Patients’ Perception Towards Branded and Generic Medicines in an Emerging Economy: A Scale Development and Validation Study

Abstract

The study intends to develop and validate a scale to gauge the perception of patients towards branded and generic medicines in an emerging economy like India. Items were generated through literature review and exploratory semi-structured interview with patients and physicians. In the way of establishing generic medicines in the market, patients’ acceptability is very much essential. However, with the advent of information age, the patients are now becoming more conscious and aware regarding the generic medicines, and there is an improvement in the acceptability of generic medicines. Hence, the measurement of their perception towards generic medicines becomes an important issue for various stakeholders of the medical world—physicians, government, pharmaceutical companies and chemists. However, no studies regarding the measurement of perception towards the branded and generic have been conducted to develop and validate measurement scale. The present study is an attempt towards fulfilling this gap. A total of 361 valid responses were obtained using purposive sampling. Exploratory factor analysis (EFA) was carried out through principal component analysis (PCA) followed by confirmatory factor analysis (CFA) to establish the validity of the proposed measurement model. The five factors extracted from EFA were named as quality (Cronbach’s alpha: 0.887), trust (Cronbach’s alpha: 0.919), sustained effectiveness (Cronbach’s alpha: 0.832), reputation (Cronbach’s alpha: 0.881) and psychological benefits (Cronbach’s alpha: 0.737). The obtained factors were found reliable and valid for measuring perception of the patients towards generic and branded medicines in emerging market settings. Convergent and discriminant validity of the scale was also established.

Keywords

Perception branded medicine generic medicine exploratory factor analysis (EFA)confirmatory factor analysis (CFA)

Introduction

Many of the human rights organizations have voiced for right to health for all people irrespective of their capacity to pay. This demand holds more significance for population in developing economies where glaring disparities in health care still need to be addressed. Realization of better health is dependent on many factors. One such important factor is availability and affordability of medicines. Moreover, there has been mounting pressure from the government agencies directed at physician and the private and public hospital pharmacies to prescribe and ensure the availability of generic medicines. Patients are the end users of the prescribed medications; hence, it is important to understand the perceptions of the patient and their extent of willingness towards the intake of the generic medicines.

According to US Food and Drug Administration (2017), ‘A generic drug is identical—or bioequivalent—to a brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use’. In other words, generic drug are copies of brand-name product having same pharmacological effects, sold without any proprietary name.

Generic medicines are generally marketed under the non-proprietary name. 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. Generic drugs are cost-effective ways to treat common illness. Affordable and timely treatment is important to control disease and their complications. Significantly, generic medicines can effectively treat many of today’s illnesses, and their use provides the opportunity to substantially reduce costs in healthcare budgets of patients. Although branded medicines have significant influence in medicine utilization, generic drugs, being bioequivalent to their branded counterparts, are considered safe and cost-effective (Karim, Pillai, Ziqubu-Page, Cassimjee, & Morar, 1996). Generic drugs make treatment affordable for a larger section of the society. In this research work, consumer refers to a person who buys medicinal products either for personal use or for the treatment of their known one. Despite the financial benefits, there is considerable debate and discussion concerning the generic substitution (switching from a brand to generic apparently equivalent product usually within the drug class) among the patients and prescribers, with regard to its clinical outcome and safety profile.

The body of research in management, reveals that brand image is of paramount significance, and thus must be investigated from the companies’ and consumers’ perspectives. (Das, Prakash, & Khattri, 2016). Building brand image is mandatory for sustainability and survival of the companies (Bahal & Sahay, 2015). However, most of such studies have been conducted in FMCG service sector.

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 (Bearden & Mason, 1978). Patient’s willingness to accept a generic medicine is a core requirement to facilitate the uptake of generic medicines (Andersson, Sonesson, Petzold, Carlsten, & Lönnroth, 2005). Very limited number of studies have been undertaken in developing countries expect for few, like Brazil and Malaysia, to explore the consumers’ perspective towards branded and generic medicines (Al-Gedadi, Hassali, & Shafie, 2008; Bertoldi, Barros, & Hallal, 2005). Moreover, there is lack of studies that investigate Indian patients’ perceptions towards the generic medicines and branded medicines. According to Das (2007), while explaining perception, he opined that perception is influenced by the experience, value and belief systems, and this leads to possessing either the optimistic or pessimistic view.

The article is organized as follows: the first section sets the context of the need to study the perceptions of the patients towards branded and generic medicines in emerging economy. The next section examines the existing literature on gauging the consumer’s perception; the third section highlights the objectives of the study and the fourth section discusses the rationale of the study, followed by research methodology, analysis and findings, discussion and conclusion, managerial implications and limitations and scope for future study.

