Scale development on consumer behavior toward counterfeit drugs in a developing country: a quantitative study exploiting the tools of an evolving paradigm

In recent decades, the counterfeit drugs trade has developed into a substantial threat to both public health and the pharmaceutical industry [1]. According to the World Health Organization (WHO), 60% of counterfeit drug cases occur in less-developed countries where, it is estimated, more than 25% of the drug supply is counterfeit [2]. To combat this problem effectively, it is important to recognize the differences between drug counterfeiting incentives in developing countries and in the developed world, because each requires appropriate and different solutions. In developed countries where medicines are highly accessible, consumers balance financial cost against perceived benefits in all purchases [3]. By contrast, in developing countries, where there is low access to medicines, high drug prices and counterfeiting are linked [4]. According to the WHO, an estimated one-third of the world’s population still lacks regular access to essential drugs, with this figure rising to over 50% in the poorest parts of Africa and Asia [5]. This is reflected in the fact that essential and life-saving drugs, such as antibiotic and antimalarial drugs, are the most affected by counterfeiting [6, 7]. Quite often, the quality of these counterfeits is poor, but for life-saving drugs that are not available or not affordable through the regular distribution channels, there is a desperate need-driven demand, allowing counterfeit drugs to be successfully distributed in the market despite their poor quality. Therefore, in developing countries, in order to develop more effective and successful strategies to combat counterfeit drugs, it may be advantageous to include measures targeting the demand side of the problem: this paper addresses the need for a scale to aid in understanding the demand for counterfeit drugs.

Even though the counterfeiting of products compromises quality, consumers may be willing to overlook this fact because of attitudinal and/or motivational factors. Therefore, governments and businesses must emphasize the need for more research to determine how to target these consumers and what manner of appeal to use in order to eliminate the demand for counterfeit drugs [3]. Unfortunately, while consumer research has extensively examined consumer behavior toward counterfeit luxury goods or software piracy (see, for example, Albers-Miller [8]), consumer behavior toward counterfeit drugs (CBTCD) has been largely ignored [1]. Consequently, the constructs most closely related logically to CBTCD and the measures available are those measuring consumer behavior toward counterfeit luxury goods. Despite the apparent similarities of these constructs and, in some cases, their theoretical relationship to the counterfeiting of medicines, none of these constructs captures the construct of CBTCD. Moreover, findings from previous research have suggested that consumer behavior toward counterfeits tends to be product specific [9‐11]. Addressing this gap in the theoretical literature by offering a methodological contribution—that is, a valid and reliable measure of CBTCD—would allow public health policymakers and marketing managers to understand the demand side of the problem of counterfeit drugs better. This research was carried out as a step in that direction, using the Theory of Planned Behavior (TPB) [12] as a framework model. The TPB was originally designed to predict people’s intention to buy as a secure indicator of actual purchase. According to the TPB, people act in accordance with their intentions and perceptions of control over the behavior, while intentions are influenced by attitudes toward the behavior, subjective norms, and perceptions of behavioral control [12, 13].

It should also be noted that most of the studies on consumers’ perceptions of counterfeiting have focused on consumers in the developed world and little is known about those in developing countries. If public health policymakers or marketing managers wish to measure the extent to which consumers in the developing world have a high or low tendency to acquire counterfeit drugs, they have no valid and reliable instrument to measure the trait. Moreover, an empirical study regarding the basic characteristics of consumers vulnerable to counterfeit drugs could provide an anchor for further methodological investigations into this under-studied area. This research aims to contribute to filling that gap by developing a measurement scale. Additional file 1 was developed to analyze the factors that may influence consumers in Sudan to purchase counterfeit drugs. In other words, it aims to develop a sound multidimensional measure of CBTCD in a developing country setting based on an accepted practice while exploiting the tools of an evolving paradigm.

