This cross-sectional study was carried out in Doha area, the capital city of Qatar between October 2014 and December 2014. The study was approved by the Qatar University IRB. The sample included 190 respondents selected conveniently from two distinct groups: community pharmacists and public only in Doha area, the capital city of Qatar. All community pharmacists and public who were fluent in either English or Arabic and agreed to be interviewed were included in the study. The public must also be residents of Qatar. If they were health personnel or under 18 years of age, they were excluded from the study.

The survey questionnaire was developed in two languages i.e., English and Arabic, and consisted of 50 questions distributed into five parts: a) demographic characteristics (12 items), b) attitude (25 items), c) subjective norm (two items), d) motivation (nine items), and e) behavioural intentions of pharmacists and public regarding counterfeit medicines (two items). Questions in sections (b) to (e) were prepared based on a five-point Likert scale, ranging from five (strongly agree) to one (strongly disagree). This scale was used to assess the level of vulnerability to counterfeit medicines; it depends on the total score: low-level (151-190), moderate level (81-150), and high-level (38-80). The same survey questionnaire was used for both the pharmacists and public. The vulnerability score was tested for normality. The questionnaire was validated (Cronbach’s alpha=0.862) and was already used in a previous study [13].

Collected data was statistically analysed using SPSS version 22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Both descriptive and inferential statistics were applied. Chi-square test and two sample t-test were used for statistical analysis at p-value of 0.05.

One hundred ninety surveys were distributed to both community pharmacists and public, however, only 167 (87.8%) were collected which resulted in response rate. Number of pharmacists was 75 (44.9%), whereas number of public respondents was 92 (55.1%) [Table/Fig-1].

Analysis showed that there was no significant difference between public and pharmacists in the way they perceive counterfeit medicines in most of the surveyed items (p-value≥0.05). However, results revealed significant differences (p≤0.05) for four items [Table/Fig-2]. First, to investigate the awareness of sale of counterfeit medicines in Qatar; both public and pharmacists were asked direct question about their awareness about counterfeit and substandard medicines; pharmacists have higher awareness (p=0.05). Similarly, results showed significant difference between public and pharmacists regarding their awareness about the societal consequences of purchasing counterfeit medicines with pharmacists having higher awareness (p=0.003). On the other hand, results showed significant difference in perception about the effect of pressure exerted by relative and friends (p=0.045), and affordability of medicine price (p=0.002) on purchase intention of counterfeit medicines, with public perceiving stronger effect for both factors. Results of this study showed no relationship between socio-demographic characteristics and purchase intent of counterfeit medicines.

Difference between community pharmacists and public in vulnerability towards counterfeit medicines was not significant (p-value=0.833) [Table/Fig-3].

In addition, there is no significant difference for both groups in terms of level of vulnerability (low, moderate and high) towards counterfeit medicines (p-value=0.550) [Table/Fig-4].

Results of this study suggest very few disparities between pharmacists and public in perceiving counterfeit medicines phenomenon. Among these disparities is the level of awareness about sale of counterfeit medicines in Qatar where pharmacists showed higher awareness than public. This may highlight the importance of involving pharmacists in educating and raising the awareness of public about the problem of counterfeit medicines. It is not peculiar for the public to have low knowledge and awareness about the existence of counterfeit medicines in the market as this seems to be a common problem hindering the efforts to combat sale of counterfeit medicines even in the developed world. A survey conducted in Europe revealed that only 18% of the respondents were aware about the presence and sale of counterfeit medicines in the market [14]. Hence, low knowledge about the presence of counterfeit medicines in the market is a serious worldwide problem and it needs to be addressed and tackled. It is not logical to continue neglecting this problem especially in the light of findings of some studies which presented the possibility of combating counterfeiting through changing consumers behaviour [15].

