacist for Limitations not mentioned by authors.
1994[17] based a generic medication.
29% aged 65 and older requested a generic drug from the
physician/pharmacist.
Muirhead USA Mailed questionnaire Nation-wide 876 29% considered generic drugs to be ‘equal’ in quality Limitations not mentioned by authors.
1994[18] survey survey to branded products.
45% considered the two types of drug to be ‘about the same’.
Lower-income patients viewed generic drugs as being lower in
quality.
Ganther and USA Mailed questionnaire Household 355 Perceptions of risks depended on the medical condition. Limitations not mentioned by authors.
Kreling survey 54% perceived generic prescription drugs to be riskiest in heart
1995[19] ailments.
14% perceived generic prescription drugs to be least risky in
streptococcal throat infections.
Financial incentives were important to the increased use of generic
products.
Momani USA Mailed questionnaire Household 303 The patient’s health plan mandated generic substitution in 51% of cases. Generalization was not possible as the
et al. 2000[20] survey Overall attitude towards generic substitution was somewhat positive. study was conducted in three states only.

(Continued)
Table 1 (Continued)

Study Country Method Setting Number of Outcomes Limitations highlighted

participants

Valles Spain A prospective 27 Public 19 Centres 99% agreed to receive a generic formulation. A low number of patients refused to
et al. 2003[21] randomized primary care (control group); Individual educational intervention with repeat prescribing change brand-name drugs to generic
multi-centre centres 8 centres with resulted in a high rate of generic acceptability. drugs.
(intervention) study 4620 subjects Duration of the study (12 months) and
(intervention the relatively low percentage of generic
group) drugs prescribed were limitations.
Bertoldi Brazil Structured Household 3182 86% showed understanding that generic drugs cost less. Limitations not mentioned by authors.
et al. 2005[22] interview- 70% showed understanding that the quality is similar to
administered survey brand-name medicines.
57% showed understanding about packaging characteristics.
Important determinants in choosing medicines were price and the
prescribed drug in the medical prescription.
Hassali Australia Semi-structured Household 16 There was a positive attitude towards generic drugs. Limitations not mentioned by authors.
et al. 2005[23] interview- Barriers to acceptance were influence from medical practitioners,
administered survey side effects and confusion with different brands.
Pereira Canada Self-administered Clinic 81 40% agreed that all generic products that Health Canada deems Limitations not mentioned by authors.
et al. 2005[24] questionnaire survey bioequivalent could be used interchangeably with their
brand-name versions.
Patients primarily had neutral views on generic warfarin, although
a minority had concerns regarding generic warfarin substitution.
Kjoenniksen Norway Mailed questionnaire Household 386 41% of patients did not allow substitution to generic medicine. Limitations not mentioned by authors.
et al. 2006[25] survey Two-thirds of those who had used them were satisfied with
generic medicines and one-third of patients who switched had
negative experiences.
Heikkila Finland Questionnaire survey Community 547 Respondents Generic substitution was a successful reform measure. Sample disparity in two geographical
et al. 2007[26] pharmacies who refused The most important reason for refusing substitution was locations as well as the response rate
generics; satisfaction with medicines used previously. of less than 50% in both geographical
213 respondents locations were indicative of weak
who accepted methodology.
generics
Figueiras Portugal Questionnaire survey Public places 1125 There were well-defined beliefs about generic drugs The study is not representative of the
et al. 2007[27] concerning their efficacy and similarity with branded drugs. whole Portuguese population as it only
Age and level of education had significant effects on beliefs covered urban residents.
about efficacy.
Iosifescu USA Interview- Tertiary care 311 Older adults with low income and low health literacy Generalizability was limited due to
et al. 2008[28] administered survey hospital mistrusted generic drugs. low recruitment rate and use of a
single institution.
Al-Gedadi Malaysia Questionnaire survey Annual 400 28% were familiar with the term generic medicine. Generalizability was limited due to
et al. 2008[29] university 64% understood that generic drugs cost less to branded ones. small sample size and non-probability
open day 32% thought generic drugs may cause more side effects. sampling technique that may have
34% had received information on generic drugs from pharmacists. caused response bias.
Consumers’ views on generic medicines Mohamed A.A. Hassali et al. 83

