I (Don’t) want to consume counterfeit medicines: exploratory study on the antecedents of consumer attitudes toward counterfeit medicines

Abstract

Background
Substandard and falsified medicine (SFM) sales (an estimated > $200 billion) has become one of the worlds’ fastest growing criminal enterprises. It presents an enormous public health and safety challenge. While the developed world is not precluded from this challenge, studies focus on low-income countries. They emphasize supply chain processes, technological, and legal mechanisms, paying less attention to consumer judgment and decision-making aspects.

Methods
With attention to the demand side of the counterfeit medicines challenge, this survey of U.S. consumers ( n = 427) sheds light on some of the social, psychological, and normative factors that underlie consumers’ attitudes, risk perceptions, and purchase intentions.

Results
Consumers who (a) self-report that they know about the problem, (b) are older, (c) view counterfeit medicine consumption as ethical, and (d) think their significant others would approve of them using such products are more inclined to perceive lower risks and have favorable purchase intentions. Risk averseness is also inversely related to the predicted outcomes.
Perceived benefit of SFMs is a factor but has no effect when risk perception and aversion, attitudes, and subjective norms are factored into the model that predicts purchase intentions.

Conclusion
The results of this study indicate that consumer knowledge (albeit in an unexpected direction), people’s expectations about what will impress their significant others, their ethical judgments about selling and consuming counterfeits, and their risk-aversion are associated with their decision-making about counterfeit medicines. The study offers insights into a demand-side approach to addressing SFM consumption in the U.S. Implications for public health, consumer safety, and brand advocacy education are discussed.

Full text

Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
https://doi.org/10.1186/s12889‑022‑13529‑7
RESEARCH
I (Don’t) want toconsume
counterfeit medicines: exploratory study
ontheantecedents ofconsumer attitudes
towardcounterfeit medicines
Sylvester Senyo Ofori‑Parku1* and Sung Eun Park2
Abstract
Background: Substandard and falsified medicine (SFM) sales (an estimated > $200 billion) has become one of the
worlds’ fastest growing criminal enterprises. It presents an enormous public health and safety challenge. While the
developed world is not precluded from this challenge, studies focus on low‑income countries. They emphasize supply
chain processes, technological, and legal mechanisms, paying less attention to consumer judgment and decision‑
making aspects.
Methods: With attention to the demand side of the counterfeit medicines challenge, this survey of U.S. consumers
(n = 427) sheds light on some of the social, psychological, and normative factors that underlie consumers’ attitudes,
risk perceptions, and purchase intentions.
Results: Consumers who (a) self‑report that they know about the problem, (b) are older, (c) view counterfeit medi‑
cine consumption as ethical, and (d) think their significant others would approve of them using such products are
more inclined to perceive lower risks and have favorable purchase intentions. Risk averseness is also inversely related
to the predicted outcomes.
Perceived benefit of SFMs is a factor but has no effect when risk perception and aversion, attitudes, and subjective
norms are factored into the model that predicts purchase intentions.
Conclusion: The results of this study indicate that consumer knowledge (albeit in an unexpected direction), people’s
expectations about what will impress their significant others, their ethical judgments about selling and consuming
counterfeits, and their risk‑aversion are associated with their decision‑making about counterfeit medicines. The study
offers insights into a demand‑side approach to addressing SFM consumption in the U.S. Implications for public health,
consumer safety, and brand advocacy education are discussed.
Keywords: Counterfeit medicines, Substandard medicines, Consumer attitudes, Risk perception, Purchase intentions,
Pharmaceutical industry, Subjective norms
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Introduction
e illicit trafficking and consumption of fake and sub-
standard medicines has become one of the worlds’ fastest
growing criminal enterprises during the past two decades
globally [1–4]. is phenomenon is fueled by factors such
as the lack of access to medical care, consumers’ appetite
Open Access
*Correspondence: soforiparku@gmail.com
1 School of Journalism and Communication, University of Oregon, Eugene,
OR, USA
Full list of author information is available at the end of the article
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
for cheap medicines, corruption in governments, the
proliferation of illicit online pharmacies, the complexity
of medical product supply chains, and the availability of
sophisticated technologies for counterfeiting and pack-
aging products [1–3, 5, 6]. Although often framed as a
third-world problem [7, 8], the challenge is not limited to
the developing world. According to estimates, between 10
to 60% of the drugs distributed in the developing world
and the vast majority of those sold online in the U.S.
are considered “counterfeit” [9, 10]. Also, Rahman et al.
