‘Prevalence, experience and awareness of substandard and falsified medicines among the public and healthcare professionals in Jordan’

Demographic characteristics

A total of 345 participants took part in the study, with 61% (n=209) from the public and 39% (n=136) from healthcare professionals. Among public respondents, 57% (n=119) held higher education degrees (bachelor’s or above), while 42% (n=87) had lower education levels (community college or below). In the healthcare professional group, 66% (n=90) were pharmacists, and 32% (n=43) were clinicians, including 38 junior doctors (28%) and 5 general practitioners (4%).

The gender distribution was similar across groups, with 66% (n=138) of the public and 53% (n=72) of healthcare professionals being female. The majority of respondents were from Jordan’s Central Region (Amman, Balqa, Zarqa and Madaba), accounting for 76% (n=159) of the public group and 91% (n=124) of healthcare professionals, which closely align with the 63.3 % Central Region representation in Jordan’s total population. Responses from other governorates accounted for less than 24% (n=50) of the public and 7% (n=10) of healthcare professionals.

The modal age group for both cohorts was 26–35 years, representing 32% (n=66) of the public and 46% (n=62) of healthcare professionals. Among healthcare professionals, 66% worked in community pharmacies, while clinicians worked in hospitals (79%), government clinics (14%) and mixed clinical settings (7%). Their patient populations were from low (16%), medium (20%), high (15%) and mixed-income (47%) groups. Table 1 illustrates the full demographic breakdown.

Essential & non-essential medicine use

Participants reported frequent use of essential medicines, with cough treatments (67%, n=139), antibiotics (56%, n=117), pain relief medications (56%, n=117) and allergy treatments (55%, n=115) being the most commonly used. Other widely used medications included gastrointestinal (GI) treatments (36%, n=75), blood pressure medications (27%, n=57) and antidiabetics (24%, n=50) (online supplemental appendix). Additional essential medicines, such as those for rheumatoid arthritis, thyroid disorders and anaemia, were also mentioned by respondents (online supplemental appendix).

Doctors were the primary source of information on essential medicines for 85% (n=178) of respondents, followed by pharmacists (60%, n=125). Most participants (90%, n=188) purchased their essential medicines from community pharmacies, while government clinics were another key source (58%, n=121). A smaller proportion (13%, n=27) obtained these medications online. The study also explored non-essential medical product use (online supplemental appendix), with multivitamins (72%, n=151) being the most frequently used, followed by moisturizing skincare products (49%, n=102) and sexual health products (44%, n=91). Pharmacies were the primary source for non-essential medical products (69%, n=144), while 21% (n=44) purchased them from supermarkets and general stores.

Purchasing decisions for both essential and non-essential medicines were influenced by several factors. 31% (n=65) of respondents reported product availability as a moderate influence, while 32% (n=67) considered store location important. Cost was identified as a strong determinant in purchasing decisions by 32% (n=67).

Awareness of SF medicines

Awareness and knowledge of SF medicines were assessed among both general public participants and healthcare professionals. Among the general public, only 24% (n=50) reported awareness of SF medicines, with some of their responses reflecting their own opinions and views on what they anticipated as an SF medical product. The majority (76%, n=159) were unaware.

χ² analysis showed no significant association between education level and awareness (χ²(1) = 0.313, p=0.576). No significant associations were found between awarness with gender χ² (1)=0.0116, p=0.9143 but awareness levels vary significantly across different age groups χ ² (5)=12.43, p=0.0293. Awareness was most prevalent among the (46–55) age group (40.74%), while the (18–25) age group had the lowest awareness (14.29%). Among healthcare professionals, 34% (n=46) reported complete knowledge of SF medicines. However, there was no statistically significant difference in awareness levels between the general public and healthcare professionals (χ²(1) = 3.468, p=0.06).

