Counterfeit drugs have emerged as a major global public health challenge affecting both developed and developing nations. The World Health Organization (WHO) defines counterfeit medicines as products that are deliberately and fraudulently mislabelled with respect to identity, composition, or source.[1] These medicines may contain incorrect ingredients, inadequate amounts of active pharmaceutical ingredients, no active ingredients, or harmful contaminants, and are often packaged to closely resemble genuine pharmaceutical products.[2] The increasing globalization of pharmaceutical manufacturing and online drug distribution has contributed significantly to the widespread circulation of counterfeit medicines worldwide.[3] Counterfeit drugs not only compromise patient safety but also undermine confidence in healthcare systems and contribute to significant economic losses.

The burden of counterfeit medicines is particularly high in low- and middle-income countries where weak regulatory mechanisms, poor drug surveillance systems, and limited public awareness facilitate the circulation of falsified pharmaceutical products.[4] According to previous reports, the prevalence of counterfeit medicines varies considerably across regions, ranging from 10% to more than 30% in certain developing countries.[5] Substandard and falsified medicines have been associated with therapeutic failure, adverse drug reactions, antimicrobial resistance, prolonged illness, and even mortality.[6] Counterfeit antimicrobial agents, antimalarials, and life-saving medications are especially concerning because they can lead to treatment resistance and poor clinical outcomes.[7] The growing use of internet pharmacies and unauthorized drug vendors has further intensified the challenge of ensuring drug authenticity and patient safety.

India is one of the largest pharmaceutical producers globally and plays a vital role in supplying affordable medicines to many countries. However, the country also faces significant challenges related to counterfeit and substandard medicines.[8] Factors such as inadequate enforcement of drug regulations, complex supply chains, illegal online pharmacies, and lack of consumer awareness contribute to the persistence of counterfeit drug practices. Previous studies conducted among healthcare professionals in India have demonstrated varying levels of awareness regarding counterfeit medicines and their consequences.[9] Despite increasing attention toward pharmacovigilance and medicine safety, underreporting and inadequate identification of counterfeit drugs remain important concerns in clinical practice.

Healthcare professionals, particularly medical postgraduate students, are at the forefront of patient care and prescribing practices. Their ability to recognize counterfeit medicines, educate patients, and report suspicious products is crucial for preventing the circulation and use of falsified medications. Adequate knowledge and positive attitudes among medical professionals can significantly strengthen the fight against counterfeit drug distribution. However, deficiencies in practical training, limited exposure to detection methods, and lack of structured educational programs may reduce their preparedness to address this issue effectively.[10] Studies assessing the knowledge, attitude, and practice (KAP) regarding counterfeit medicines among healthcare providers are relatively limited, especially among postgraduate medical students in tertiary care teaching hospitals.

Assessment of KAP among medical postgraduates is essential because these future specialists are expected to contribute actively to safe prescribing practices, patient counselling, and pharmacovigilance activities. Understanding their level of awareness and identifying gaps in practice can help institutions design targeted educational interventions and strengthen regulatory vigilance. Therefore, the present study was undertaken to assess the knowledge, attitude, and practice regarding counterfeit drugs among medical postgraduate students at a tertiary care hospital. The objectives of the study were to evaluate their knowledge regarding counterfeit medicines, assess their attitudes toward prevention and reporting, and determine the practices adopted to identify and avoid counterfeit drugs.

MATERIALS AND METHODS

Study Design: A hospital-based cross-sectional observational study was conducted to assess the knowledge, attitude, and practice (KAP) regarding counterfeit drugs among medical postgraduate students.

Study Setting: The study was conducted in the Department of Pharmacology at Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research (MAPIMS), Tamil Nadu, India, which is a tertiary care teaching hospital catering to undergraduate and postgraduate medical education and healthcare services.

Study Duration: The study was conducted over a period of three months.

Study Population: The study population comprised medical postgraduate students from various clinical and non-clinical departments of MAPIMS who were available during the study period and consented to participate.

Inclusion Criteria

• Medical postgraduate students enrolled in MAPIMS during the study period.
• Participants who were willing to participate voluntarily.
• Participants who provided written informed consent.

Exclusion Criteria

• Postgraduate students who were absent during data collection.
• Participants unwilling to participate in the study.
• Incompletely filled questionnaires were excluded from final analysis.

Sample Size: The sample size was calculated using the single population proportion formula:

Where:

• ( n ) = required sample size
• ( ) = standard normal deviate at 95% confidence interval (1.96)
• ( p ) = expected prevalence/proportion from previous literature
• ( q = 1-p )
• ( d ) = allowable error

Considering the proportion of adequate knowledge regarding counterfeit drugs among healthcare professionals from a previous study to be approximately 57.7%, an allowable error of 10%, and a 95% confidence interval, the minimum calculated sample size was approximately 75. To account for incomplete responses, a total of 80 participants were included in the study.

Sampling Technique: A simple random sampling technique was employed to recruit eligible postgraduate students from different departments of the institution until the required sample size was achieved.