[11] found that out of 48 recorded incidences of health
impairment owing to fake medicines, they were virtually
evenly split between developing (27 cases, 56.3 percent)
and developed countries (21 cases, 43.7 percent). is
study focuses on the demand side of the issue. It assesses
some social, psychological, and normative determinants
of consumer attitudes and intentions to patronize such
medicines in a developed country context: United States.
Quantifying the global counterfeit medicines market is
exceedingly difficult. For example, the Organization for
Economic Co-operation and Development (OECD) pegs
the size of the international trade (based solely on cus-
toms seizure statistics) in counterfeit medicines at $4.4
billion in 2016 [2]. As OECD’s 2020 report explains, this
figure “does not include a very large volume of domesti-
cally produced and consumed illicit pharmaceuticals”
([2] p. 11). Other analysts estimate “counterfeit” medi-
cine overall sales to be worth between $200 billion [3, 12]
and $432 billion annually [13]. Miller and Winegarden’s
[12] sales estimate make fake medicines the number one
illegal goods (in terms of sales), ahead of other illicit traf-
ficking activities such as prostitution and marijuana. e
OECD (2020) data also identifies counterfeit pharmaceu-
ticals as a top 10 (out of 97) recorded product categories
based on customs seizures [2].
Generally, counterfeit medicines raise brand equity and
brand safety concerns [4], leading to over $80 billion in
financial loss each year [2, 14]. However, this research
focuses not on the brand equity, intellectual property,
and competitive advantage implications of “counterfeits
medicines” as a catch-all phrase but on the health and
safety risks of fake pharmaceutical products. ere is no
universally accepted definition of “counterfeit medicines.”
e World Health Organization (WHO) originally used
the term “substandard, spurious, falsely labeled, falsified,
and counterfeits (SSFFC) to describe these medical prod-
ucts. Substandard medical products are often designed to
appear identical to genuine product and may not cause
an obvious adverse reaction [15]. However, such medica-
tions often fail to properly treat the disease or condition
for which they were intended, and can lead to serious
health consequences including death [15]. Falsified drugs
“deliberately/fraudulently misrepresent their identity,
composition or source” ([15] para, 8). A recent systemic
review of 47 global studies on medicine quality studies,
McManus and Naughton [8] identified the following cat-
egories of issues and their prevalence rates: inadequate
amount of active ingredients (94%), dissolution failure
(39%), no active ingredient (18%), excessive amount of
active ingredients (12%), wrong ingredients (3%), and
impurities (3%).
In line with this, “counterfeit medicine” is used nar-
rowly in this study to mean “substandard and falsified
medicines” (SFMs) [2, 8]. e SFM terminology empha-
sizes the threat to public health and safety, not intellec-
tual property infringements of illegally “copying” original
pharmaceuticals as “counterfeit” connotes [2, 15]. Spe-
cifically, the term refers to “falsified medicines” that are
fraudulently produced and distributed, do not meet qual-
ity specifications, but are sold “with the explicit intent to
deceive the end-user of their origin, authenticity, and effi-
cacy” ([8] p. 1). It also entails “substandard drugs” that do
not have the right or correct amounts of active pharma-
ceutical ingredients. e term as used here is not synony-
mous with low-cost generics that are as safe and effective
as existing brand-name versions protected by intellectual
property [15]. For example, such low-cost copies of medi-
cines (that are not substandard) have proved to be life-
saving, cheaper alternatives for fighting health problems
(see Ghinea et al. [5] for debate on medication pricing
and low-cost generic importation regulations). Besides,
while, in theory, fake medicines that infringe on the cop-
yrights of innovator brands may contain the right kind
and quantities of active ingredients, enforcement and
industry experts explain that such cases are virtually non-
existent [2].