The level of understanding among general public participants who reported awareness of SF medicines varied significantly. When asked to provide an example, the majority (29%, n=18) identified unregulated or unlicensed sources, such as online vendors, while 22% (n=14) perceived generic medicines supplied by the government as SF products. These responses primarily reflected concerns over perceived lower quality and effectiveness, with some generalising generic drugs as SF medicines. Additionally, 8% (n=5) reported personal experiences with SF medicines, including specific mentions like cardiovascular drugs.

Some respondents, however, demonstrated a more accurate understanding. 13% (n=8) recognised SF medicines as containing the wrong active ingredient, incorrect concentration or dosage. Another 11% (n=7) identified the risk of contamination in unregulated medicines, while 17% (n=11) associated SF medicines with ineffectiveness or harm.

Among healthcare professionals, the majority recognised SF medicines as those containing the wrong active ingredient, lacking an active ingredient or having incorrect dosages (25%, n=26). Additional concerns included low quality (21%, n=22), contamination (6%, n=6) and storage or packaging issues (17%, n=18). Furthermore, 11% (n=11) highlighted non-equivalence between generic and branded drugs.

Interestingly, 11% (n=11) of respondents from the healthcare professional cohort stated that SF medicines are not a problem in Jordan, citing strict regulatory controls. Additionally, 11% (n=11) attributed SF medicines to external sources, such as drug smuggling or online markets. Further breakdown of qualitative insights and an integration of quantitative data with qualitative responses themes are detailed in tables 2 and 3, respectively.

When asked about the reasons behind the circulation of SF medicines, respondents highlighted economic factors, with 16% (n=20) linking SF medicines to cost-related issues. Some respondents believed that the high price of original medicines, along with financial constraints, contributed to increased demand for falsified or low-quality alternatives. Notably, four respondents reported knowledge of pharmacists or colleagues who had dispensed SF medicines, with one explaining that their colleague distributed smuggled medicines to assist low-income patients.

Experiences with SF products

Overall, 36 members of the public reported experiences with SF medicines, with 10 knowingly purchasing them and 26 suspecting they had encountered them unintentionally. Among those who knowingly purchased SF medicines, three acquired them through smuggling, while 33% (n=4) mistakenly classified generic medications as SF medicines, believing that opting for generics instead of brand-name versions constituted voluntary engagement with SF medicines.

For those who unexpectedly encountered SF medicines, 14% (n=5) reported ineffectiveness with alternative or generic medicines, while another 14% (n=5) suspected they had unknowingly used falsified or substandard medicines. Additionally, 17% (n=6) of reported cases involved smuggled medicines. Notably, 50% (n=18) expressed that they did not seek medical advice after such experiences, but 56% (n=20) reported side effects, with 21% (n=4) said they required emergency medical intervention (tables 4 and 5).

Healthcare professionals provided similar accounts, with 35 respondents witnessing cases related to SF medicines. The most frequently reported concerns were with antidiabetic (31%, n=15), blood pressure (27%, n=13) and cardiovascular medications (20%, n=10). Additionally, 10% (n=5) mentioned issues with GI medications, antivirals or cancer treatments.

A notable concern among healthcare professionals was the ineffectiveness of alternative or generic medicines, reported by 42% (n=15) of respondents. Some expressed that their patients opted to purchase branded versions after experiencing treatment failure with generics. Stability and packaging concerns were noted in 22% (n=8) of incidents, with patients encountering damaged blisters, empty capsules or incorrect labels (tables 4 and 5). While some pharmacists recognised these defects, they were uncertain whether they classified as SF medicines. Some respondents from healthcare professionals group highlighted the fact that they lacked knowledge on differentiating side effects from SF medicine reactions, making it challenging to confirm cases.

