Original Paper

Journal of Generic Medicines

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Exploring the knowledge and attitude of ! The Author(s) 2017

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medical and pharmacy students about DOI: 10.1177/1741134317748344
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generic medicine in Lahore, Pakistan

Usama Asif1, Zikria Saleem1, Mahrukh Yousaf1, Hamid Saeed1,

Furqan Khurshid Hashmi1 and Mohamed Azmi Hassali2

Abstract
Background: The age of out-of-pocket health-care expenditures demands the practice of generic medicine.
Our objective was to evaluate the knowledge and attitude about generic medicine among medical and
pharmacy students of Lahore, Pakistan.
Methods: A cross-sectional study was performed among calculated sample size (via online Raosoft calcula-
tor) of 295 students including 185 pharmacy and 110 medical students from third, fourth, and final year of
studies using convenient sampling approach. A pre-validated questionnaire was used to assess the know-
ledge of students regarding generic medicine. Data were analyzed using SPSS version 20.
Results: We found that a majority of both pharmacy and medical students were aware of the meaning of brand
and generic medicine where 86 (29.7%) students believed that generic medicine is bioequivalent to brand name
product and 108 (36.5%) students agreed that cost burden will be reduced with the use of generics. There were
concerns about quality (P  0.05) and side effects (P  0.005) of generic medicine as compared to brands.
Significant associations were found between the knowledge of medical and pharmacy students (P  0.005).
Conclusion: Educational interventions and policies regarding generic medicine practices are strongly needed
to overcome the knowledge deficits among pharmacy and medical students.