All types of medications have been falsified [11]. ey
include generics and “innovator” ones; life-saving drugs
for illnesses such as cancer and those for routine ail-
ments such as painkillers; antimalarials; antibiotics;and
cheap as well as expensive drugs. e internet is playing
an increased role in the proliferation and consumption
of substandard and falsified medicines [2, 10]. e Euro-
pean Alliance for Access to Safe Medicines (EAASM)
found that over 90% of websites that sell medications did
not require prescriptions, and 62% of the medicines sold
on these websites were falsified or substandard [16]. Only
four percent of randomly sampled online pharmacies
(out of 11,700) adhere to U.S. pharmacy laws and practice
standards [17].
A recent study on online no-prescription somatropin
medicines [18] found results similar to EAASM: most
(94%) did not require valid prescriptions and were sub-
standard. Further, all online medication samples analyzed
contained significantly lower active ingredient concentra-
tions than labeled. All of this notwithstanding, “nearly
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
one in four adult consumers has purchased prescrip-
tion medicines online and almost one in five of [of them]
bought from a website that was not associated with a
local pharmacy or health insurance plan” in the U.S. ([19]
para 8). Generally, consumers who frequently buy online
and spend more time on the internet have more favora-
ble attitudes toward online pharmacies than those who
do not [20]. (e focus of this study is, however, not on
where SFMs are accessed or sold. us far, the discussion
is to illustrate and reflect on how easy it is to access sub-
standard and falsified medicines.)
Besides their implications for pharmaceutical brands,
SFMs proliferation is a more significant public health
threat than diseases they purport to cure [8, 21]. ey
have dire long-term health consequences for consumers
(e.g., organ failure, antimicrobial resistance, overdose,
or even death) [6, 8, 10, 15]. As Lybecker [21] observes,
counterfeiting is a less understood, invisible barrier to
medication access and safety compared to pharmaceuti-
cal pricing. us, medication access does entail not only
availability and affordability but also quality [22]—all
three of which relate to SFMs. e health, safety, risks
notwithstanding, most people, including Americans, are
unaware of the prevalence of the problem and the con-
sequences of purchasing and taking such drugs [2, 4, 20,
21]. e lack of rigorous and universal drug regulatory
frameworks, the complexity of drug supply chains and
the sophistication of medicine packaging make it diffi-
cult for regulators, pharmaceutical firms, activists, and
consumers to detect counterfeit drugs [6]. Much of the
fake medicine problem comes from the globalization of
the pharmaceutical industry itself [2, 14, 18]. With an eye
on cost reduction and competitiveness, many compa-
nies have outsourced the supply of ingredients and even
the actual manufacturing of their final goods around the
globe (e.g., China and India).
e falsified and substandard medicines problem strad-
dles business and public health, given the public health
and safety, financial, and brand equity implications [6, 10,
23]. is study was part of a larger project on SFMs as
global health, brand, marketing, and public policy chal-
lenge. It examines the association between demographic
factors (i.e., age and income), self-reported knowledge of
the problem, ethical judgment, risk aversion and subjec-
tive norms (on the one hand), and consumers’ attitudes
toward falsified and substandard medicines, their risk
perception, and purchase intentions (on the other hand).
Despite the pervasiveness of the substandard and falsi-
fied medicines challenge, existing research (except for a
few studies in low-income countries [7, 21]) has mainly
focused on the supply chain. Others concentrate on reg-
ulatory conditions and technologies that make it chal-
lenging to—or can help—address the challenge [14, 24].
