fake drugs and active pharmaceutical ingredients most often originate in evolving industrial economies  especially developing countries  before entering the global market . trafficking in counterfeit drugs
has become one of the fastest growing immoral businesses . improved technological capabilities have enabled counterfeiters to produce packaging that looks good enough to deceive legitimate wholesalers and retailers .
world health organization ( who ) defines a counterfeit drug as one that is deliberately and fraudulently mislabeled with respect to identity and/or source .
counterfeiting can apply to both branded and generic products , and counterfeit products may include products with the correct ingredients or with the wrong ingredients , without active ingredients , with insufficient active ingredients , or with fake packaging .
who defines a substandard drug as one which does not intentionally have incorrect packaging , but may have the incorrect quantity or ratio of ingredients .
counterfeiting of drugs as a  problem  was first alluded at the who conference of experts on the  rational use of the drugs  held in nairobi in 1985 .
today , the manufacturing of substandard and fake drugs is an extensive and under - reported problem .
describing the extent of counterfeiting is difficult as the variety of information sources makes compiling statistics a difficult task ; however , the most important sources of data on counterfeits are who and international medical products anti - counterfeiting taskforce ( impact ) as the who 's organization for the fight against counterfeit drugs . the estimates given by impact
differentiate between developed countries , where less than 1% of the drugs sold are counterfeit , and some less - developed countries where the number is around 10% .
for some of these countries in parts of asia , the estimates go further up above 30% .
a much higher prevalence can be found for drugs bought from illicit internet pharmacies , where up to 50% of the sold medicines are assumed to be fakes even in developed countries . a survey on the extent of counterfeit medicines in india
was carried out by sear pharma forum in association with searo , who in 2007 , which stated the extent of counterfeit suspects was around 3.1% .
government and health care workers jointly have an obligation to provide the society with solutions to the problems of counterfeit medicine .
health care workers are not only the most important source of information about proper pharmacotherapy , but also play a crucial role in detecting and preventing the distribution of counterfeit medicine .
thus , the present study was conducted to assess the knowledge , attitude , and practice of doctors and medical storekeepers regarding counterfeit medication in western india .
the present study was a descriptive , cross - sectional , questionnaire study conducted in september 2014 .
the questionnaire for doctors consisted of 12 close - ended questions and the one for medical storekeepers had 13 questions ( 12 close - ended and 1 open - ended questions ) .
the initial set of questions was designed to assess the knowledge of the participants , the next set to assess their attitude , and the last set was designed to assess their practice regarding counterfeit medication .
the questionnaire was designed to be completed in approximately 5 min . prior to being finalized ,
the questionnaire was pilot - tested on a group of 30 dental practitioners and 30 medical wholesale distributors to ensure its clarity and validity .
ethical clearance was obtained from the institutional review board and a verbal consent was obtained from all the participants .
all registered doctors and medical storekeepers who agreed to fill the questionnaire were included in the study .
a list of all registered medical and dental practitioners ( up to 20132014 ) was obtained from their respective associations .
there were a total of 3567 medical practitioners and 590 dental practitioners in jaipur city .
hundred members from each group were included in the study through simple random sampling . for medical wholesale distributors ,
100 medical stores were randomly identified in different areas of the city and the head of the store was asked to fill the questionnaire . analyzing the results of the participants for the knowledge , attitude , and practice questions , scores of 1 and zero
the differences among participants based on their age , years of professional life , years of any institutional attachment , and qualification were analyzed using analysis of variance ( anova ) test and anova with post - hoc test .
a list of all registered medical and dental practitioners ( up to 20132014 ) was obtained from their respective associations .
there were a total of 3567 medical practitioners and 590 dental practitioners in jaipur city .
hundred members from each group were included in the study through simple random sampling . for medical wholesale distributors ,
100 medical stores were randomly identified in different areas of the city and the head of the store was asked to fill the questionnaire .
analyzing the results of the participants for the knowledge , attitude , and practice questions , scores of 1 and zero were assigned to true and false answers , respectively .
the differences among participants based on their age , years of professional life , years of any institutional attachment , and qualification were analyzed using analysis of variance ( anova ) test and anova with post - hoc test .
in the present study , a total of 300 participants which included 100 dental practitioners , 100 medical practitioners , and 100 medical wholesale distributors were surveyed .
the data concerning knowledge about counterfeit drugs showed that only 22% of the participants knew about counterfeit drugs .
seventy - one percent of the participants believed that unregistered pharmacies are the most common source of procuring these drugs .