Keywords
Generic, brand, health care, practices, knowledge

Introduction
In the age of rising health-care expenditures, high cost
of brand name medicine remains to be a barrier to
medication adherence and cannot be neglected.1
Generic substitution serves as an important mean to
lessen the high cost associated with prescription/brand
name drugs.2 Generic medicines are approved to be
bioequivalent to brand name drugs in terms of safety,
strength and quality by the US Food and Drug
Administration.3 Same clinical outcome can be
achieved with the use of generic medicine as that of
brand name medicine at low cost, cutting down the
socioeconomic pressure and health-care burden from
the community.4 Generic drug use plays a major role
in effective implementation of financial savings, and the
practice of generic substitution is common in many
countries.5 Despite the continuous efforts by health-
care policy makers to uplift the use of generic medicine,
it is still under-utilized by the majority.6 Patients usually
feel insecure about switching their prescription drug to
a cost-effective generic alternative and seek more
information regarding medicine substitution.7 It is
also seen that physicians tend to prescribe brand
name medicine even when a safe and cost-effective sub-
stitute is available.8 Although the use of generics is
accepted by general physicians, they still hesitate to
practise generic prescribing due to safety and reliability
concerns. Moreover, the bonuses offered by pharma-
ceutical companies and patient factors affect the pre-
scribing trends of the physician.9 Much emphasis
towards generic prescribing is made on the physician
1
Department of Pharmacy Practice, University College of
Pharmacy, University of the Punjab, Lahore, Pakistan
2
Discipline of Social & Administrative Pharmacy, School of
Pharmaceutical Sciences, Universiti Sains Malaysia, Penang,
Malaysia
Corresponding author:
Zikria Saleem, Section of Pharmacy Practice, University College of
Pharmacy, University of the Punjab, Allama Iqbal Campus, 54000
Lahore, Pakistan.
Email: zikria.pharmacy@pu.edu.pk
2 Journal of Generic Medicines 0(0)
by health-care system, but a debate about the miscon-
ceptions of safety and efficacy remains.10 Self-con-
sciousness to prescribe from local drug manufacturers
and incentive schemes as well as pressure from medical
representatives contribute to malpractice of brand drug
prescribing in Pakistan.11 A study conducted in
Peshawar, Pakistan, shows that high number of pre-
scription drugs had brand names indicating partial
knowledge on behalf of prescribers.12 Implementation
of policies to promote generic prescribing and opting
ways to minimize increased health-care burden in terms
of high cost is mandatory to curtail poor medication
adherence and economic pressure from the commu-
nity.13 Pharmacy and medical students are future care-
taker of drugs and they are supposed to have
appreciable and sound knowledge about medicine.
Therefore, it is important to incorporate the subject
of generic medicine in their study curricula which in
turn would positively influence their future practice as
qualified pharmacists and doctors.14 A study in
Bangladesh indicated the gaps in the knowledge of
pharmacy and medical students that may affect their
role as health-care professional and need to be
addressed with effective implementation of educational
interventions.15 It is therefore essential to improve and
update the knowledge of future health-care practi-
tioners and promote the notion of generic drugs
among them to rationalize and optimize the drug use
in the community. To the best of our knowledge, no
studies regarding assessment of knowledge and attitude
about generic medicine among medical and pharmacy
students has been conducted in Lahore, Pakistan.
Therefore, this study targeted to investigate the know-
ledge and attitude of future health-care practitioners
about generic medicine, which would provide a plat-
form for health-care officials and institutions to realize
the importance of inculcating the concept of generic
medicine in the community.
Material and methods
Study design
A cross-sectional survey-based study was conducted
from March to June 2017 among pharmacy and med-
ical students from three government institutions, that
is, University of the Punjab, King Edward Medical
University and Ameer-ud-din Medical College and
one private institute, that is, University of Lahore
from Lahore, Pakistan.
Study participants
A convenient sampling approach was applied. The
total population size was 1250, and sample size
of 295 was calculated using online calculator Raosoft
with 95% confidence interval and 5% margin of error.
Reasonable knowledge and sound information back-
ground is expected from students during higher years
of their study; therefore, we included students from
third, fourth and final years to analyze their percep-
tions about generic and brand medicines. Current
admissions (first- and second-year students) were
excluded from the study.
Data collection
A pre-validated questionnaire was used as a study tool
to assess the knowledge and perception about generic
medicine among pharmacy and medical students.16
The questionnaire was divided into three major por-
tions: (a) demographics of the study population, (b)
perception of respondents about generic and brand
name medicine and (c) this part contained 11 ques-
tions to investigate the knowledge and attitude of
respondents towards generic substitution. The ques-
tions in this part were framed in five-point Likert
scale format comprising five points from strongly dis-
agree (i.e. point 1) to strongly agree (i.e. point 5).17
Data analysis
Data analysis was done using statistical package for
social sciences (SPSS version 20.0). Non-parametric
chi-square test was applied to see the association
among variables. Simple frequencies and cross tabula-
tion was performed to study characteristics of the
respondents. P value greater than 0.05 was considered
as non-significant.
Results
A total of 295 students participated in the study with
185 pharmacy and 110 medical students. Majority of
pharmacy (84.3%) and medical (95.5%) students
were 18–22 years of age and more than half of medical
students (53.6%) were enrolled in third year of study
with a good number of pharmacy students from fourth
year. A majority of both pharmacy and medical stu-
dents were aware of generic and branded medicine as
shown in Table 1.
Data suggest that majority of pharmacy and med-
ical students had correct knowledge about what a gen-
eric and brand medicine means as indicated in Table 2.
Further, we analyzed the knowledge of participants by
asking questions related to generic and brand name
medicine. Table 3 depicts the response of the students
and their views regarding generic medicine, its cost as
well as quality. Out of the total number of respondents
(n ¼ 295), only 86 agreed that a generic medicine is
Asif et al. 3