Another disparity is the difference between public and pharmacists regarding their awareness about the societal consequences of purchasing counterfeit medicines where, again, pharmacists showed higher awareness. In fact, previous study conducted in developing country supported the notion that messages highlighting societal consequences such as its chilling effect on the economy, its tendency to discourage companies from investments in research and developments, the hazardous labour conditions found in countries engaged in drug counterfeiting, undermining the official health system, loss of jobs, illegal nature of the behaviour (buying counterfeit) implying social stigma, and potential link to organised crime that would profit from counterfeit purchases might not be strong enough to discourage public from buying the counterfeits as consumers in developing countries are not well familiar with these consequences [15-17]. In fact, weak discouraging effect of these societal consequences of drug counterfeiting was not reported only in developing countries, but also even among consumers in developed countries. A survey in USA investigated the effects of awareness of societal consequences on the purchase intent of three counterfeit goods, among them the pain reliever Tylenol^®, reported that awareness of societal consequences does not influence the purchase intent [18].

On the other hand, stronger influence on public than on pharmacists was shown when effect of family and friends, and effect of affordability of medicines price were explored. Regarding family and friends, the findings of this study show the strength of their influence in shaping the decision of consumers in Qatar. According to the public opinion, their relatives and friends really encourage them to purchase non-registered medicines. This finding is very important as it can be exploited in discouraging counterfeit medicines purchase behaviour. In fact, this finding is consistent with previous literature which reported the influence of family and friends on consumer’s decision to engage in a deviant behaviour [17,19,20]. When it comes to the effect of affordability of medicines price on purchase intention of counterfeit medicines, Qatari consumers seem to be consistent with other consumers studied in previous literature who link prices and willingness to purchase counterfeits [1,21-25]. The public tends to purchase unregistered medicines due to the unaffordability of registered medicines.

Unlike many previous studies which addressed the importance of demographic factors in the purchase intent of counterfeits [15,26,27], results from this study suggest that all demographic factors such as education, age and gender have no effect on counterfeit medicine purchase decision. This may be due to the fact that counterfeit purchase is a complex phenomenon and could not be easily linked to one factor or another but, moreover, strongly affected by the broader cultural context [28-30].

Finally, it is not surprising to find no high vulnerability to counterfeit medicines among Qatari people, both public or pharmacists, as Qatari have very high GDP. It was documented in previous literature that the main reason for the increment in vulnerability to counterfeit medicines among consumers is the unaffordable prices of medicines [16]. However, based on the level of vulnerability to counterfeit medicines in the moderate level (89.3% of public and 92.2% of pharmacists), it is still a worrying finding.

This study has laid the ground for further long-term studies on distribution and sale of counterfeit medicines in the pharmaceutical market in Qatar and neighbouring countries. By assessing the factors enhancing vulnerability to counterfeit medicines in the Arab and Gulf Cooperation Council (AGCC) countries, an effective collaboration in designing more efficient plan to combat the problem could be set.

In future studies, including all AGCC countries is recommended. A larger sample size representing other health professionals should be considered; otherwise, generalisability of the study findings may be compromised. Nevertheless, the findings of the current study enhance the knowledge about perceptions regarding counterfeit medicines phenomenon among relatively reasonable group of pharmacists and public, in atleast one country in the AGCC.

There are few aspects that have affected the generalisability of the study findings: study duration, sample size, subject selection and survey responses. The study was conducted within a short period with a small sample size. It is the intention of the researcher to conduct a preliminary study prior to a nationwide study. The subjects were also selected using a non-random method which could cause a bias sample. Furthermore, due to the nature of a survey method, the responses were based on the subjects self-perception and they may not feel encouraged to provide accurate and honest answers. Few respondents were not included in some of the analysis e.g., level of vulnerability, because of not responding to all of the required questions. Thus, the total score could not be calculated.

Overall findings of the study suggested that there is no significant difference between pharmacists and public in the way they perceive counterfeit and substandard medicines and both of them have the same susceptibility level toward counterfeit medicines. Both pharmacists and public have low-level of knowledge and moderate level of vulnerability to counterfeit and low-quality medicines. The problem of counterfeit and poor-quality medicines has to be extensively addressed, and more education and awareness among the society are needed.