χ² analysis assessed the influence of availability, cost and location on SF medicine exposure. No significant associations were found between these factors and participants’ experience with SF medicines availability (χ² (6)=10.36, p=0.1104; cost: χ² (6) =3.88, p=0.6932 and location: χ² (6)=4.00, p=0.6766). This suggests that availbility, affordability or accessibility did not significantly determine the likelihood of encountering SF medicines within this sample. Similarly, no significant association was found between income level and the need for medical intervention after consuming SF medicines (χ² (6) = 4.43, p=0.619), indicating that adverse effects occurred across all income groups.

Reporting of SF medicines

Among the general public who experienced incidents with SF medical products (n=36), 81% (n=29) did not report these incidents to the authorities. The most cited reasons included lack of time, resolution by medical staff, contacting the seller instead or not knowing how to report. Additionally, 10% (n=3) feared repercussions from reporting.

Similarly, 100% of pharmacists and clinicians (n=35) who had suspected SF medicine cases did not report them to authorities. The primary reasons included lack of awareness on how to report (51%, n=18), insufficient time or knowledge (27%, n=10) and the belief that reporting was the patient’s responsibility (9%, n=3).

Overall, within the entire pharmacist and clinician cohort (n=136), 71% (n=96) of the total respondents reported not knowing how to report SF medicines. This widespread lack of reporting highlights significant gaps in pharmacovigilance awareness and regulatory reporting mechanisms.

Views and increasing awareness of falsified medicines

The responses revealed clear concerns across both the general public and healthcare professionals. A majority of participants from the general public (96%, n=199) strongly agreed or agreed that falsified products can be dangerous. Additionally, 90% of the members of the public (n=186) and 93% of pharmacists and clinicians (n=106) strongly disagreed or disagreed that most falsified medicines are as good as the originals. Furthermore, 68% of the general public (n=140) and 91% (n=103) of pharmacists and clinicians disagreed or strongly disagreed that falsified medicines have better value than original ones. 80% of members of the public participants (n=165) and 85% (n=98) of pharmacists and clinicians strongly disagreed or disagreed that it is easy to spot falsified medicines by quality or price. Moreover, 93% (n=192) of the general public and 99% of pharmacists and clinicians (n=114) strongly agreed or agreed that action should be taken against any pharmacist who knowingly dispenses falsified medicines (figure 1).

It is noteworthy that 1% (n=2) of participants from the general public did not answer all or part of the questions due to uncertainty, compared with 15% (n=20) of clinicians and pharmacists who also refrained from answering for the same reason.

Healthcare professionals’ perceptions and recommendations on SF medicines

When asked whether they believed the public was aware of SF medical products, 66% (n=65) of pharmacists and clinicians who answered this question (n=98) provided estimates ranging from 0% to 70%, with a median estimate of 10%. Many respondents expressed uncertainty, with 41% (n=40) admitting a lack of knowledge on the topic, indicating limited awareness even among healthcare professionals. This was reflected in statements such as ‘If we pharmacists do not know exactly’ and ‘Even we as doctors do not know’. Additionally, 7% (n=7) referenced specific examples, including ‘Medicines smuggled from Turkey’ and ‘People expect generics to be substandard’.

Suggestions for increasing awareness

Pharmacists and clinicians were asked for their suggestions to improve knowledge and awareness of SF medicines. Education and awareness campaigns emerged as the most frequently mentioned strategy (64%, n=84). Respondents emphasised the need for public education, training for healthcare professionals and integrating SF medicine awareness into pharmacy and medical school curricula.

Social media was suggested as a tool for raising awareness by 12% (n=15), while 8% (n=10) highlighted the need for research to better understand the scale and impact of SF medicines. Additionally, 6% (n=7) pointed to the role of government agencies—such as the Ministry of Health—in strengthening regulations and enforcement. One response also mentioned corporate engagement, suggesting that pharmaceutical manufacturers could play a role in raising awareness and addressing SF medicines.

Finally, 5% (n=6) of respondents were unsure or had no specific suggestions for tackling the issue. These findings highlight the urgent need for targeted awareness initiatives, structured training programmes and stronger regulatory frameworks to combat the SF medicine problem effectively.