Pharmaceuticals are increasingly adopting technologies
to support electronic tracking or point of purchase veri-
fication codes (e.g., mPedigree). But some manufactur-
ers claim such technologies are unreliable and increase
drug costs [24]. Wechsler [24] also observes how phar-
macists protest taking on the additional responsibility of
checking the authenticity of every drug coming in from
wholesalers and distributors. Besides, the pharmaceutical
industry insists that counterfeit detection and resistance
technologies must be regularly rotated as counterfeit-
ers can easily duplicate them within 12–18months [14].
ese observations suggest the importance of a comple-
mentary consumer-facing, demand-side approach, which
considers the socio-cognitive antecedents of consumers’
judgment and decision making. e decision-making
process is further complicated by packaging characteris-
tics not being reliable markers of authenticity [25] since
counterfeits and genuine drugs tend to look identical.
Complementing studies on how policymakers can cur-
tail the SFM market to ensure health and safety, we focus
on the consumer. Understanding the psycho-social fac-
tors that underlie their attitudes and purchase intentions
can inform public health communication and advocacy
efforts to improve consumer decision-making.
Literature andhypotheses
Given the lack of theoretical development on consumer
attitudes toward SFMs, this study set out to ascertain
some predictors of consumers’ attitudes toward falsified
medicines (to know how best to engage them). e study
is based on aspects of the theory of planned behavior
and reasoned action [26, 27] and literature on consumer
behavior in general consumption contexts and risk per-
ception and decision-making. We propose six hypotheses
and three research questions. Each hypothesis (except
H1) had three dependent variables: attitudes toward
SFMs, risk perception, and purchase intent.
While the global falsified and substandard medicines
challenge transcends legal, regulatory, and engineering
considerations, studies examining this problem are lim-
ited in scope, often framing the problem in terms of low-
resource countries (see systematic review by McManus
and Naughton [8]). In response to this, some researchers
have long suggested that communication strategies need
to be implemented to address the safety issue of using
SFMs and traits that consumers can use to detect coun-
terfeits [28]. e study developed partly in response to
these calls to execute aggressive campaigns to increase
public awareness of counterfeits [29–31], implement
anti-counterfeit programs that emphasize the quality and
safety of using authentic products, and develop tailored
communication strategies to address attitudes and beliefs
about counterfeits [32].
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To deliver compelling messages about fake drugs and
increase public awareness, advocates’ understanding
of the motivations or predictors of using counterfeits is
essential. For example, Nigeria spent over $68 million
trying to address the fake medicines challenge over a
decade ago but has made little progress [25]. Given the
lack of studies on consumer attitudes toward substand-
ard and falsified medicines in general and the United
States, we observe some lessons from the few studies
in low-income countries. e study also borrows from
the literature on consumer behavior regarding counter-
feit products in general consumer contexts (although
counterfeited medicines are, arguably, different from
other consumer goods). ese studies suggest that social
norms, demographics, perceived risks, risk aversion, and
ethical judgment are associated with consumer attitudes
and purchase intentions toward counterfeit products [7,
21, 33–41]. In non-pharmaceutical contexts, perceived
risk, whether individuals view consuming such products
as fair or unfair, and whether they feel counterfeit prod-
ucts make a positive contribution to their well-being is
associated with consumer attitudes and purchase inten-
tions [39]. e association between perceived risk and
consumer attitudes is such that individuals who view
counterfeit products as risky are less likely to consume
counterfeit products [34, 42–45]. Besides, when peo-
ple think the social costs victims of counterfeit products
incur are too high, they disapprove of fake products [36].
us, we hypothesize that:
H1a: ere is an inverse relationship between the risk
consumers associate with SFMs and their attitude
toward such medication.
H1b: Consumers’ perceived risk of SFMs is negatively
associated with their purchase intentions.
Overall, people’s ethical judgments about counterfeit
medications are associated with their attitudes, con-
sumption intentions, and behaviors. ose who see buy-
ing counterfeit consumer products as unfair or unethical
tend to have unfavorable attitudes and purchase inten-
tions [35, 38, 39, 45, 46]. Hence, we hypothesized that:
H2a: e ethical judgments consumers make about
SFMs have a negative effect on their overall attitude
toward such medicines.
H2b: ere is a positive relationship between con-
sumers’ ethical judgment about SFMs and how
much risk they associate with such medication.