Literature Review

An extensive review of literature was performed for a robust theoretical background of the present study on consumer’s perception towards generic and branded medicines. Approximately 66 per cent of the respondents (majorly higher income and age group) were not concerned with price factor and rejected lower-cost generic alternatives. The rejecters viewed low-priced drugs to be less effective (Lambert, Doering, Goldstein, & McCormick, 1980). Dunne, Shannon, Dunne, and Cullen (2014) found that about one-third of patients had no knowledge of generic medicines, and about 40 per cent of them exhibited confusion between ‘generic’ and ‘genetic’. Bearden and Mason (1978) conducted research employing the Fishbein and Ajzen’s theory of reasoned action on 105 consumers to know their attitudes towards the risks associated with the use of generic medicine. Risks were perceived through importance of loss across six dimensions: financial, social, drug performance, psychological, physical and convenience. Of all the respondents surveyed, one-third had negative perceptions towards the use of generic drugs, one-third was positively inclined and the remaining were neutral. Those who held negative perception perceived higher risk levels for each of the six dimensions. Mason and Bearden (1980) repeated their study and concluded that patients were hesitant in taking medicines of unknown manufacturer but were overall supportive in favour of taking the generic medicines as this will help them in cost reduction. Contrary to this finding, Shepherd (1988) found that 33 per cent of those surveyed had never bought generic prescription medicines. The patient perceived generic drugs were of lower quality, riskier, less effective and less healthful. Similar observations were made by Tootelian, Gaedeke, and Schlacter (1988) that patients viewed branded drugs as more effective, having less potential for adverse effects and providing greater value than their generic counterparts. The respondent’s positive perception towards the branded medication was influenced by the perceived risk of the prescription drug. Positive belief is infused among the patients about the generic medicines if it is recommended to them by a physician or a pharmacist. This was evident by the study conducted by Podulka, Krautkramer, Amerson, Phillips, and Dolinsky (1989), which concluded that generic medicines were perceived to be equal in quality to their brand-name counterparts. Kendall, Ng, and Schoner (1991) in their study on patients visiting chain drug store found that 80 per cent of the patients accepted the offered generic substitute prescription drug, but the older patients were reluctant to accept generic substitute. Satisfaction level with generic medicines was the lowest among patients who were not supposed to pay for the medication. Muirhead (1994) surveyed 876 consumers and concluded that 34 per cent of pharmacists and 36 per cent of physicians had started generic substitution on consumers’ request. Generic medicines were considered ‘equal’ in quality to branded medicines by 29 per cent of respondents, and 45 per cent viewed that the two were ‘about the same’. Momani (2000), while investigating patients in the USA, found that approximately 51 per cent of the respondents indicated that their health plan mandated generic substitution. Overall, this group of patients had a slightly positive attitude towards generic medicines and were most aware of generic substitution and drug co-payments as a means to manage drug costs. Vallès et al. (2003) in their study on 4,620 subjects found that 99 per cent agreed to receive a generic formulation. Repeat educational intervention leads to higher acceptability towards generic medicines. Figueiras, Marcelino, and Cortes (2008) conducted another cross-sectional study on 1,125 consumers in Portugal to explore the impact of the common illnesses such as influenza, asthma and angina pectoris on the extent of agreement with the prescription of generic medicines by their physician as well as to explore the influence of socio-demographic profile on beliefs about generic medicines. It was observed that respondent had well-defined beliefs about generic drugs concerning their efficacy and similarity with brand medicines. Though participants were almost neutral in their opinion about their willingness with the prescription of generic medicines for influenza, asthma and angina pectoris, their agreement decreased significantly with the perceived severity of the illness. The overall results indicated that participants generally believed that generic medicines were effective and similar to their brand equivalents. Those who were educated and young held the strongest opinion about the efficacy of generic medicines, whereas the older participants strongly believed in the similarity of generics to their branded equivalents. Iosifescu et al. (2008) conducted a research to decipher beliefs of older adults of age more than 65 years towards generic medicines and assessed potential correlates of these beliefs, including socioeconomic and health status variables, health literacy and physician communication skills. The respondents were interviewed in two primary care practices of a tertiary care hospital. Beliefs about generic drugs were assessed using a scale that compared generic and brand-name drugs across four domains, namely efficacy, safety, tolerability and ease of use. Patients of non-White race origin, lower levels of education and income and having medic aid coverage held negative views about the generic medicines.

In countries like Norway, new pharmacy legislation has been implemented that permit pharmacy for generic substitution. Pharmacists should make the patient aware about the cheapest available generic drug listed by the Norwegian Medicines Agency. Kjoenniksen, Lindbaek, and Granas (2006) conducted a study in Norway to assess patients’ attitudes towards and experiences of generic substitution 3 years after generic substitution of prescription medicines was permitted. The study concluded that 41 per cent of patients were not in favour of 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 suggests that generic drug substitution for a number of patients is not viewed as an equal alternative to branded drugs. Al-Gedadi et al. (2008) found that 28 per cent were familiar with the term ‘generic medicine’. Sixty-four per cent understood that cost of generic drugs is lesser than branded ones. Thirty-two per cent thought that generic drugs may cause more side effects. Thirty-four per cent had received information on generic drugs from pharmacists. In another study conducted by Thomas and Vitry (2009) which surveyed 203 consumers in 10 pharmacies in Kuala Lumpur and Selangor, Malaysia. The findings of this study concluded that overall, 137 consumers (67.5%) did not know about generic medicines. Among the 86 consumers who had used generics before, most of them (79.0%) felt that generics worked well. Gill, Helkkula, Cobelli, and White (2010) performed a qualitative study with 15 pharmacists and 30 customers in Australia, Finland and Italy. The findings revealed that customers lacking knowledge of generic prescription medicine were confused and suspicious with generic substitutes.

Wong, Hassali, Saleem, Yahaya, and Aljadhey (2014) translated and validated (content validity) the generic medicine scale in the Malaysian context. The respondent assumed that generics have the same efficacy as brand medicines but have a considerably weaker belief in their similarity to brand medicines. The authors further argued that generic substitution may not be the problem for the patient if efficacy beliefs are stronger than similarity beliefs.

On the basis of the aforementioned review, it is realized that very few studies have been conducted to gauge the perception of the patients towards the branded and generic medicines based on valid and reliable scale. Unfortunately, no such study has been conducted in the Indian context to develop and validate a scale for measuring perception of patients towards branded and generic medicines. The present research tries to fill this gap. The framework of this study includes exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA), which are the widely accepted techniques for development and validation of scale.