thirty - six percent of the participants stated that they can not distinguish between genuine and fake drugs . around sixty - six percent of the participants
eighty - one percent of the participants stated that they warn the patients about not to buy medicines from unknown sources , which reflects their practice behaviors .
knowledge , attitude , and practice of the participants were compared with their qualification , age , work experience , and their place of practice .
figure 1 depicts the comparison of knowledge , attitude and practice of all the participants .
socio - demographic background of the participants comparison of knowledge , attitude , and practice of participants with age , work experience , and place of practice comparison of knowledge , attitude , and practice among the participants .
the present study reveals that knowledge about counterfeit medicines was less among the study participants when compared to a study conducted by khan et al . in 2011 , which reflects the need to increase the awareness about counterfeit medicines .
the results of the present study were in contrast with the results of a study conducted by shahverdi et al . in 2012
in which majority of the participants had the knowledge about distinguishing original and counterfeit medicines . on comparison
this can be attributed to the fact that dental practitioners are limited to prescribing only a handful number of drugs in their daily practice compared to medical practitioners , which reduces their awareness about these medicines .
the present study also revealed that none of the medical storekeepers had knowledge about the drug testing laboratories in india and also did not have an authorized degree , which might be a reason for their lesser awareness about the counterfeit drugs .
drug control department , together with the government should implement strict laws and carry out inspections to protect the supply of pharmaceutical products from the intrusion of counterfeit medicines .
online availability and shopping is the most common source of counterfeit medicines , but majority of the participants in the present study had no information about purchasing of these medicines online .
this is in agreement with the study conducted by binkowska - bury et al . in 2008 - 2009 .
if this lack of awareness continues in future , it will contribute toward an increase of counterfeit medicine trade in the city .
therefore , the phenomenon of counterfeit medicine should be inculcated in educational programs aimed at health care workers .
adequate training by the government as well as by the relevant agencies in detection of counterfeit drugs should be implemented in practice . in affirmation with the study by shahverdi et al . in 2012 ,
this can be attributed to the fact that as an individual grows older , he becomes more responsible for the society and becomes ethically stronger .
on comparing the attitude , the present study showed that dental practitioners had a better attitude toward counterfeit medicines and least scores were shown by the medical storekeepers .
medical storekeepers are less aware of the threats posed by counterfeit medicines to patients health as compared to the doctors , which can be thought as the reason as to why they preferred the use of counterfeit drugs in cases of shortage which was asked to them in the questionnaire . in these situations
, there is an intense need to orient and sensitize storekeepers to the issues of counterfeit medicines .
the present study also showed a close relationship between good practice and increase in age and work experience , which was in contrast to the study conducted by shahverdi et al . in 2012 .
medical storekeepers were found to exhibit best practice behaviors among the study participants and the worst behavior was shown by dental practitioners in the present study .
this can be due to the fact that medical storekeepers are more aware and are in contact with the drug authorities which makes it more feasible for them to report of any encounters with counterfeit drugs .
if this lack of awareness about the drug regulatory authorities continues in the future among doctors , it will contribute toward an increase of counterfeit medicines in the city .
anti - counterfeit measures need to be incorporated into a set of guidelines to be developed for the doctors and medical storekeepers .
majority of the participants in the present study warned the patients about not to purchase medicines from an unknown source , which was in contrast to the results of a study conducted in 2008 - 2009 by binkowska - bury et al .
, though the present study was in affirmation with its finding that majority of the participants did not know the procedure for reporting about suspicious medicines .
these findings suggest that there is a great need for training doctors and medical storekeepers in the field of counterfeit .
it can be understood that because of market competition , storekeepers try to find shortcuts to avoid taxes and make quick money . in this vicious circle ,
even the doctors are involved in getting commissions or favors such as free holiday trips from illegal sources to bring their medicines in the supply chain .
this chain needs to be broken by strict vigilance by the drug control department . unless this chain is broken , the poor patients who tend to buy these spurious medicines at low cost not only suffer from health losses but also are at long - term financial loss .
the present study reveals that knowledge about counterfeit medicines was less among the study participants when compared to a study conducted by khan et al . in 2011 , which reflects the need to increase the awareness about counterfeit medicines .
the results of the present study were in contrast with the results of a study conducted by shahverdi et al . in 2012
in which majority of the participants had the knowledge about distinguishing original and counterfeit medicines . on comparison
this can be attributed to the fact that dental practitioners are limited to prescribing only a handful number of drugs in their daily practice compared to medical practitioners , which reduces their awareness about these medicines .