The vast majority of previous research on drug counterfeiting has been limited in scope in that it focused on the supply side of the problem. One objective of this study was to begin to fill this gap in the literature. To this end, based on accepted methods of scale construction, this study has developed a scale to measure CBTCD in a developing country setting. After a thorough examination of the literature on product counterfeiting and consumer behavior, and based on TPB, it was assumed that consumers in Sudan may sometimes intentionally buy counterfeit drugs. Four main influencing factors were identified, namely, attitude, subjective norms, motivation, and behavioral intention. A qualitative study conducted with health policymakers and community pharmacists in two state offered some empirical support for the relevance of these factors [17]. Prospective items for use in the CBTCD scale were aggregated. The result was a pool of 69 prospective items. Seven expert judges in the areas of public health and marketing evaluated the items for face and content validity. The process produced 44 items that were judged as having both face validity and content validity. The 44 items produced from the item generation and expert judging were tested on a sample of 100 Sudanese consumers, and a principal component analysis was performed on the data. An iterative purification process produced a preliminary 11-factor structure for the CBTCD scale. These factors exhibited acceptable preliminary reliability (coefficient alpha). Item-total correlations and inter-item correlations both met recommended thresholds. Some researchers have suggested that maximizing internal consistency is a misguided approach to scale development, however; particularly because items with the highest item-total correlations often share a considerable proportion of variance so subtests containing only these items will probably not maximize variance in the original test score. Moreover, by maximizing reliability, researchers may have created a narrower measure with suppressed validity coefficients. Therefore, statistical thresholds for item retention/deletion are assumed merely to be guidelines and should not result in the deletion of items that have face and/or content validity; rather, they should be retained for the next round of the study [28]. For this reason, score-reduction decisions in the current research were made with great circumspection, and some items were retained in the scale for the next test (EFA) despite their low item-total correlations and SMCs.

The psychometric properties of the scale were assessed with a second sample of Sudanese adult consumers, and a 10-dimensional scale of 38 items was developed covering the four factors proposed by TPB (for detailed dispersion of dimensions through the factors and items through the dimensions, refer to the scale). The results showed that the items converged toward their corresponding factors and that the 10 sub-scales composing the instrument were reliable.

Prior to this research, no scale existed to measure CBTCD, which prevented empirical examination of the construct and its relationship with other consumer behavior constructs. The creation of a CBTCD measure with acceptable psychometric properties provides public health policymakers with an opportunity to examine empirically this important consumer trait. More specifically, the CBTCD scale developed and validated in this study may help researchers and public health policymakers to determine empirically the extent to which consumers favor counterfeit drugs over authentic ones under the influence of certain factors and, moreover, to identify the variables that may drive the intention to purchase counterfeit drugs. This knowledge may in turn be used to develop strategies that are more efficient in combating the demand side of the drug counterfeiting problem.

Furthermore, the theoretical development of this construct, along with the construction of an empirical measure, will allow public health policymakers and marketing managers interested in dissuading consumers from opting for counterfeit drugs to begin to understand an important consumer trait. Without the ability to understand fully the nature of individuals with this trait, it would be difficult to appeal to consumers who exhibit the tendency to purchase counterfeit drugs. Knowing what type of factors significantly affect consumers’ attitudes and motivate them to behave in a manner that favors the purchase of counterfeit drugs is the first step in enabling public health policymakers and marketing practitioners to refine their policy, marketing, and advertising strategies in order to persuade these consumers to change their behavior. With the help of the CBTCD scale, it will be possible to estimate the relative importance of each influencing factor in predicting the behavioral intention of the consumer and, consequently, to adapt strategies to combat the problem so that they are more effective. In addition, several scholars have called for systematic empirical research on the demand side of counterfeit products in general and drug counterfeiting in particular (e.g., [1, 3, 29]). The lack of empirical research in this area may have been caused, in part, by the lack of a scale to measure CBTCD. The CBTCD scale should facilitate further empirical studies into the demand side of the drug counterfeiting problem and, thus, a more refined and efficient policy to combat the problem. The CBTCD scale yields a range of scores that can be used to assess the degree of vulnerability to counterfeit drugs. According to the CBTCD scale, a score of 151 to 190 indicates low vulnerability, 81 to 150 indicates moderate vulnerability, and 38 to 80 indicates high vulnerability.

Despite its contribution, this study has limitations that should be addressed in further research. It is evident from the literature that researching the demand side of the counterfeit drug problem is more important in developing countries where high, unaffordable, drug prices and counterfeiting are linked [1]. Accordingly, the development of an instrument for the measurement of CBTCD seems especially relevant in developing countries. Nevertheless, further research is also to be encouraged in countries other than Sudan, because previous research has shown that national culture has an impact on consumer behavior toward counterfeit products [30‐32]. In addition, as is generally the case with research dealing with sensitive issues, people try to appear unselfish and more society-oriented than they actually are. There is, therefore, always the possibility of a social desirability bias, which, it could be argued, is inherent in all surveys that concern consumers’ willingness to adopt socially undesirable behaviors [33‐35]. Further research involving the CBTCD scale should therefore consider including an independent measure of social desirability, such as that developed by Crowne and Marlowe [36].

The authors propose that CBTCD be measured by the CBTCD scale developed in the current study. It is a scale of 37 items using a 5-point Likert-type response format. The results indicate that the CBTCD scale is a valid, reliable scale with a solid theoretical base. Marketing managers and public health officers could employ this scale to gain better knowledge about counterfeit drug problems in a specific market and then use this knowledge according to their particular needs.