Objectives of the Study

The objective of the study was to develop and validate a scale to measure the perception of patients towards branded and generic medicines in the emerging market setting with special context to India. For the fulfilment of this objective, underlying factors of consumers’ perceptions towards the branded and generic medicines are determined, and the reliability and validity of the extracted factors were ascertained through CFA.

Rationale of the Study

In the medical treatment process, physicians are the ultimate decision makers for prescription drugs (weather generic or branded). However, through the review of extant literature, patients’ perception has been found more positive towards branded medicine as compared to the generic medicines (Shepherd, 1998; Tootelian et al., 1988). Favourable perception towards the generic medicines will lead to therapy adherence and ultimately provide relief from the diseased state at a lower cost. Hence, in the way of establishing generic medicines in the market, patients’ acceptability is very much essential. However, with the advent of information age, the patients are now more conscious and aware regarding the generic medicines, and there is an improvement in the acceptability of generic medicines. Hence, the measurement of their perception towards generic medicines becomes an important issue for various stakeholders of the medical field—physicians, government, pharmaceutical companies and chemists. Though few studies have been conducted in the Western countries, but no such work exists in the Indian context. It is found from the review of extant literature that there is a lack of valid scale to measure the perceptions towards generic and branded medicines. To fulfil this purpose, the present study validates a scale that measures the patients’ perception towards the generic and branded medicines through CFA.

Moreover, the findings of this study will help the government healthcare agencies and other healthcare service providers, like hospitals and physicians, to devise and formulate awareness programmes to educate the masses about the benefits of generic medicines, thereby helping them to reduce out-of-pocket expenditures of the patients who are to a great degree not insured either from the government or from any mediclaim/health insurance companies.

Scale Development Methodology

The methodology for this study is based on Hinkin’s (1995) scale development process. According to Hinkin (1995), the first stage of scale development is the generation of items to measure the construct. The items are developed on the basis of a strong theoretical foundation and definition of the construct. This study employs both the deductive and theoretical approaches to construct a scale to measure the patient’s perception towards branded and generic medicines.

In the case of the deductive approach, an extensive review of literature has been carried out to identify the items that could be used to measure the perception.

In the case of the inductive approach, semi-structured in-depth interviews were conducted with the patient and physician to identify the factors that were considered important in influencing the perception of the patient. Fifty patients were interviewed. A pool of 14 items was developed in the interview process. The details of the research methodology are depicted in Figure A1. The details of the interview are given in the following sections.

Development and Conduction of Interview

In order to develop new items for the scale, semi-structured interviews were held with 40 patients, and 10 physicians were interviewed. The patients and physicians were informed before about the purpose of conducting semi-structured interviews. The physician was consulted at this stage because they know about their patients, and this knowledge is a result of their discussions with the patients at different contact points. The interviews were conducted face to face, with each interview being completed in approximately 45 min. From the analysis of the interviews, statements falling under five dimensions were developed. Using content analysis, those items which were mentioned more than five times were taken into consideration. The analysis of interview is depicted in Table 1.

Table 1.

Items Obtained Through Interview

S. No	Items	Frequency Count
1.	I feel emotionally secured when I consume branded medicines than generic medicines.	20
2.	If I need to suggest someone a medicine, I would suggest a branded one rather than the generic one.	10
3.	Branded medicines are less harmful than generic medicines even if taken for a longer period of time to treat the disease.	22
4.	Medicinal effects of branded medicines last for longer time period as compared to generic medicines.	24
5.	If I need to take medicines for a longer period of time in any circumstances, I would only prefer branded medicines over generic ones.	21
6.	Branded medicines are more powerful as compared to generic medicines.	26
7.	Branded medicines are widely available as compared to generic medicines.	20
8.	I am sure of getting rid of my disease when my doctor prescribes me branded medicines over the generic medicines.	27
9.	Branded medicines cure the disease more quickly as compared to generic medicines.	28
10.	My family members (reference groups) advise me to buy branded medicines rather than generic medicines.	7
11.	Branded medicines are widely available as compared to generic medicines.	10

Source: The authors.

Questionnaire Development

The survey instrument was developed on the basis of inferences drawn from the inductive (qualitative interviews) and deductive (literature review) approaches. The instrument consisted of 20 statements. Each of the items was evaluated on a five-point Likert scale, ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). All the statements are shown in Table A1.

Sampling and Data Collection

A survey was conducted from January 2016 to May 2016. The respondents were patients visiting private clinic centres in Delhi and National capital region. Subjects who met the following criteria were included in the study: (a) respondents of either gender older than 18 years and (b) respondents who could understand English. The purposive sampling technique was used in order to ensure that the respondents chosen for the study had appropriate information about the subject area of the study. The respondents were included in the survey after their verbal consent. A self-administered questionnaire was developed based on the review of extant literature and relevant discussion with consumers on generics and branded medicines. Initially, 612 patients were contacted for the survey, of which 501 agreed to be the part of the survey. A total of 361 valid and complete responses have been used for the final study as shown in Figure 1.

Expert Opinion

After obtaining the list of 20 items from the deductive and inductive approaches, it was reviewed by 5 physicians, 10 patients and 2 academicians in order to establish the content validity of the 20 items. The content validity of a construct can be defined as the degree to which the measure spans the domain of the construct’s theoretical definition (Rungtusanatham, 1998). The physicians were having more than 10 years of experience in clinical practice. The participants examined the instrument for its comprehensibility, bias and appropriateness of the items. Finally, one item was removed on the basis of suggestions provided by the panellist. The remaining 19 items were subjected to pilot testing.