Titles and abstracts identified by electronic search

of all nine databases and, wherever possible, review
of the reference lists (n = 382)

Titles and abstracts not related to

consumer views on generic medicines
and duplications (n = 313)

Full text of articles retrieved for

further assessment (n = 69)

Papers not really assessing

patient/consumer views on generic drugs,
but rather largely looking at the clinical
effectiveness of generic medicines in
patient populations (n = 41)

Potentially appropriate studies for possible

inclusion in the review (n = 28)

Observational quantitative studies with

a sample size of less than 50 were
excluded from the review (n = 8)

Studies related to consumers’ perceptions of generic

drugs, and which satisfied the selection criteria,
were included in the review (n = 20)

Figure 1 Quorum flow chart of the review process.

The 1980s In a 1988 study involving 621 consumers in Austin and

To supplement the findings from their previous research,[10]
Mason and Bearden conducted another study to explore
salient issues affecting prescribing, dispensing and use of
generic medicine.[12] Consumers did not feel that they would
face greater risks if prescribing generic drugs became a
practice. Although neutral on generic substitution practices
by pharmacists, they believed that prescribing generics
would maintain a steady and continued supply of drugs.
They endorsed the idea that generic drugs would produce the
intended therapeutic effects, but showed hesitancy in
utilizing drugs produced by unknown manufacturers and
agreed that the high prices of branded drugs were due to high
expenditure on advertising to encourage physicians to
prescribe brand-name products. Overall, consumers seemed
supportive of generic drug prescribing and substitution
because they believed this would result in them saving
money. The authors concluded by emphasizing the role of
educating physicians early in their career about generic
prescribing and the viable role other health professionals,
such as pharmacists, can play in health care.
San Antonio, Texas, USA, 33% of those interviewed had
never purchased generic prescription medications.[13] Con-
sumers felt that, compared with branded drugs, generic drugs
were of lower quality, more risky, less effective and less
healthful. Yet, contrary to findings from previous studies,
individuals older than age 55 years thought that generic drugs
were of higher quality than did younger respondents.
A study conducted by Tootelian et al. in 1988,[14] which
focused on 389 college students and their perceptions of
eight types of prescription medication, found that branded
drugs were viewed as being more effective, having less
potential for adverse effects and providing greater value than
their generic counterparts. The greater the perceived risk of
the prescription drug, the greater the respondent’s inclination
to view the brand medication more favourably. Age may
have influenced the views of this group, since more than 85%
of individuals in the sample were 30 years or younger.
Furthermore, in a study of 100 consumers in the Chicago
area, published in 1989, the majority of consumers replied that
generic medications were equal in quality to their brand-name
84 International Journal of Pharmacy Practice 2009; 17: 79–88
counterparts.[15] Almost all the consumers surveyed said they
would feel confident about a generic drug if a physician or a
pharmacist recommended it. Although consumers knew what
generic drugs were, had positive experiences with them and
thought they were equal in quality to brand-name products,
they were less likely to take them for chronic and serious
conditions. The authors concluded that the influential variable
in consumers’ attitude towards generic drugs may have been
their perception of their illnesses and not that of the generic
products.
The factors that influence generic substitution, satisfac-
tion and intention to purchase generic drugs surfaced again in
a field experiment involving 295 patients who had obtained
prescriptions for one of two brand-name products at one
chain pharmacy in Vancouver, British Columbia, Canada.[16]
More than 80% of the patients offered a generic substitute for
one of the study drugs accepted it. Patients who were older,
less educated and had prescription drug coverage were less
likely to accept a substitute. Satisfaction with generic drugs
was lowest for those who had no choice in their use and did
not have to pay anything to receive the medication. Intention
to purchase another generic drug product in the future was
influenced by having recently accepted a generic substitute,
perceiving that the cost savings would be high and having to
pay some or all of the cost of the medication. As did previous
authors, Kendall et al. concluded that having pharmacists
actively promote generic drugs and having patients pay some
part of the cost of the medication would increase the rate of
generic substitution.
The 1990s
A study conducted by the American Association of Retired
Persons (AARP) and published in 1994 found that more than
84% of consumers were familiar with the term generic
drug.[17] The author of the study estimated that approxi-