bioequivalent to a brand name medicine whereas 100 preference of brand over generic medicine. Contrary
(33.8%) were of the view that brand name medicines to this, 98 (33.1%) students agreed to the statement.
are safe as compared to generic medicine. Moreover, And 35.1% were against the view that due to low qual-
100 students strongly agreed about the reliability of ity, generics are available at low cost. Furthermore, on
medicine from a multinational than national firms. one hand, students believed that generics produce
A total of 84 students were neutral about the more side effects as compared to brand medicine and
almost equal number of students were of the opposite
view. Moreover, 108 students believed that cost will be
less if generics are preferred yielding significant asso-
Table 1. Demographic characteristics of the respondents ciations among pharmacy and non-pharmacy students
(P  0.005).
Pharmacy Medical
Table 3 signifies that significant associations were
Parameters N (%) N (%) present for the response of almost all the statements
about generic medicine between medical and phar-
Age (years) macy students (P  0.005) as well as the year of
18–22 156 (84.3) 105 (95.5)
study (P  0.005).
23–27 29 (15.7) 5 (4.5)
Gender
Male 55 (29.7) 44 (40) Discussion
Female 130 (70.3) 66 (60) In our study, results indicated that a majority of both
Year of study pharmacy and medical students were aware of the def-
Third 61 (33) 59 (53.6) initions of brand and generic medicine. A study from
Fourth 66 (35.7) 51 (46.4) Karachi, Pakistan, indicates that pharmacist have
Final 58 (31.4) 0 (0) sound knowledge of generic medicine, and their 24-h
Type of scholar availability at the pharmacies could improve the per-
Day 118 (63.8) 40 (36.4) ception of patient as well as other health-care practi-
Hostelite 67 (36.2) 70 (63.6) tioners such as doctors regarding generic medicine.18
Household income However, 88 students disagreed and 77 students were
Less than 20,000 PKR 41 (22.2) 15 (13.6) neutral about the statement that generic medicine is
Above 20,000 PKR 144 (77.8) 95 (86.4) bioequivalent to brand name medicine. Despite the
Area of residence approval of bioequivalence studies for World Health
Rural 31 (16.8) 10 (9.1) Organization, the controversy for bioequivalence stu-
Urban 154 (83.2) 100 (90.9) dies of generic versus brand name medicine con-
Have you ever heard of branded medicine tinues.19 We found that both pharmacy and medical
Yes 166 (89.7) 90 (81.8) students agreed that the use of generics has the cap-
No 19 (10.3) 20 (18.2) acity to reduce pharmaceutical expenses as compared
Have you ever heard of generic medicine to high-priced brand name medicines. Several prior
Yes 171 (92.4) 88 (80) studies indicated that generic substitution is an effect-
No 14 (7.6) 22 (20) ive tool to reduce the cost associated with health care
in the community.20,21 Barriers to poor practice of

Table 2. Response of participants about definition of generic and brand medicine

Statement about generic and branded Generic Branded

medicine Groups medicine % medicine %

A drug that is produced and distributed without Pharmacy 148 80.0 37 20.0
patent protection. The generic drug may still Medical 90 81.8 20 18.2
have a patent on the formulation but not on
the active ingredients.
A drug that is the property of the company that Pharmacy 38 20.5 147 79.5
manufactures it through research and Medical 24 21.8 86 78.2
development and markets it under a patent.
No other companies are allowed to produce it
until the patent expires.
4 Journal of Generic Medicines 0(0)

Table 3. Students’ knowledge and perception of generic medicine

Response of participants 2 test P value

Strongly Strongly Study Year of

Statements disagree Disagree Neutral Agree agree Age Gender groups study Residence