Pilot Testing

Pilot testing was conducted with an aim to purify the measurement scale by checking the internal reliability of the measurement scale (Churchill, 1979). The instrument was checked for its reliability by conducting a pilot study on 23 patients. The reliability was ascertained with the help of Cronbach’s alpha. The reliability was found to be 0.81 which is above 0.7 (Nunnally, 1978). Further, an item-to-total correlation was checked. Items having value greater or equal to 0.4 are acceptable (Nunnally, 1978). After examining the item-to-total correlation, one item was found to possess value less than 0.4 and thus excluded from further analysis. The reliability was enhanced to 0.85 after excluding the item having item-to-total correlation less than 0.4.

Analysis

A series of validated tools and procedures were used to analyse the data. The steps involved in analysing the data were: assessment of the construct reliability (CR), conduction of the factor analysis and finally confirmation of the findings through a confirmatory factor analysis (CFA).

Exploratory Factor Analysis

The filled questionnaires were coded in the SPSS software package version 20. EFA was conducted on 18 items, the obtained data set for identifying latent or underlying factors from an array of seemingly important variables. Measures of sample adequacy such as Bartlett’s test of sphericity (approx. χ² = 1842.806, degree of freedom (df) = 120, significance = 0.000), indicate that co-relation matrix is significantly different from identity matrix. KMO value (0.833) showed that data were fit for factor analysis as was above the cut-off value 0.6 (Kim & Mueller, 1978). Principal component analysis (PCA) was employed along with varimax rotation. The communalities of the items were greater than 0.5. The PCA with varimax rotation was performed. The communalities of all the measures were relatively large, greater than 0.5 (Hair et al., 2006). All the communalities ranged from 0.45 to 0.88. A minimum cut-off criterion for item deletion was that of factor loadings (<0.5) (Hair et al., 2006).

Five factors were extracted explaining total variance of 73.413 per cent. The obtained factors were labelled as quality, trust, sustained effectiveness, reputation and psychological benefits as depicted in Table 2.

Table 2.

Factor Extraction Results of Perception Towards Branded and Generic Scale

Name of Dimension	Factor Loading	Co-efficient Alpha
D1. Quality
1. Branded medicines are safer than generic medicines	0.728	0.887
2. Branded medicines are more effective than generic medicines	0.890
3. Branded medicines have lesser side effects than generic medicines.	0.826
4. Branded medicines give faster results as compared to generic medicines.	0.790
5. Branded medicines are healthier than generic medicines. Branded medicines are healthier than generic medicines.	0.785
D2. Sustained effectiveness
6. Branded medicines are less harmful than generic medicines even if taken for a longer period of time to treat the disease.	0.804	0.832
7. Medicinal effects of branded medicines last for a longer time period as compared to generic medicines.	0.789
8. If I need to take a medicine for a longer period of time in any circumstances, I would only prefer branded medicines over generic ones.	0.808
9. Branded medicines are more powerful as compared to generic medicines.	0.759
D3. Trust		0.919
10. I am sure of getting rid of my disease when my doctor prescribes me branded medicines over the generic medicines.	0.931
11. I prefer to be prescribed a well-known brand by my physician than a generic brand.	0.935
12. Branded medicines cure the disease more quickly as compared to generic medicines.	0.899
D4. Reputation
13. I prefer my chemist to offer me branded medicines rather than generic medicines.	0.824	0.881
14. Branded medicines are manufactured by famous pharmaceutical company than their generic counterparts.	0.884
15. All the standard and norms are followed in the manufacturing of branded medicines as compared to generic medicines.	0.882
D5. Psychological benefits
16. I feel emotionally secured when I consume branded medicines than generic medicines.	0.884	0.737
17. If I need to suggest someone a medicine, I would suggest a branded one rather than the generic one.	0.791
18. I prefer my chemist to offer me branded medicines rather than the generic medicines.	0.737

Source: The authors.

Notes: Factor loadings should be greater than 0.5. (Hair, Anderson, Tatham, & Black, 1995). Alpha value to check the reliability should be 0.7 or higher (Nunnally, 1978). The results obtained from the analysis in the aforementioned case satisfy all these criteria.

Factor 1. Quality: The rotated matrix has revealed that respondents have perceived this factor to be the most important factor with the highest explained variance of 28.66 per cent. Five out of 18 items loaded significantly on this factor. The items under this construct reflect the components of quality such as safety, efficacy, side effects and results.

Factor 2. Sustained effectiveness: This is the next important factor, which accounts for 14.753 per cent of the variance. Four items were loaded on to this factor. This factor comprises items that highlight the long-term effectiveness of the medicine that is appropriate for long-term usage (less harmful), long-lasting medicinal effects and suitability in chronic treatment and powerful.

Factor 3. Trust: Trust has been revealed to be the third most important factor with explained variance of 11.080 per cent. Three items were loaded on to this factor. Hence, it can be concluded that trust is the second most influencing set towards influencing the consumer perception towards generic and branded medicines. The items under this construct reflect the component of trust such as surety, well known and quick.

Factor 4. Reputation: This factor explains 10.25 per cent of the total variance. Three items were loaded on this factor. The factor consists of items considering the preference of the consumer towards the branded medicines due to their perception that branded medicines are manufactured by famous companies and all standard manufacturing process guidelines are followed while manufacturing them. This factor comprises items that highlight the aspects such as preference towards branded medicine, liking for products from famous companies, following standard and norms.

Factor 5. Psychological benefits: This factor explains 8.65 per cent of the total variance. Three items were loaded on to this factor. It covers the items that comprise emotional and suggestive part of the consumers’ psychology. This factor comprises items that highlight aspects such as emotional security, informal suggestion of medicines, (branded medicines) and chemist role.