mately 33% of Americans aged 45–65 years had asked their
physician for a generic medication and asked their pharma-
cist to fill a prescription with a generic medication. However,
a slightly lower proportion (29%) of those aged 65 and older
were likely to request a generic version of a drug from their
physician or pharmacist.
In 1994, a survey by Muirhead[18] examined how 876
consumers across the USA viewed managed care and generic
medications. Approximately 40% of respondents reported
that they were likely to request generic substitution. The
findings indicated that 34% of pharmacists and 36% of
physicians had initiated generic substitution on consumers’
behalf. Generic products were considered ‘equal’ in quality
to brand-name products by 29% of consumers, and 45%
indicated that the two were ‘about the same’. Patients with
lower incomes were more likely than higher-income
individuals to view generic drugs as lower in quality.
A study of consumers conducted in 1995 but published in
2000[19] rekindled the concept of risk with the use of generic
medicines. Ganther and Kreling[19] surveyed 355 adults in
central Wisconsin, USA, and found that consumers’ percep-
tions of the risks of generic prescription drugs depended on
the medical condition being treated. Study participants were
asked to assess the comparative risk associated with
purchasing a generic drug instead of a brand product for
heart problems, high blood pressure, streptococcal throat
infection, pain and cough. Respondents thought that
substituting generic prescription drugs was riskiest when
treating heart problems (54%) and least risky when treating
streptococcal throat infection (14%). Respondents also
indicated the amount of savings they would require before
they would accept a generic version of a drug instead of the
branded product. As the risk rating for the medical condition
decreased, more respondents were willing to take the generic
product for less than a US$2 cost saving. As the risk rating
increased, so did the percentage who wanted a cost savings of
more than $15 before they would buy the generic drug or
who would not buy the generic product at any cost saving.
The authors concluded that financial incentives might be
important to increasing consumers’ use of generic products.
Similar to authors of previous studies, Ganther and
Kreling[19] identified patient education by the pharmacist as
another important factor in increasing generic drug use for
medical conditions perceived by patients as high risk.
The 2000s
Momani et al.,[20] in a study published in 2000, investigated
consumer awareness of drug-management strategies (for-
mularies, drug co-payments, prior authorization and generic
substitution). This mail survey was sent to 303 members of
managed care organizations in Maryland, Pennsylvania and
West Virginia, USA. Approximately 51% of the respondents
indicated that their health plan mandated generic substitu-
tion. Consumers agreed that generic substitution affected
their compliance with medications. In addition, consumers
were neutral in regard to the following statements: ‘generic
substitution makes it more convenient to get my medicines’
and ‘generic substitution limits my chances to get the best
medicine’. Consumers agreed mildly with the statements
‘generic substitution results in less effective medicines’ and
‘generic substitutions compromises the quality of my
medicines’. Although these statements reflected a slightly
negative view towards generic substitution, when consumers
were asked a general question regarding their overall attitude
towards generic substitution, a somewhat positive response
was obtained (mean ± SD = 4.6 ± 1.99 on a seven-point
scale where 1 is negative and 7 is positive). The authors
concluded that, overall, this group of consumers held a
slightly positive attitude towards generic drugs and were
most aware of generic substitution and drug co-payments as
means to manage drug costs.
In Spain, where the implementation of drug patent
legislation was introduced in late 1997 and generic drugs
shared only 0.15% of the Spanish drug market, Valles
et al.[21] assessed patients’ acceptance of the substitution of
brand-name drugs for generic drugs for chronic conditions in
primary health care practices. A prospective randomized
multicentre study was conducted over a 12-month period in
which patients taking medications for chronic disorders
received an educational intervention on generic drugs at the
time they attended different general practices in the city of
Barcelona for repeat prescribing. Twenty-seven public
primary care centres were randomized to the intervention
group (eight centres) or the control group (19 centres). Of
4620 patients in the intervention group who received verbal
Consumers’ views on generic medicines
information and handout materials on the advantages and
disadvantages of generic equivalents and brand-name drugs,
98.9% agreed to receive a generic formulation. The primary
care centre and the class of drug were associated with
statistically significant differences in the percentage accep-
tance of generic drugs. In the overall population, generic