H2c: ere is a negative relationship between con-
sumers’ ethical judgment about SFMs and their pur-
chase intentions.
Studies in non-pharmaceuticals contexts [34, 35, 42,
46] also suggest that consumers who have bought coun-
terfeit products in the past have more favorable views
on such products. us, knowing about or having expe-
rience with counterfeit products may not necessarily be
associated with unfavorable attitudes toward such prod-
ucts. Our third set of hypotheses predicted that:
H3a: Consumers’ self-reported knowledge of SFMs is
inversely related to their attitudes toward such medi-
cines.
H3b:Consumers’ self-reported knowledge of SFMs
positively correlates with the risk they associate with
SFMs.
H3c:Consumers’ self-reported knowledge of SFMs is
inversely related to their intention to purchase such
drugs.
Further, as the theory of planned behavior and rea-
soned action propose, individuals’ subjective norms
[26, 27] have implications for their attitudes, intentions,
and behaviors. is mechanism is also termed norma-
tive susceptibility —people taking actions based on their
expectations about what will impress others [7, 27, 39]. In
simple terms, subjective norms refer to individuals’ per-
ception or “opinion about what important others believe
the individual should do [or not do in a specific situa-
tion]” ([47] p. 2015]). Applied to counterfeit products,
extant research [7, 39, 46, 48] shows that when consum-
ers think people who are important to them (e.g., family
and friends) will disapprove of their decision to patron-
ize counterfeit products, they tend to have unfavorable
attitudes and purchase intentions. erefore, the fourth
hypothesis predicted that:
H4a: ere is a positive relationship between con-
sumers’ subjective norms and their attitudes toward
consuming SFMs.
H4b: ere is a negative relationship between con-
sumers’ subjective norms and risk perception.
H4c: ere is a positive relationship between con-
sumers’ subjective norms and purchase intentions.
Further, research on counterfeit products in general
consumption contexts links risk aversion to consumer
attitudes toward and intention to purchase such prod-
ucts. Individuals with a predisposition to avoid risks
tend to express concern over the efficacy of counter-
feit products and how safe they are [39, 44, 46]. Similar
to the effect of risk perception on consumer attitudes
toward counterfeit products [34, 42], risk aversion can
negatively affect consumers’ attitude toward counterfeit
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
goods [44]. In line with these studies, our fifth set of
hypotheses predicted that:
H5a: Risk aversion is negatively related to attitude
toward purchasing SFMs.
H5b: ere is a positive relationship between risk
aversion and consumers’ risk associated with SFM
consumption.
H5c: ere is an inverse relationship between risk
aversion and consumers’ risk associated with SFM
consumption.
Regarding demographics, some studies suggest that
income is not a significant determinant of consumers’
intention to purchase counterfeits (e.g., [42, 49]). But
others have associated having lower income levels and
being young with favorable attitudes toward counterfeit
goods [39, 41]. It is reasonable to expect that people of
lower socioeconomic status are most likely to patron-
ize SFMs because of price incentives or economic con-
cerns. is may not always be the case, however. For
example, individuals who order medications —often
SSFFCs— from no-prescription websites tend to be
literate and have relatively high socioeconomic status
[50, 51]. Although price incentives are often cited as a
reason for online medication purchases (94% of which
tend to be fake), for some medications, SFM online
versions can be more expensive (40–65% higher) than
genuine brands [18]. e mixed results on income and
SFM purchase intentions notwithstanding since coun-
terfeit medicines tend to be, perceived as, or marketed
as cheaper [2, 18], we hypothesize that:
H6a: ere is an inverse relationship between con-
sumers’ income and their attitude toward SFMs.
H6b: ere is an inverse relationship between con-
sumers’ income and the perceived risks of SFMs.
H6c: Consumers who earn more are less likely to
purchase SFMs than those who earn more.