A generic medicine is bioequiva- 17 (5.7) 88 (29.7) 72 (24.3) 86 (29.1) 32 (10.8) 0.098 0.014 0.000 0.000 0.237
lent to a brand-name
medicine.
Generic products of a particular 15 (5.1) 90 (30.4) 68 (23.0) 103 (34.8) 19 (6.4) 0.292 0.004 0.000 0.000 0.218
medicine are therapeutically
equivalent to the innovator
branded product.
Branded medicines are safer than 54 (18.2) 33 (11.1) 64 (21.6) 100 (33.8) 44 (14.9) 0.465 0.007 0.000 0.000 0.059
generic medicines because
they have been tested through
bioequivalence studies.
Generic medicines are in the 56 (18.9) 74 (25.0) 61 (20.6) 74 (25.0) 30 (10.1) 0.290 0.011 0.000 0.000 0.068
same dosage form (e.g. Tablet,
Capsule) as the brand-name
medicine.
Medicines manufactured by 16 (5.4) 32 (10.8) 61 (20.6) 86 (29.1) 100 (33.8) 0.246 0.024 0.000 0.040 0.495
multinational companies are
more reliable than those
manufactured by national
firms.
Branded medicines should be 19 (6.4) 46 (15.5) 84 (28.4) 98 (33.1) 48 (16.2) 0.278 0.210 0.005 0.001 0.449
preferred over generic medi-
cine in life-threatening
conditions.
When buying generic medicine, 15 (5.1) 65 (22.0) 55 (18.6) 110 (37.2) 50 (16.9) 0.268 0.196 0.001 0.000 0.671
the safety, effectiveness and
quality of generic medicine is
my major concern.
Generic medicines are of inferior 32 (10.8) 104 (35.1) 76 (25.7) 65 (22.0) 18 (6.1) 0.176 0.006 0.033 0.000 0.338
quality to brand-name drugs:
that why they are less
expensive.
Generic medicines produce more 30 (10.1) 81 (27.4) 95 (32.1) 80 (27.0) 9 (3.0) 0.820 0.015 0.000 0.000 0.114
side effects than brand-name
medicines.
Brand-name medicines are 19 (6.4) 58 (19.6) 72 (24.3) 99 (33.4) 47 (15.9) 0.421 0.176 0.000 0.000 0.519
required to meet higher safety
standards than generic
medicines.
Cost of treatment will be less if 8 (2.7) 31 (10.5) 96 (32.4) 108 (36.5) 52 (17.6) 0.670 0.193 0.004 0.000 0.176
generic medicines are used.