prescribing in the intervention practices increased to 5.9%
as compared with 2.8% in controls. Individual educational
intervention in patients with repeat prescribing resulted in a
high rate of generic acceptability.
In the context of developing countries, only one study,
which was conducted in Brazil, was retrieved.[22] In this
study, the authors estimated the proportion of generic drug
use from the total of medicines used, assessed the popula-
tion’s knowledge of generic drug characteristics and studied
the most common criteria used by consumers for purchasing
medicines. A representative household sample was selected,
making a final sample of 3182 individuals. Data were
collected using a structured interview. Interviewees were
asked about the utilization of any medicine in the previous
15 days and requested to show the packaging and prescrip-
tion, and according to these packages drugs were classified as
branded or generic. Population knowledge of generic drug
characteristics were assessed by asking the following
questions: (a) Does the generic drug cost more, the same or
less than the brand-name drug? (b) Is the quality of generic
drugs better, the same or worse than that of brand-name
drugs? (c) What does the generic drug packaging contain that
differentiates it from other drugs? Strategies for choosing
preparations when purchasing a medical prescription were
investigated for the last purchase in the previous 15 days, or
the habitual strategy for interviewees who had not purchased
medicines during that period. Interviewees were asked
whether they (a) buy (or always buy) exactly the prescribed
medicine, (b) replace (or usually replace) the prescribed drug
with the corresponding generic one, (c) replace (or usually
replace) the prescribed drug with a formulated product and
(d) replace (or usually replace) the prescribed drug with a
lower-priced alternative, regardless of whether it was a
generic, formulated or similar drug. Findings showed that the
proportion of generics in total medicines was 3.9%. While
86% knew that generic drugs cost less and 70% knew that the
quality is similar to brand-name medicines, only 57% knew
any packaging characteristics that distinguish generic
medicines from other ones. The authors concluded that the
most important determinants in choosing medicines are price
and the medical prescription, as the majority of individuals
reported buying exactly what was prescribed.
In a recent Australian study,[23] the researchers used a
qualitative approach to explore consumers’ perceptions and
opinions of generic medicines and to identify barriers to
their use of generic medicines. The researchers interviewed
16 consumers aged 22–80 years, living in the metropolitan
area of Melbourne, Australia, and using thematic content
analysis they identified four themes related to generic
medicine utilization. These were: knowledge about generics,
acceptance of generics, non-acceptance of generics and
educational needs pertaining to generics. In this study, it was
found that most patients were not familiar with the term
generic medicine but they were more familiar with the term
Mohamed A.A. Hassali et al. 85
cheaper brand of medicine. The major reason for acceptance
was cost, and the major barriers to acceptance were influence
from medical practitioners, side effects from generic brands
and confusion from using different brands. Finally, the
authors concluded that consumers generally had positive
attitudes towards the use of generic medicines and suggested
that direct patient education by the health care providers on
issues relating to safety and efficacy of generic medicines
could further enhance their uptake.
Since 2000, three generic brands of warfarin have been
approved in Canada as bioequivalent to Coumadin“ (Bristol-
Myers Squibb) and generic warfarin has been added to
provincial drug formularies. In this context, Pereira et al.[24]
investigated perceptions and attitudes towards usage and
prescribing of generic alternatives to branded warfarin.
Respondents were required to indicate their level of
agreement on a scale of 1–7 (1 being ‘strongly disagree’
and 7 being ‘strongly agree’) to 10 statements regarding their
perceptions of generic brands and, more specifically, the
safety and efficacy of the generic brands of warfarin
compared to brand-name warfarin. From 500 patients of an
anticoagulation clinic, 81 responded to the surveys. Overall,
respondents were familiar with generic brands and comfor-
table taking generic brands of drugs (42.5 and 46.9%
respectively). Of all respondents, fewer than 5% agreed or
strongly agreed that the lower cost of generic warfarin was a
good reason to take it rather than brand-name warfarin.
However, patients taking branded warfarin did not see that
low price of generic warfarin is a good incentive for its use.
Fourteen percent of respondents agreed or strongly agreed
that generic warfarin was neither as safe nor as effective as
brand-name warfarin. Additionally, 32.1% of respondents
agreed or strongly agreed that they were aware that generic
products such as warfarin must undergo bioequivalence
testing with brand-name warfarin and the same percentage