As Tom et al. [41] found concerning age, individu-
als who have purchased counterfeit products in the
past are “significantly younger” than those who have
never purchased faked goods. But studies linking age
and consumer behavior relating to counterfeits are
inconclusive. For example, other researchers [42, 49]
have found no significant relationship between the two
variables. erefore, we pose no specific hypotheses;
instead, our first research question asked:
RQ1a: To what extent does attitude toward coun-
terfeit drugs differ by age?
RQ1b:To what extent does risk perception differ
by age?
RQ1c: To what extent does purchase intention for
counterfeit drugs differ by age?
e second set of research questions addresses the
cumulative relationship between our predictor vari-
ables of interest and the specified outcomes.
RQ2a: Controlling for age, to what extent do con-
sumer knowledge, ethical judgment, risk aversion,
and subjective norm predict their overall attitudes
toward SFMs?
RQ2b: Controlling for age, how do consumer
knowledge, ethical judgment, risk aversion, and
subjective norm predict their overall risk percep-
tion?
RQ2c: Controlling for age, to what extent do con-
sumer knowledge, ethical judgment, risk aversion,
and subjective norm predict consumers’ purchase
intentions?
Method
Participants
e researchers collected 427 valid samples through
Amazon’s Mechanical Turk (MTurk), a crowdsourc-
ing service. Social science experiments and surveys
are increasingly using MTurk samples [52–54]. Despite
these samples being self-selected, they are representa-
tive of the general United States population on charac-
teristics such as party identification, political ideology,
geographical categories, education, age, marital status,
religion, and employment than in-person convenience
samples [55, 56].
e respondents’ age ranges from 18 to 74. e
majority of samples range from age 25 to 44 (n = 274,
64.1%). We recruited an equal proportion of people
from both genders (n = 213 for each). In terms of eth-
nicity, more than 70% of the respondents were White
(n = 332, 77.8%), followed by Asian Pacific (n = 38,
8.9%), African American (n = 27, 6.3%) and Hispanic
(n = 24, 5.6%). Approximately 74.2% of the respond-
ents had some level of college education (n = 317), and
15.2% of the samples had professional degrees, master’s
or doctorate (n = 65), while 10.5% of the samples have
had a high school degree or less (n = 45). More than
half of the sample has a fixed income less than $50,000
(n = 242, 56.7%), 26.9% earn $50,000 to less than
$80,000, and approximately 16.4% have a yearly income
of $80,000 to more than $100,000 (n = 70).
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Procedure
e online survey consisted of two sections. e first
section of the questionnaire asked about respondents’
knowledge of the substandard and falsified medicines
challenge, risk aversion, the ethicality of buying or sell-
ing fake medicines, subjective norms about the issue,
risk perception, perceived benefit, attitudes, and pur-
chase intention of purchasing SFMs. Demographic
information includes age, gender, income, and educa-
tional background. Before answering the actual ques-
tions, the researchers informed the respondents: “e
term ‘counterfeit’ is used to describe products that
are deliberately mislabeled with respect to their iden-
tity and/or source. Counterfeiting can apply to both
branded and generic products. It may include prod-
ucts that contain the wrong ingredients, without active
ingredients, with insufficient quantities of ingredient(s),
or with fake packaging.”
Measurement reliability
All items were measured using a five-point Likert scale
(1 = strongly disagree, 5 = strongly agree). e measures
used for this study include knowledge of SFMs, perceived
value, perceived risks, attitude toward counterfeit drugs,
subjective norms about SFMs, ethical judgment, risk
aversion, behavioral control, and purchase intention. All
computed Cronbach’s alphas are reliable.
Knowledge ofSFMs
e study used a three-item measure (adapted from Yoo
and Donthu [57]) to assess respondents’ awareness of
SFMs. e statements include: “I can recognize coun-
terfeit medicines among other genuine brands,” “I am
aware of counterfeit products,” and “Some characteris-
tics of counterfeit medicine come to my mind quickly”
(α = 0.73, M = 2.71).
Perceived risk
Five items were adapted and used to assess the risks
participants associate with consuming SFMs (α = 0.92,
M = 3.65) [37, 58].