Confirmatory Factor Analysis

According to Fabrigar, Wegener, MacCallum, and Strahan (1999), CFA helps in assessing unidimensionality and allows focused testing of specific hypotheses. In the present study, CFA-based measurement model was run through AMOS 21. Under this, reliability and validity estimates along with model fit indices were ascertained.

Reliability Analysis

All constructs were found to be reliable as their individual composite reliability (CR) values are greater than the floor estimate of 0.7 (Nunnally & Bernstein, 1978) (Table 3). The construct-wise reliability was estimated. In addition, the overall reliability of the measurement model was also established by achieving a Cronbach’s alpha statistic of 0.801 (Table 4).

Table 3.

Confirmatory Factor Analysis—Average Variance Extracted and Composite Reliability

Construct	CR	AVE
Psychological benefits	0.752	0.508
Quality	0.880	0.597
Sustained effectiveness	0.828	0.547
Reputation	0.893	0.736
Trust	0.910	0.771

Source: The authors.

Table 4.

Reliability Statistics

Cronbach’s Alpha	Number of Items
0.825	18

Source: SPSS output.

Validity Analysis

Towards establishing validity of independent constructs and over all measurement model, CFA has been carried out. Three types of validity measures have been conducted, namely content validity, construct validity (comprising convergent validity and discriminant validity) and nomological validity.

Content Validity

The content validity of a construct can be defined as the degree to which the measure spans the domain of the construct’s theoretical definition (Rungtusanatham, 1998). Content validity of the instrument was established in consultation with professional domain experts and patient.

Construct Validity

This involves the assessment of the degree to which an operationalization correctly measures its targeted variables (O’Leary-Kelly & Vokurka, 1998). According to them, establishing construct validity involves the empirical assessment of unidimensionality, reliability and validity (convergent and discriminant). In the present study, in order to check unidimensionality, zero order CFA was run for all the constructs. Individual items in the model were examined to see how closely they represent the same construct. A comparative fit index (CFI) of 0.90 or above for the model implies existence of strong evidence of unidimensionality (Byrne, 1994). The CFI values obtained for the model is well above 0.90. Upon satisfaction of unidimensionality and reliability parameters, the scale was further subjected to empirical validation analysis. After the satisfactory results of unidimensionality and reliability, the scale was further empirically validated.

Convergent Validity

Convergent validity refers to the degree to which multiple methods of measuring a variable provide the same results (O’Leary-Kelly & Vokurka, 1998). Convergent validity can be established with the help of CR based on Cronbach’s alpha and average variance extracted (AVE). The following criteria must be satisfied towards ensuring convergent validity: CR > 0.7, CR > AVE and AVE > 0.5 (Hair, Black, Babin, & Anderson, 2010).

The alpha value of all the five constructs is higher than 0.7. AVE of five individual constructs was found to be greater than 0.5. Further, in case of all five individual constructs, the CR statistic is significantly greater than their respective AVE statistic (Table 3). Thus, all individual constructs satisfied the statistical conditions of convergent validity.

Discriminant Validity

According to Fornell and Larcker (1981), to establish discriminant validity, AVE should be greater than inter-construct squared correlation. The result shows that AVE values for all the constructs were observed to be greater than their corresponding square of the inter-construct correlations as depicted in Table 5.

Table 5.

Discriminant Validity Matrix

	Trust	SustainedEffectiveness	Reputation	PsychologicalBenefits	Quality
Trust	0.771
Sustainedeffectiveness	0.035	0.547
Reputation	0.058	0.447	0.736
PsychologicalBenefits	0.007	0.059	0.064	0.508
Quality	0.192	0.391	0.397	0.144	0.597

Source: The authors.

Notes: The diagonal elements are the AVE values of constructs; the off-diagonal elements are the squared inter-construct correlations.

Nomological Validity

Nomological validity refers to ascertaining logical relation between a particular model construct and items on which the same is reflected upon. The obtained measurement model has been duly checked for nomological validity in terms of construct item.

Model Fit Estimation—Measurement Model

Upon satisfaction of reliability and validity of individual constructs as well as for the overall measurement model (Figure 2), the study proceeded to determine fitness of the overall measurement model based on model fit indices generated as a part of AMOS output. Model fit is assessed on the basis of CMIN/df, p-value, comparative fit index (CFI), goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI) and root mean square error of approximation (RMSEA) (Table 6). All the fit indices were found to be satisfactory and meeting the defined criteria. Bentler (1990) recommended the following cut-off values for these indices:

CMIN/df (Normed Chi square) < 3,

AGFI > 0.80,

CFI > 0.90,

RMSEA (root mean square residual) < 0.05,

P-value (model) > 0.05 and

GFI > 0.90.

All five constructs forming the part of model reflected good results with respect to seven model fit indices comprising five goodness-of-fit and two badness-of-fit indices. This established fitness of the proposed measurement model (Table 6). Further, the indices of default model were found to have higher convergence towards the saturated model indices compared to the indices of independent model as indicated by AMOS output.

Table 6.

Model Fit Indices (measurement model)

Indices	Recommended Value	Model Fit Indices
GFI	≥0.90	0.947
P-value (model)	≥0.05	0.817
CFI	≥0.90	0.984
CMIN/df	<3	1.357
AGFI	≥0.80	0.927
RMSEA	≤0.05	0.033

Source: Compiled from AMOS output.