were satisfied that such testing ensured their safety. Patients
taking brand-name warfarin were less likely to agree that
generic warfarin products are as safe and as effective as
brand-name warfarin. A large percentage of patients who
completed the surveys indicated that they were unaware that
generic drugs are tested as rigorously as brand-name
warfarin. The authors concluded that the patients held neutral
views on generic warfarin, although a minority had concerns
regarding generic substitution, and an obvious lack of
awareness of bioequivalence regulations as they pertain to
warfarin.
In Norway, new pharmacy legislation implemented in
March 2001 allowed Norwegian pharmacies to switch the
medication originally prescribed to a generic medicine.
Pharmacists in Norway are obliged to inform the patient
about the cheapest available generic drug according to a list
produced by the Norwegian Medicines Agency. The patient
and/or the doctor can refuse generic substitution, but the
patient may as a result pay a higher price in some cases.
Kjoenniksen et al. conducted a study in 2006[25] to assess
patients’ attitudes towards and experiences of generic
substitution 3 years after generic substitution of prescription
medicines was permitted. A mailed questionnaire was sent to
404 patients receiving eight or more different drugs on the
fifth level in the Anatomical Therapeutic Chemical (ATC)
86 International Journal of Pharmacy Practice 2009; 17: 79–88
system, which yielded 386 usable responses. The study
showed that a high percentage of patients (41%) did not
allow their medicines to be substituted, two-thirds of the
patients who had used generic medicines were satisfied, and
about one-third of patients who switched had negative
experiences. This confirms that generic drug substitution for
a number of patients is not perceived as an equal alternative
to branded drugs, and these patients may need additional
information and support. Information about generic substitu-
tion strongly affected whether patients had switched or not,
where a combined effort from doctors and pharmacy staff
seemed to be the most effective, and this confirms that efforts
to increase generic substitutions should be targeted first and
foremost at health care practitioners.
Generic substitution was introduced in Finland at the
beginning of April 2003 with the aim of curbing the rise in
the medical expenses of society and individuals. Pharmacists
are obligated to substitute the cheapest or close to the
cheapest medicine for prescribed medicine unless the
customer refuses or the physician forbids substitution,
which the physician can do for medical or therapeutic
reasons. Heikkila et al.[26] conducted a descriptive study to
explore the opinions, attitudes and experiences that physi-
cians and customers had of this legislative reform. Custo-
mers’ views were explored using two questionnaires: the
first questionnaires were handed out in 15 pharmacies in
five geographical areas of Finland to customers (n = 544)
who had refused generic substitution, and the second in
18 pharmacies in six geographical areas to customers
(n = 214) who had accepted substituted medicines at least
once. They found that the majority of customers thought
generic substitution was a good reform measure, and the
physicians had accepted it. Generic substitution was thought
to be a good reform measure especially among customers
who had accepted it and had experience with it. Customers
who had refused substitution might have a negative prejudice
or they were careful with this reform. The savings in medical
expenses and the advice given by the pharmacists were the
main reasons for accepting substitutes. The most important
reason for refusing substitution was satisfaction with
medicines used previously. Most of them thought cheaper
medicines were as effective and safe as more expensive ones.
The authors concluded that generic substitution had been a
successful reform measure, but that some customers had been
confused and cautious, at least in the early stage, because the
situation was new to them.
In 2007, Figueiras et al.[27] conducted a cross-sectional
survey in Portugal to explore the influence of the common
illnesses influenza, asthma and angina pectoris on the level
of agreement with the prescription of generic medicines as
well as to investigate the implication of socio-demographic
factors on lay beliefs about generic medicines. The
opportunistic sample (n = 1278) was recruited from the
general population of Portugal over a 4-week period. A total
of 101 questionnaires were incomplete and 52 people
declined to participate, so the final sample was 1125
Portuguese (61% females; mean age 33 years), giving a
response rate of 88%. Participants seemed to have had
well-defined beliefs about generic drugs concerning their
efficacy and similarity with brand medicines. Beliefs about
the efficacy of generic medicines differed significantly
according to age group and level of education. Although
participants exhibited a moderate level of agreement with the
prescription of generic medicines for influenza, asthma and
angina pectoris, their agreement decreased significantly when