Data Collection Tools and Procedure: Data were collected using a predesigned, prevalidated, self-administered questionnaire consisting of 21 items distributed across three domains: knowledge, attitude, and practice regarding counterfeit drugs. The questionnaire was developed based on previously published literature and expert validation. Prior to administration, the purpose and objectives of the study were explained to all participants. Written informed consent was obtained, and confidentiality was assured.

The knowledge domain consisted of multiple-choice questions assessing awareness regarding the definition, risks, causes, and identification of counterfeit drugs. Correct responses were scored as 1 and incorrect responses as 0. The attitude domain included statements measured using a three-point Likert scale (agree, neutral, disagree) to assess perceptions toward counterfeit drug prevention and reporting. The practice domain evaluated behaviors related to identification, reporting, and preventive measures regarding counterfeit medicines using yes/no responses. Participants completed the questionnaire independently without discussion, and completed forms were collected immediately after administration.

Study Variables: The primary dependent variables in the study were the knowledge, attitude, and practice scores related to counterfeit drugs among medical postgraduate students. Knowledge scores reflected participants’ awareness and understanding of counterfeit medicines, attitude scores assessed perceptions and opinions regarding prevention and reporting, and practice scores evaluated behaviors adopted to identify and avoid counterfeit drugs. Independent variables included demographic and academic characteristics of the participants such as age, gender, department, and year of postgraduate training. Additional variables included exposure to training programs, seminars, or workshops related to counterfeit medicines and awareness regarding regulatory authorities involved in drug safety monitoring.

Statistical Analysis: Data obtained from completed questionnaires were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) software version 29.0. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used to summarize participant characteristics and KAP responses. Categorical variables were presented as proportions and percentages. Where applicable, associations between categorical variables were assessed using the Chi-square test or Fisher’s exact test. A p-value of less than 0.05 was considered statistically significant.

Ethical Considerations: Ethical clearance for the study was obtained from the Institutional Ethics Committee of Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research prior to commencement of the study. Written informed consent was obtained from all participants after explaining the objectives and voluntary nature of participation. Confidentiality and anonymity of participant information were strictly maintained throughout the study. Participants were informed that they could withdraw from the study at any stage without any academic or professional consequences. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki for research involving human participants.

RESULTS

A total of 80 medical postgraduate students participated in the study. The majority of participants belonged to the age group of 26–28 years (47.5%), and females constituted 55% of the study population. Nearly one-third of participants had previously attended awareness programs related to counterfeit medicines (Table 1).

Table 1. Sociodemographic Characteristics of the Study Participants (n = 80)

Most participants demonstrated adequate knowledge regarding counterfeit drugs. Seventy percent correctly identified counterfeit medicines, while 95% recognized their potential risks, including treatment failure and toxicity. Awareness regarding regulatory authorities responsible for drug safety was comparatively lower (55%) (Table 2).

Table 2. Knowledge Regarding Counterfeit Drugs Among Study Participants (n = 80)

Attitude assessment revealed that a large proportion of participants considered counterfeit drugs a serious public health threat and strongly supported training of healthcare professionals regarding counterfeit medicine detection and prevention. However, less than half of the participants believed that existing regulatory measures were sufficiently effective (Table 3).

Table 3. Attitude Regarding Counterfeit Drugs Among Study Participants (n = 80)

Practice-related findings showed that although awareness regarding harmful effects of counterfeit medicines was high, only a small proportion of participants had formally reported suspected counterfeit drugs. Approximately two-thirds reported using digital verification tools, while less than half expressed confidence in identifying counterfeit medicines independently (Table 4).

Table 4. Practice Regarding Counterfeit Drugs Among Study Participants (n = 80)

Overall KAP assessment demonstrated that the majority of participants had good knowledge (65%) and positive attitudes (75%) regarding counterfeit drugs. However, practice scores were comparatively lower, with only 35% demonstrating good preventive and reporting practices (Table 5).

Table 5. Overall Distribution of Knowledge, Attitude, and Practice Scores Among Participants (n = 80)

DISCUSSION

The present study assessed the knowledge, attitude, and practice regarding counterfeit drugs among medical postgraduate students in a tertiary care teaching hospital. The findings demonstrated that the majority of participants possessed adequate knowledge and positive attitudes toward counterfeit medicines; however, practical implementation and reporting practices remained suboptimal. Most participants were aware of the harmful effects of counterfeit medicines and recognized them as a significant public health concern. At the same time, comparatively lower confidence in identifying counterfeit products and poor reporting behavior highlighted important gaps between theoretical awareness and practical application.

Adequate knowledge among healthcare professionals is an essential component in combating counterfeit medicines because medical practitioners are often the first point of contact for patients.[1] In the present study, most postgraduate students correctly identified counterfeit medicines and recognized their association with therapeutic failure, toxicity, and public health risks. These findings are comparable to those reported by Yadav et al., who observed that a majority of doctors were aware of the dangers associated with counterfeit medications.[11] Similarly, Siraj et al. reported that healthcare providers demonstrated relatively good awareness regarding counterfeit medicines and their impact on patient safety.[10] The relatively higher knowledge levels observed in the present study may be attributed to increased exposure to pharmacovigilance programs, improved access to digital information resources, and growing discussions regarding medicine safety during postgraduate training.