Conclusion

This validation study suggests that the proposed five factor model is a psychometrically robust instrument, covering the dimensions of patients’ perceptions towards the branded and generic medicines. Very limited numbers of study have been undertaken in developing countries expect for few, like Brazil and Malaysia, to explore the consumers’ perspective towards branded and generic medicines (Al-Gedadi et al., 2008; Bertoldi et al., 2005). Despite the efforts taken by the government agencies in promoting the generic medicines, the intake of generic medicines is not preferred much by the consumers. Misconception and less knowledge of patients about generic medicines might be one of the factors contributing to this scenario (Wong et al., 2014). In developing countries more than 70 per cent of medicine expenditures are out of pocket (Garg & Karan, 2009). Therefore, the availability of low-cost generic medicines will surely be an advantage for the patients (Boxtel, 2004). A scale that can measure the patient perception towards the branded and generic medicine is of paramount importance for the healthcare service providers (physician, pharmaceutical companies, hospital, etc.) and government agencies.

The scale may be used in the diagnostic studies to measure the consumers’ perception over different time periods and the results may be compared so that to know whether the consumers’ perception is changing towards generic medicines over a period of time, accordingly the strategies may be formulated. The government agencies should focus on spreading awareness regarding generic medicines in society. Further, the pharmaceutical companies have to accordingly redefine and redesign their strategies as the shift in patients’ preference towards generic medicines will be a potential threat for the well-established pharmaceutical brands. The companies then have to redirect their marketing strategies considering the ‘generic medicines’ in mind. Moreover, these findings also fortify that healthcare professionals should be aware of patients’ beliefs about medicines as their beliefs play a crucial role in decisions about treatment and may subsequently affect the adherence to the medications. The scale validated in the present study makes it convenient for healthcare professionals to measure the perception of patients regarding the branded and generic medicines and further to explore their beliefs regarding the same. Earlier, such a scale was not available to the Indian context.

Furthermore, making the patients aware about the benefits and cost effectiveness, generic medicines will be a strategic move by the governments in emerging economies. It will ensure better health at an affordable cost. It is, therefore, necessary to make the patient aware and demystify their negative views towards the generic medicines. The present research establishes the reliability and validity of the five-construct model comprising ‘Quality’, ‘Trust’, ‘Sustained Effectiveness’, ‘Reputation’ and ‘Psychological benefits’. The instrument is a valid approach of evaluating and comparing patients’ perceptions towards branded and generic types of medications.

Managerial Implication

One of the significant benefits that the generic medicine renders to the patient is that it provides the same therapeutic benefits to its user at a much lower price than its branded counterparts provide. In order to promote the generic medicines, it is necessary on the part of the government agencies and healthcare providers to spread awareness about the benefits of taking the generic medicines, as they are equivalent to their branded counterparts. The physician should enquire the patients about their cost-related concerns, as many times patients have inhibitions about discussing out-of-pocket costs with their doctors (Alexander, Casalino, Tseng, McFadden, & Meltzer, 2004). The current research showed that consumers have negative beliefs about the generic medicines. On the basis of the findings of this study, it is suggested that there is a need for educational interventions to provide the patients with adequate knowledge about generic medicines. Healthcare professionals, like physician and pharmacist, can play a very important role in spreading awareness about the benefits of generic medicines. In fact, direct education and advice from healthcare professionals are one of the most effective strategies (Hassali, Shafie, Jamshed, Ibrahim, & Awaisu, 2009; Sharrad & Hassali, 2011). The healthcare policymakers in India and other emerging economies should stress on formulating measures to build positive attitude towards generic medicines in order to lessen the exorbitant healthcare treatment cost. The government and the policymakers in India and other similar developing countries should focus on building the confidence of patients towards unbranded generic medications. The other healthcare professionals, like pharmacist and nurses, can play a significantly important role in educating the patients about the benefits of generic medicines and dislodging their misconceptions.

Limitations and Scope for Future Research

The study design and sample selection may have influenced the psychometric parameter estimates and the generalizability of results. The geographical limitations of the study could be detrimental in the generalizability of the results. Therefore, future research can be transcended to other geographical locations (Tier I and Tier II cities) and make the findings more acceptable. It was deemed that the respondent have the idea of branded and generic medicines. It is also recommended that this questionnaire be made in Hindi and other regional languages for better understanding of the pan country respondent. It will further help the healthcare policymakers to design strategies that could further enhance the uptake of generic medicines by the patients. The future scope of the study is that perception of the consumers (patient) can be studied in government hospital and can be compared along with that of patient going to private hospital.

Appendix

Table A1. List of Items Derived Through Inductive and Deductive Approach

S. No	Items	References
1	Branded medicines are safer than generic medicines.	Shepherd (1988)
2	Branded medicines are more effective than generic medicines.	Shepherd (1988)
3	Branded medicines have lesser side effects than generic medicines.	Shepherd (1988)
4	Branded medicines give faster results as compared to generic medicines.	Wong et al. (2014)
5	Branded medicines are widely available as compared to generic medicines.	Semi-structured interview
6	I am sure of getting rid of my disease when my doctor prescribes me branded medicines over the generic medicines	Semi-structured interview
7	I prefer to be prescribed a well-known brand than a generic brand.	Gill et al. (2010)
8	My family members (reference groups) advise me to buy branded medicines rather than generic medicines.	Semi-structured interview
9	Branded medicines cure the disease more quickly as compared to generic medicines.	Semi-structured interview
10	Branded medicines are less harmful than generic medicines even if taken for a longer period of time to treat the disease.	Semi-structured interview
11	Medicinal effects of branded medicines last for longer time period as compared to generic medicines.	Semi-structured interview
12	If I need to take a medicine for a longer period of time in any circumstances, I would only prefer branded medicines over generic ones.	Semi-structured interview
13	Branded medicines are more powerful as compared to generic medicines.	Semi-structured interview
14	I prefer my chemist to offer me branded medicines rather than generic medicines.	Gill et al. (2010)
15	Branded medicines are manufactured by famous pharmaceutical company than their generic counterparts.	Thomas and Vitry (2009)
16	All the standard and norms are followed in the manufacturing of branded medicines as compared to generic medicines.	Wong et al. (2014)
17	I feel emotionally secured when I consume branded medicines than generic medicines.	Semi-structured interview
18	If I need to suggest someone a medicine, I would suggest a branded one rather than the generic one.	Semi-structured interview
19	I prefer my chemist to offer me branded medicines rather than the generic medicines.	Semi-structured interview

Source: The authors.