the illness was perceived as more serious. The overall results
indicated that participants generally believed that generic
medicines were effective and similar to their brand equivalents.
The strongest beliefs in the efficacy of generic medicines were
held by the more educated and younger participants, whereas
the strongest beliefs in the similarity of generics to their
branded equivalents were held by older participants.
Iosifescu et al. published a study in 2008[28] about the
beliefs of older adults regarding generic drugs and assessed
potential correlates of these beliefs, including socioeconomic
and health status variables, health literacy and physician
communication skills. Adults more than 65 years of age
(n = 311) were interviewed in two primary care practices of
a tertiary care hospital. Beliefs about generic drugs were
measured using a scale that compared generic and brand-
name drugs across four domains. Negative beliefs about
generics were associated with non-white race, lower levels of
education and income and having Medicaid coverage.
Individuals with low health literacy and who reported that
their physicians had poor communication skills were more
likely to hold negative views.
A recent study in Malaysia[29] explored consumer
perceptions and knowledge about the issues of generic
medicines. Survey forms were given to 400 respondents on
an annual university open day for 5 consecutive days.
Analysis of the 396 usable forms revealed that only 28.3%
respondents were aware of the term generic medicine.
Seventy per cent of the respondents were unaware of the
marketing of generic medicines with different names, and
34% of the respondents stated that information about generic
medicines was passed to them by pharmacists. Most of the
consumers (64%) showed their understanding about generics
being less costly than their branded counterparts and 32%
perceived generics to cause more side effects. This survey
showed a gap in consumer knowledge and understanding
about generic medicines; educational outreach by health care
providers can be a key to increase generic uptake.
Table 1 presents a comparison of the reviewed studies,
outlining methodologies, study setting, sample size, out-
comes and limitations.
Discussion
This review encompassed 20 studies on consumers’ views and
their perceptions of generic prescription and non-prescription
medicines. Based on the review undertaken, the majority of
the consumers have mixed reactions towards the acceptance
of generic medications. Although a positive attitude seems to
have remained fairly stable across the years, as approximately
40–60% of consumers from the studies reviewed held
favourable views about generic medications, a positive attitude
does not necessarily translate to increased use of generic drug
products. In a Florida-based study,[11] irrespective of the cost
savings, 66% of the older respondents, even those with lower
incomes, rejected lower-cost generic alternatives and cited
Consumers’ views on generic medicines
them to be less effective. The studies we reviewed indicated
several probable reasons for this discrepancy. For example,
differences were found according to the economic develop-
ment of the country, whether a developed or developing
nation. Except for two studies from Brazil[22] and Malaysia,[29]
no other studies were retrieved regarding consumers’ views
about generic medications in developing countries. In
developing countries where approximately 77% of medicine
expenditures are out of pocket,[30] low cost is an important
advantage of generic drugs.[31]
This review has managed to contribute substantial
additional information on consumers’ views about generic
medicines, depicting the diversity across different countries,
in addition to what has not been reported in the literature.[32]
The narrative review was not intended to be exhaustive,
but merely an attempt to examine the general trend of
consumers’ views towards generic medicines over time.
However, the review has a number of limitations. Most
notable was the limitation of access to databases subscribed
to by our university library; as a result, important studies
available through other databases might have been missed.
Another major drawback was that studies published in
languages other than English were excluded from the review.
This review has reaffirmed that the pharmaceutical
reimbursement system implemented in a particular country
has an effect on consumers’ use of generic drugs. If a third
party pays for the medication or if there were no differences
in co-payments between branded and generic drugs, a
branded product is preferred. Consumers tended to look
more favourably on generic medications as the difference
in co-payments increased.[32] Interestingly, two of the
studies[16,19] showed financial incentives to be strong
predictors of generic prescription drug use. Moreover, these
studies also ascertained the role of the pharmacist in patient
education for increasing generic drug use.
It is worthwhile to mention that implementation of policy
changes, such as the adoption of new legislation for drug
patenting in Spain[21] and the adoption of a policy on generic
drugs in Brazil,[22] would result in more positive views of