the present study also revealed that none of the medical storekeepers had knowledge about the drug testing laboratories in india and also did not have an authorized degree , which might be a reason for their lesser awareness about the counterfeit drugs .
drug control department , together with the government should implement strict laws and carry out inspections to protect the supply of pharmaceutical products from the intrusion of counterfeit medicines .
online availability and shopping is the most common source of counterfeit medicines , but majority of the participants in the present study had no information about purchasing of these medicines online .
this is in agreement with the study conducted by binkowska - bury et al . in 2008 - 2009 .
if this lack of awareness continues in future , it will contribute toward an increase of counterfeit medicine trade in the city .
therefore , the phenomenon of counterfeit medicine should be inculcated in educational programs aimed at health care workers .
adequate training by the government as well as by the relevant agencies in detection of counterfeit drugs should be implemented in practice .
in affirmation with the study by shahverdi et al . in 2012 , the present study showed that increasing age resulted in improvement of the attitude .
this can be attributed to the fact that as an individual grows older , he becomes more responsible for the society and becomes ethically stronger .
on comparing the attitude , the present study showed that dental practitioners had a better attitude toward counterfeit medicines and least scores were shown by the medical storekeepers .
medical storekeepers are less aware of the threats posed by counterfeit medicines to patients health as compared to the doctors , which can be thought as the reason as to why they preferred the use of counterfeit drugs in cases of shortage which was asked to them in the questionnaire . in these situations
, there is an intense need to orient and sensitize storekeepers to the issues of counterfeit medicines .
the present study also showed a close relationship between good practice and increase in age and work experience , which was in contrast to the study conducted by shahverdi et al . in 2012 .
medical storekeepers were found to exhibit best practice behaviors among the study participants and the worst behavior was shown by dental practitioners in the present study .
this can be due to the fact that medical storekeepers are more aware and are in contact with the drug authorities which makes it more feasible for them to report of any encounters with counterfeit drugs .
if this lack of awareness about the drug regulatory authorities continues in the future among doctors , it will contribute toward an increase of counterfeit medicines in the city .
anti - counterfeit measures need to be incorporated into a set of guidelines to be developed for the doctors and medical storekeepers .
majority of the participants in the present study warned the patients about not to purchase medicines from an unknown source , which was in contrast to the results of a study conducted in 2008 - 2009 by binkowska - bury et al .
, though the present study was in affirmation with its finding that majority of the participants did not know the procedure for reporting about suspicious medicines .
these findings suggest that there is a great need for training doctors and medical storekeepers in the field of counterfeit .
it can be understood that because of market competition , storekeepers try to find shortcuts to avoid taxes and make quick money . in this vicious circle ,
even the doctors are involved in getting commissions or favors such as free holiday trips from illegal sources to bring their medicines in the supply chain .
unless this chain is broken , the poor patients who tend to buy these spurious medicines at low cost not only suffer from health losses but also are at long - term financial loss .
in conclusion , the findings from this study extend the understanding of the knowledge , attitudes , and practice regarding counterfeit drugs among doctors and medical storekeepers and they point out the need for designing and implementing continuing educational programs among them .
this training should be teaching them how to identify these drugs and how to inform the responsible authorities about counterfeit drug suppliers .
the findings also suggest the need for enforcement of vigilant laws on the unauthorized medical storekeepers .
 background : fake drugs and active pharmaceutical ingredients most often originate in emerging industrial economies before entering the global market . 
 health care workers play a crucial role in detecting and preventing the distribution of counterfeit medicines.aim:the present study was conducted to assess the knowledge , attitude , and practice of doctors and medicine wholesale distributors regarding counterfeit medication in western india.materials and methods : a cross - sectional questionnaire survey was conducted among 300 participants consisting of 100 medical practitioners , 100 dental practitioners , and 100 medical storekeepers.results:it was observed that medical practitioners had more knowledge , followed by medical storekeepers and dental practitioners ( mean 2.82 , 2.52 , and 2.37 , respectively ) . 
 dental practitioners had the best attitude , followed by medical practitioners and wholesale distributors ( mean 1.77 , 1.76 , and 1.55 , respectively ) . 
 best practice behaviors were observed in medical storekeepers followed by medical practitioners and dental practitioners ( mean 1.46 , 1.29 , and 1.12 , respectively).conclusion : the study points out the need for designing and implementing continuing educational programs and enforcement of vigilant laws . 
INTRODUCTION
MATERIALS AND METHODS
Study sample
Statistical analysis
RESULTS
DISCUSSION
Knowledge
Attitude
Practice
CONCLUSION