Footnotes

Acknowledgement

The authors are grateful to the anonymous referees of the journal for their extremely useful suggestions to improve the quality of the article. Usual disclaimers apply.

Declaration of Conflicting Interests

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

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

References

Al-Gedadi

N. A.

Hassali

M. A.

Shafie

A. A.

(2008). A pilot survey on perceptions and knowledge of generic medicines among consumers in Penang. Pharmacy Practice , 6(2), 93–97.

Alexander

G. C.

Casalino

L. P.

Tseng

C.-W.

McFadden

Meltzer

D. O.

(2004). Barriers to patient-physician communication about out-of-pocket costs. Journal of General Internal Medicine , 19(8), 856–860. Retrieved from http://doi.org/10.1111/j.1525-1497.2004.30249.x

Andersson

Sonesson

Petzold

Carlsten

Lönnroth

(2005). What are the obstacles to generic substitution? An assessment of the behaviour of prescribers, patients and pharmacies during the first year of generic substitution in Sweden. Pharmacoepidemiology and Drug Safety , 14(5), 341–348. Retrieved from http://doi.org/10.1002/pds.1055

Bahal

Sahay

(2015). Promoting oral health in rural India: The case of Pepsodent. Global Business Review , 16(3), 524–536.

Bearden

W. O.

Mason

J. B.

(1978). Consumer-perceived risk and attitudes toward generically prescribed drugs. Journal of Applied Psychology , 63(6), 741–746. Retrieved from http://doi.org/10.1037/0021-9010.63.6.741

Bentler

P. M.

(1990). Comparative fit indexes in structural models. Psychological Bulletin , 107(2), 238–246. Retrieved from http://doi.org/10.1037/0033-2909.107.2.238

Bertoldi

A. D.

Barros

A. J. D.

Hallal

P. C.

(2005). Generic drugs in Brazil: Known by many, used by few. Cadernos de Saúde Pública , 21(6), 1808–1815. Retrieved from http://doi.org/10.1590/S0102-311X2005000600029

Byrne

B. M.

(1994). Structural equation modeling with EQS and EQS/Windows: Basic concepts, applications, and programming . Thousand Oaks, CA: SAGE Publications.

Churchill Jr

G. A.

(1979). A paradigm for developing better measures of marketing constructs. Journal of Marketing Research , 16(1), 64–73.

10.

Das

G. S.

(2007). Student perception of globalization: Results from a survey. Global Business Review , 8(1), 1–11. Retrieved from http://doi.org/10.1177/097215090600800101

11.

Das

J. K.

Prakash

Khattri

(2016). Brand image mapping: A study on bathing soaps. Global Business Review , 17(4), 870–885.

12.

Dunne

Shannon

Dunne

Cullen

(2014). Patient perceptions of generic medicines: A mixed-methods study. The Patient—Patient-Centered Outcomes Research , 7(2), 177–185. Retrieved from http://doi.org/10.1007/s40271-013-0042-z

13.

Fabrigar

L. R.

Wegener

D. T.

MacCallum

R. C.

Strahan

E. J.

(1999). Evaluating the use of exploratory factor analysis in psychological research. Psychological Methods , 4(3), 272–299. Retrieved from http://doi.org/10.1037/1082-989X.4.3.272

14.

Figueiras

M. J.

Marcelino

Cortes

M. A.

(2008). People’s views on the level of agreement of generic medicines for different illnesses. Pharmacy World & Science , 30(5), 590–594. Retrieved from http://doi.org/10.1007/s11096-008-9247-y

15.

Fornell

Larcker

D. F.

(1981). Structural equation models with unobservable variables and measurement error: Algebra and statistics. Journal of Marketing Research , 18(3), 382–388.

16.

Garg

C. C.

Karan

A. K.

(2009). Reducing out-of-pocket expenditures to reduce poverty: A disaggregated analysis at rural-urban and state level in India. Health Policy and Planning , 24(2), 116–28. Retrieved from http://doi.org/10.1093/heapol/czn046

17.

Gill

Helkkula

Cobelli

White

(2010). How do customers and pharmacists experience generic substitution? International Journal of Pharmaceutical and Healthcare Marketing , 4(4), 375–395. Retrieved from http://doi.org/10.1108/17506121011095218

18.

Hair

J. F.

Anderson

R. E.

Tatham

R. L.

Black

W. C.

(1995). Multivariate data analysis (4th ed.). Englewood Cliffs, NJ: Prentice Hall.

19.

Hair

J. F.

Black

W. C.

Babin

B. J.

Anderson

R. E.

(2010). Multivariate data analysis (7th ed.). Prentice Hall. Retrieved from http://library.wur.nl/WebQuery/clc/1809603

20.

Hair

J. J.

Black

W. C.

Babin

B. J.

Anderson

R. T.

Tatham

R. L.

(2006). Multivariate data analysis (6th ed.). Upper Saddle River: Prentice Hall.

21.