consumers towards generic medicines. Likewise, the findings
from the study conducted in Portugal[27] are in line with
the study of Ganther and Kreling[19] which showed less
inclination towards and acceptance of generic drugs by
patients with serious illnesses.
Furthermore, demographic and socioeconomic character-
istics of consumers have an effect on their views of generic
drug products. Among these characteristics we identified the
following: income, education level, ethnicity, age, gender and
chronicity of the medical condition. In general, individuals
with lower incomes and less education held more negative
attitudes towards, and were less knowledgeable about, generic
drugs than were those with higher incomes and more
education. Also, low-income non-white seniors mistrusted
generic medicines.[28] The influence of age was mixed.
Several studies indicated that older consumers held more
negative views, but others found that younger individuals held
more negative views. This may mean that there is a segment of
the population (young and old) that is brand-conscious and
will always view non-branded (generic) drug products with
some suspicion.
Mohamed A.A. Hassali et al. 87
In addition, drug product characteristics have important
influences on consumer views of generic drug products.
Among these characteristics are price, perceived quality,
perceived effectiveness and manufacturer reputation. Price
of generic drugs is the reason for them to be considered in the
first place and the potential savings by consumers play the
main role in the spread of generic drugs.[31] Perceived
quality, safety, effectiveness and manufacturer reputation are
proportionately related to the acceptance of generic drugs
and therefore to their increased usage.
Similarly, consultation with health care professionals
regarding generic medications seems to influence their use.
When consumers had talked with their health care profes-
sionals about a generic substitute, and these had positive
views about generic medicines, the drugs were more likely to
be accepted or used.
It was also found that past experience and knowledge of
generics, and the risks associated with them, were all
important influences on consumers’ views of generic drug
products. Several studies found that the use of generic
products (non-prescription drugs, groceries, etc.) in the past
and knowledge or awareness of generic drugs were important
influences on current or future use. Also, the more serious or
risky a consumer believed a medical condition to be, the less
likely he or she would be to choose or accept a generic drug
product for treatment.[27,32] Finally, the prescription itself has
a substantial effect on use of generic drugs, especially in
developing countries where patients seek to buy exactly what
is prescribed.[22]
Conclusions
As per our literature review, which was focused on
developed countries, consumer confidence and knowledge
about generic medicines use have increased steadily over
time. Mass education efforts, financial incentives and greater
communication between patients and health care profes-
sionals were seen as major influences on the uptake of
generics among consumers. Safety and efficacy issues were
viewed as major barriers to the acceptance of generic drug
substitutions.
The following conclusions and recommendations are
provided on the basis of our analyses of the literature
published over the past three decades related to consumers’
views of generic drugs. First, more research about con-
sumers’ views on generic drug products should be carried out
in developing countries, where cost savings are needed more
than in developed countries. This will enable us to contrast
the findings with those from the developed world and to
reach a universal view. Second, researchers should consider
further study of consumers’ decision-making processes
regarding generic medications. Third, better communication
among patients and health care professionals regarding the
equivalency between most branded and generic products
should increase the use of generic medications. Finally, mass
educational efforts should be directed by consumer and
health professional organizations and individual health care
practitioners (pharmacists, physicians, nurses and others)
towards consumers to make them more aware and to increase
their knowledge about generic medications, and to encourage
 88 International Journal of Pharmacy Practice 2009; 17: 79–88
them to take an active role in managing their medical
conditions. Educational efforts should take into account the
concerns of specific groups, such as those with low levels of
literacy, to overcome their fears or misconceptions about
generic medications.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of
interest to disclose.
Funding
This review received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Acknowledgement
This paper is dedicated to the late Mr. Nabil Abdo Al-Gedadi
who passed away peacefully in 2008. Nabil was instrumental
in devising the first version of this manuscript and his sudden
demise is a great loss for all the authors.
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