generic substitution may involve lack of generic substi-
tution regulation, obscure system of medicine supply
and distribution and lack of awareness and marketing
regarding generic medicine.22 Further, poor confi-
dence level on behalf of prescribers, inferior feeling
of getting medicine at low cost from the patient and
lack of incentive schemes on generic prescribing and
substitution to health-care professionals such as
pharmacists and physicians are the factors leading to
discouraged use of generic medicine.23 Our study indi-
cated that a number of students (n ¼ 65) had a view
that generics are of inferior quality as compared to
brand name medicine. A study conducted in India
says that generics are similar in quality to the brand
name medicine, but there is a strong need to perform
and publicize the quality control testing to improve
awareness among the concerned officials.24
Educational interventions, allocation of financial
sources and good patient–health-care professional
communication can create a positive impact of generic
medicine in patients’ mind. And appropriate commu-
nication between the health-care professionals such as
Asif et al.
doctors, pharmacists and nurses enhance the exchange
of knowledge and may improve generic prescribing
habits. According to a study, it is noticed that patients
prefer to purchase exactly the same medicine as writ-
ten on the prescription. Updated information on gen-
erics at educational level would help future
pharmacists and physicians to practise generic pre-
scribing without hesitancy so that patients may not
feel insecure in getting medicine suitable with their
family incomes.25 In United Kingdom, 83% generic
practices are followed, highest throughout the world,
and main driver behind the practice might be the edu-
cation given in schools and hospitals to the students
and trainees who afterwards are better able to play
their role as a practitioner to serve the community.26
Educational sessions and knowledge provided at edu-
cational level can boost up the confidence of pre-
scribers in the future to promote generic prescribing
habits.27 Addition of generic medicine information in
syllabi of medical and pharmacy students as well as
training on technical and communication skills can
develop professionalism and confidence to practise
generic medicine without any doubts.28 Our study
indicated significant associations between perception
and knowledge of medical and pharmacy students
(P  0.005), but still deficits were observed among
the level of knowledge in both groups. A study in
Australia found that concepts of generic were not so
good among the students belonging to health care that
need to be looked at to overcome cost burden and
improve medication adherence among the public.29
Effective educational sessions are needed to augment
the knowledge of future health-care practitioners.30
Conclusion
The current study identifies that adequate knowledge
regarding generic medicine is required among medical
and pharmacy students. The matter of generic medi-
cine cost and quality need to be focused. Educational
interventions and development of policies by health-
care government officials can improve the practice of
generic medicine.
Study limitations
The study had few limitations. The study was con-
ducted in four institutes of with a sample size of 295
that is not enough to generalize perceptions of all the
students of Lahore, Pakistan.
Author contributions
ZS, HS and FKH designed the experiment. MY, UA and ZS
performed the study. UA statistically analyzed the data. MY
and UA wrote the paper. MAH critically revised the
5
manuscript. All the authors critically revised the final manu-
script and made amendments where necessary.
Acknowledgment
The authors are extremely thankful to the university students
for their participation and precious time.
Data availability statement
The data sets used/analyzed in the study could be available
from corresponding author (zikria.pharmacy@pu.edu.pk)
upon reasonable request.
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.
Ethical approval
The research protocol for the study was approved by the
ethical committee of University College of Pharmacy,
University of the Punjab, Lahore, Pakistan, under the refer-
ence number (HEC/UCP/0942/2017). Informed written
and verbal consent was taken from the participants prior to
initiation of the study.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author biographies
Usama Asif is a registered Pharmacist from Punjab
Pharmacy Council. He is a pharmacy graduate
(2015) from University of the Punjab and is currently
enrolled in M Phil (Pharmacy), session 2016–2018,
from the same institute. His research interests include
pharmacy practice, clinical pharmacology, social phar-
macy and public health.
Zikria Saleem is working as Lecturer – Pharmacy
Practice at PU. He is doing his PhD from School of
Pharmaceutical Sciences, Universiti Sains Malaysia on
Antimicrobial Stewardship and conducted his M Phil
research work at Shaukat Khanam Cancer Hospital &
Research Centre on Safety of Chemotherapy. He
supervised clinical research projects of more than 25
MPhil students. He is also doing his job as the coordi-
nator of Clinical training programme of Pharm.D
students. His topics of research interest are pharma-
coeconomics, infectious diseases and antimicrobial
resistance.
Mahrukh Yousaf is a registered Pharmacist from
Punjab Pharmacy Council. She is a pharmacy gradu-
ate (2015) from University of Punjab and is currently
enrolled in M Phil (Pharmacy), session 2016–2018,
from the same institute. Her current research interests
include pharmacy practice, therapeutics, social phar-
macy and public health.
Hamid Saeed is working as Assistant Professor,
Department of Pharmacy Practice, University of the
Punjab, Lahore, Pakistan. He has done his PhD from
Denmark and post doctorate from Stanford
University, USA. He has supervised many research
projects related to the field of pharmacy practice. He
has several high impact factor publications in
renowned national and international Journals.
Asif et al.
Furqan Khurshid Hashmi is currently working as
Assistant Professor, Department of Pharmacy
Practice, University of the Punjab, Lahore, Pakistan.
He has done his PhD from School of Pharmaceutical
Sciences, Universiti Sains Malaysia. He has extensively
worked in the area of pharmacy practice. His research
interests include pharmacy practice, extended phar-
macy services and patient compliance.
7
Mohamed Azmi Hassali is a Professor at School of
Pharmaceutical Sciences, Universiti Sains Malaysia.
His research expertise include quantitative and quali-
tative aspects of quality use of medicine in society and
evaluation of Pharmaceutical & Pharmacy workforce
policy. He has extensively worked in the field of social
and administrative pharmacy and has many publica-
tions with more than 3000 citations.