Hassali

M. A. A.

Shafie

A. A.

Jamshed

Ibrahim

M. I. M.

Awaisu

(2009). Consumers’ views on generic medicines: A review of the literature. International Journal of Pharmacy Practice , 17(2), 79–88. Retrieved from http://doi.org/10.1211/ijpp.17.02.0002

22.

Hinkin

T. R.

(1995). A review of scale development practices in the study of organizations. Journal of Management , 21(5), 967–988. Retrieved from http://doi.org/10.1177/014920639502100509

23.

Iosifescu

Halm

E. A.

McGinn

Siu

A. L.

Federman

A. D.

Federman

A. D.

… Ubel

P. A.

(2008). Beliefs about generic drugs among elderly adults in hospital-based primary care practices. Patient Education and Counseling , 73(2), 377–383. Retrieved from http://doi.org/10.1016/j.pec.2008.07.012

24.

Karim

S. A.

Pillai

Ziqubu-Page

Cassimjee

Morar

(1996). Potential savings from generic prescribing and generic substitution in South Africa. Health Policy and Planning , 11(2), 198–202. Retrieved from http://doi.org/10.1093/heapol/11.2.198

25.

Kendall

K. W.

Schoner

(1991). Consumer response to generic/chemically equivalent drugs on JSTOR. Journal of Public Policy & Marketing , 10(2), 182–201. Retrieved from http://www.jstor.org/stable/30000243?seq=1#page_scan_tab_contents

26.

Kim

J. O.

Mueller

C. W.

(1978). Factor analysis : Statistical methods and practical issues . Beverly Hills, CA: SAGE Publications.

27.

Kjoenniksen

Lindbaek

Granas

A. G.

(2006). Patients’ attitudes towards and experiences of generic drug substitution in Norway. Pharmacy World & Science , 28(5), 284–289. Retrieved from http://doi.org/10.1007/s11096-006-9043-5

28.

Lambert

Z. V.

Doering

P. L.

Goldstein

McCormick

W. C.

(1980). Predispositions toward generic drug acceptance. Journal of Consumer Research , 7(1), 14. Retrieved from http://doi.org/10.1086/208788

29.

Mason

B. J.

Bearden

W. O.

(1980). Generic drugs: Consumer, pharmacist and physician perceptions of the issues on JSTOR. The Journal of Consumer Affairs , 14(1), 193–206. Retrieved from http://www.jstor.org/stable/23860334?seq=1#

30.

Momani

(2000). Drug-management strategies: Consumers’ perspectives. Journal of Managed Care Pharmacy , 6(2), 122–128. Retrieved from http://doi.org/10.18553/jmcp.2000.6.2.122

31.

Muirhead

(1994). How consumer see managed care. Drug Topics , 138(10), 40–54.

32.

Nunnally

J. C.

(1978). Psychometric theory . New York, NY: Mac Graw-Hill.

33.

Nunnally

Bernstein

(1978). Psychometric theory (1st ed.). New-York: MacGraw -Hill.

34.

O’Leary-Kelly

S. W.

Vokurka

J. R.

(1998). The empirical assessment of construct validity. Journal of Operations Management , 16(4), 387–405. Retrieved from http://doi.org/10.1016/S0272-6963(98)00020-5

35.

Podulka

Krautkramer

Amerson

Phillips

Dolinsky

(1989). Consumers’ attitudes toward generic drugs. Journal of Pharmaceutical Marketing & Management , 4(1), 93–104. Retrieved from http://doi.org/10.3109/J058v04n01_06

36.

Rungtusanatham

(1998). Let’s not overlook content validity. Decision Line , 29(4), 10–13.

37.

Sharrad

A. K.

Hassali

M. A.

(2011). Consumer perception on generic medicines in Basrah, Iraq: Preliminary findings from a qualitative study. Research in Social and Administrative Pharmacy , 7(1), 108–112. Retrieved from http://doi.org/10.1016/j.sapharm.2009.12.003

38.

Shepherd

M. D.

(1988). Consumer drug purchases are based on perceptions of quality, survey on generics finds. American Journal of Hospital Pharmacy , 45, 1245.

39.

Shepherd

M. D.

(1988). Consumer drug purchases are based on perceptions of quality, survey on generics finds. Am J Hosp Pharm , 45, 1245.

40.

Thomas

Vitry

(2009). Consumers’ perception of generic medicines in community pharmacies in Malaysia. Southern Med Review , 2(2), 20–23.

41.

Tootelian

D. H.

Gaedeke

R. M.

Schlacter

(1988). Branded versus generic prescription drugs: Perceptions of risk, efficacy, safety, and value. Journal of Health Care Marketing , 8(3), 26–29.

42.

US Food and Drug Administration (USFDA). (2017). A generic drug is identical–or bioequivalent–to a brand name drug in dosage form . USFDA. Retrieved from https://www.fda.gov/home

43.

Vallès

Barreiro

Cereza

Ferro

J.-J.

Martínez

M.-J.

Escribà

J.-M.

… Davey

P. G.

(2003). A prospective multicenter study of the effect of patient education on acceptability of generic prescribing in general practice. Health Policy , 65(3), 269–275. Retrieved from http://doi.org/10.1016/S0168-8510(03)00018-6

44.

Van Boxtel

C. J.

(2004). Some safety aspects of generic prescribing. International Journal of Risk & Safety in Medicine , 16(3), 191–194.

45.

Wong

Z. Y.

Hassali

M. A.

Saleem

Yahaya

A. H.

Aljadhey

(2014). Translation and validation of the Malaysian version of generic medicines scale. Journal of Medical Marketing: Device, Diagnostic and Pharmaceutical Marketing , 14(1), 32–40.