However, gaps in awareness regarding regulatory authorities and formal reporting mechanisms were still observed. Similar deficiencies have been described in previous Indian studies where healthcare professionals lacked adequate familiarity with national drug regulatory systems and anti-counterfeit initiatives.[9,11] This may reflect insufficient emphasis on regulatory pharmacology and counterfeit medicine surveillance within the medical curriculum. In addition, many healthcare professionals may encounter counterfeit medicines infrequently in clinical practice, leading to limited practical exposure and uncertainty regarding reporting procedures.

The attitude-related findings in the present study were encouraging, as most participants strongly agreed that counterfeit drugs represent a serious public health threat and emphasized the importance of training healthcare professionals. Comparable observations were made by Nagaraj et al., who reported positive attitudes among doctors toward the prevention and reporting of counterfeit medicines.[9] Likewise, studies conducted in developing regions have demonstrated that healthcare workers generally perceive counterfeit medicines as dangerous and support stronger legal and regulatory interventions.[10,12] This positive attitude may be influenced by increasing awareness regarding antimicrobial resistance, irrational drug use, and patient safety concerns associated with falsified medicines.

Despite good knowledge and positive attitudes, practice-related findings were comparatively less satisfactory. Only a small proportion of participants had reported suspected counterfeit drugs, and many lacked confidence in independently identifying counterfeit medicines. This discrepancy between knowledge and practice has also been observed in earlier studies.[11,12] Several factors may contribute to poor reporting behavior, including uncertainty in confirming counterfeit products, lack of standardized reporting channels, fear of legal implications, inadequate institutional support, and absence of practical training programs. Furthermore, postgraduate students are often primarily focused on clinical responsibilities, with limited exposure to pharmacovigilance and regulatory surveillance activities.

The increased willingness among participants to use digital verification tools such as QR codes and mobile applications represents an encouraging finding. Technological interventions including barcode systems, radiofrequency identification (RFID), serialization, and blockchain-based pharmaceutical tracking systems have been recommended as effective strategies to reduce counterfeit drug circulation.[13] Wider implementation of such technologies, along with integration into hospital pharmacy systems, may improve medicine authentication and patient safety.

Additionally, educating patients regarding the risks associated with purchasing medicines from unauthorized online vendors and unlicensed pharmacies remains an important preventive strategy.

Counterfeit medicines continue to pose substantial clinical and public health challenges worldwide. Poor-quality medicines may contribute to therapeutic failure, prolonged illness, adverse drug reactions, antimicrobial resistance, and increased healthcare expenditure.[3,6] In countries with limited healthcare resources, counterfeit medicines can further weaken public confidence in healthcare systems and compromise disease control programs. The findings of the present study emphasize the importance of incorporating structured educational interventions regarding counterfeit medicines into postgraduate medical training. Regular workshops, continuing medical education programs, and pharmacovigilance sensitization activities may help improve practical skills related to identification and reporting of counterfeit products.

The present study has several strengths. It specifically targeted medical postgraduate students who represent future specialists and prescribers and assessed all three KAP domains comprehensively using a validated questionnaire. The study also provides institution-level baseline data that may help guide educational and policy interventions. However, certain limitations should be acknowledged. The study was conducted in a single tertiary care institution with a relatively small sample size, which may limit generalizability of findings. The use of self-administered questionnaires may introduce response and social desirability bias. In addition, the cross-sectional nature of the study does not permit assessment of causal relationships between variables. Future multicentric studies with larger sample sizes and interventional educational models are recommended to better evaluate awareness and practice regarding counterfeit medicines among healthcare professionals.

CONCLUSION

The present study demonstrated that medical postgraduate students possessed reasonably good knowledge and positive attitudes regarding counterfeit drugs. Most participants recognized counterfeit medicines as a major public health threat and acknowledged the importance of healthcare professionals in preventing their circulation. Awareness regarding the harmful effects of counterfeit drugs and the need for training programs was satisfactory. However, deficiencies were observed in practical aspects such as reporting suspected counterfeit medicines and confidence in identifying counterfeit products independently. The findings highlight the gap between theoretical awareness and practical implementation among postgraduate medical students. Strengthening educational initiatives, incorporating counterfeit drug awareness into postgraduate training curricula, and improving exposure to pharmacovigilance and reporting systems may help bridge this gap. Increased utilization of digital verification technologies and stricter regulatory surveillance are also essential to reduce the circulation of counterfeit medicines. Further multicentric studies with larger sample sizes are recommended to better assess awareness and preventive practices among healthcare professionals.

DECLARATIONS

Funding: No funding sources were received for this study.

Conflict of Interest: The authors declare no conflict of interest.

Ethical Approval: Ethical approval for the study was obtained from the Institutional Ethics Committee of Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research prior to commencement of the study.

Consent: Written informed consent was obtained from all participants before enrollment in the study.

Acknowledgment: The authors acknowledge all the medical postgraduate students who voluntarily participated in the study and contributed to the successful completion of this research.

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