Attitudes of Romanian Population Towards Falsified Medicines.

Analyses were conducted on media appearances about falsified medicines, focusing on reader comments. Similarly, sets of comments on the websites of medicines and supplement distributors in Romania were analyzed. These two sources, along with the analysis of international academic and grey literature in the field, formed the basis for designing a representative survey for the adult population of Romania (face-to-face questionnaires, a sample of 1200 respondents, maximum sampling error: ±2.8%).

Presence of the Topic in Public Debate

• There is at most a minor interest from the press regarding the topic of falsified medicines. Preventive elements rarely appear in the foreground, with the focus being more on penalties for suppliers/distributors of falsified medicines. The effect is a reduced quality of texts circulated in the press and a lack of engagement from online readers with content related to falsified medicines. The analysis of comments on websites that sell drugs and dietary supplements, as well as those from press articles in Romania discussing falsified medicines, leads to the conclusion that the subject is absent from public debate.

Knowledge

• SThe survey also brings many questions to which one in four or five respondents declared they did not know how to answer, indicating a lack of real contact with the discussion about falsified medicines. However, the analysis of survey data also shows that there is a strong interest from the population in the addressed topics. The expressed interest is complemented by a low number of refusals to answer questions, but also a high proportion of “don’t know” answers for most questions directly related to falsified medicines. The proportion of “don’t know” answers decreases to usual survey values when the questions do not deal with falsified medicines, while the proportion of refusals to answer rises to usual levels for questions unrelated to medicines’ falsification.
• Two-thirds of respondents claim they knew what falsified medicines were before this survey. More than two-thirds estimate that they cannot correctly identify a falsified medicine and cannot define it spontaneously. This reinforces and makes evident the need for information. Just over half of the respondents can correctly identify at least four out of six characteristics of falsified medicines. Personal interaction with drugs increases both knowledge and confusion regarding falsified medicines. This suggests that pharmacies are a good place to place communication materials.
• For knowledge about falsified medicines, the density of family doctors does not act as a favorable factor, but the volume of prescription medicines purchases does. This means that it is not enough to have a family doctor; you also need to interact with them. Therefore, for effective communication campaigns, distributing informational materials through family doctors is below the potential of distribution through pharmacies.

Information and Interaction

• The majority of respondents want to learn more about falsified medicines, indicating a promising field of potential information demand. Those who already know something about the subject want to know even more and are more likely to seek additional information. Hence, there is a need to first bring the information to the attention of those who are unaware of the existence of falsified medicines.
• Those who neither know nor want to know about falsified medicines represent approximately 8% of the population. They are generally less educated, come from localities with more family doctors per inhabitant (perhaps these doctors fulfill the need for information?), and from counties where more dietary supplements and fewer over-the-counter (OTC) drugs are sold.
• The majority of the population (72%) trusts that there is no risk of falsifying in authorized places to distribute medicines. Similar majorities expect to frequently find falsified medicines in online pharmacies (57%), on other online sites (70%), or from street vendors (74%).
• Conversely, the proportion of those who believe that falsified medicines cannot be found in physical pharmacies or can only be found there very rarely reaches 38%, with the corresponding figure being 45% for hospital pharmacies, 46% for doctors’ offices, and 48% for medicines used in hospitals. (The corresponding proportions are 11% for online pharmacies, 6% for other online sites, and 7% for street vendors; the complement to 100% in these figures is given by those who expect to “rarely” find such medicines in the mentioned places or by those who cannot formulate an answer due to lack of information).

Behaviors

• The majority of the population would not consume falsified medicines. Three-quarters of the population firmly reject this idea, and only 7-11% would willingly accept it. In Romania, approximately 7% believe that falsified medicines have fewer side effects, and 12% think they have better effects than other medicines. Three-quarters of the sample would not consume falsified medicines under any circumstances. 8-11% are predisposed to consumption, while the rest would rather not do so even in a severe situation.
• The “objective” factors that would lead to consumption (in fact, subjective representations of the current reality) are related to accumulated poverty (not current income, but the material state of the household), the desire for profit at any cost, the habit of consuming counterfeit products, the continuous presence of illness (chronic patients in the household), and the absence or scarcity of medical services in the locality.
• The attitudinal factors that generate consumption are, in order, the need for consumption (at an affordable price), the fact that it is an accepted consumption behavior by those around, followed by the representation of a reduced risk of use. Ethical considerations also play a preventive role, but to a lesser extent. All these factors, across the Romanian population, have values that prevent the consumption of falsified medicines. However, they increase for a minority of the population, which may thus be exposed to consumption regardless of their knowledge about falsified medicines.
• Negative factors are amplified by susceptibility to fake news, credulity to unapproved advice, the desire for material gain, poor material condition, low education, and high sales of dietary supplements. Conversely, high education, medical literacy, higher presence of medical service providers, direct experience of buying drugs, and medical care contribute to enhancing preventive factors.

Evaluation of System Actors and Representations about Policies to Follow

• Generalized distrust in institutions in Romania also extends to the authorities in the field. The police and NGOs are credited as legitimate organizations to combat falsified medicines, each attracting the support of 50% of the population. The government is rated at only 20%, the same as doctors and hospitals, while drug manufacturers and pharmacies are considered to have at most a minor role.
• Information and control are the key words that manage representations about the desired type of intervention. In the background, various types of fines and penalties for those distributing falsified medicines are placed. Knowledge about the presence of serialization is low and indicates a need for information on this topic.

Types of Conditions

• Attitudes and behaviors related to counterfeit drugs do not differ substantially by type of condition. One type of condition seems to pose higher risks than the population average: dermatological problems. Those who experience them are more susceptible to consuming falsified medicines and/or developing an attitude that may lead to consumption. This would be the main distinct target that requires specially designed communication for the particularities of these conditions.
• A targeted campaign by type of condition can also consider mental health conditions to increase trust in the distribution chain (both standard and online/street vendors), and cardiovascular conditions to strengthen ethical reasons for not consuming falsified medicines.