Perceived value/benets
A three-item adapted measure of perceived benefit [58]
of consuming counterfeit medicines was also adminis-
tered (α = 0.95, M = 1.78) and used as a covariate.
Attitude towardSFMs
Fourteen items asking about the respondents’ attitude
toward SFMs were adapted from the literature [39, 46].
e items asked about participants’ attitudes toward buy-
ing and selling SFM (α = 0.98, M = 1.60).
Subjective norm aboutSFMs
Seven items [33] were adapted and used to assess the
variable asking how the respondents know would think
of buying SFMs (α = 0.92, M = 2.07).
Ethical judgment
Five items assessing the respondents’ ethical judgments
regarding buying and selling SFMs were used (α = 0.85,
M = 3.94). ree questions were adopted from a previ-
ous study [59], and two additional researcher-generated
items were added.
Risk aversion
Eight items were used to evaluate the respondents’
general risk aversion and aversion to SFMs (α = 0.78,
M = 3.87) [46, 60].
Purchase intention
Seven items were used to assess the respondents’ likeli-
hood of buying SFMs (α = 0.86, M = 1.80). e seven-
item scale was adapted from Sweeney, Soutar, and
Johnson [58] and Chakraborty etal. [37].
Results
Perceived risk, consumer attitude, andintent toconsume
SFMs
Our test of H1a found a negative relationship between
perceived risk of SFMs and consumers’ overall atti-
tudes toward such medicines (β = -0.59, B = -1.95,
t(425) = -15.20, p < 0.001, R2 = 0.35, F(1, 425) = 230.98,
p < 0.001). Risk perception explains 35 percent of the
variance in consumers’ attitudes toward counterfeits. e
relationship is such that a 100-point increase in risk per-
ception is associated with a 25-point reduction in how
favorable consumers’ views on counterfeits are.
H1b predicted a negative relationship between risk per-
ception and SFMs purchase intentions. is hypothesis
was also supported (β = -0.61, B = -0.15, t(425) = -15.97,
p < 0.001, R2 = 0.38, F(1, 425) = 255.12, p < 0.001). us,
risk perception explains 38 percent of the variance in
consumers’ intention to purchase SFMs.
Ethical judgment, attitude, risk perception, andpurchase
intention
Our analysis also found support for the hypothesis (H2a)
that consumers’ ethical judgment about SFMs is inversely
related to their overall attitude toward consuming such
medicines (β = -0.45, B = -6.97, t(425) = -10.29, p < 0.001,
R2 = 0.20, F(1, 425) = 105.86, p < 0.001). Ethical judg-
ment explains 20 percent of the variance in attitudes
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
toward counterfeits. Similarly, we found support for the
predicted relationship (H2b) between ethical judgment
and risk perception (β = 0.51, B = 2.43, t(425) = 12.29,
p < 0.001, R2 = 0.26, F(1, 425) = 151.09, p < 0.001). us,
higher risk perception is associated with consumers
who view buying and selling SFMs as unethical. Ethics
explains 26 percent of the variance in risk perceptions.
e results also support our hypothesis (H2c) regarding
ethical judgments and purchase intention. Consumers
who view SFMs as unethical are less intent on purchas-
ing such medicines (β = -0.47, B = -0.54, t(425) = -11.05,
p < 0.001, R2 = 0.22, F(1, 425) = 122.06, p < 0.001).
Knowledge ofcounterfeit drugs, attitude, risk perception,
andpurchase intention
Contrary to H3a, we found a positive relationship
between consumer knowledge and attitude toward SFMs
(β = 0.32, B = 1.29, t(425) = 6.98, p < 0.001, R2 = 0.10,
F(1, 425) = 48.68, p < 0.001). us, surprisingly, consum-
ers who are more aware of the phenomenon of SFMs
tend to have more favorable views on SFMs than those
who claim not to be aware of the problem. A 100-point
increase in consumers’ knowledge is associated with an
approximately 32-point increase in favorable attitudes
toward the issue. Knowledge explains 10 percent of the
variance in consumers’ attitudes. Also, contrary to H3b,
we found a negative relationship between knowledge and
perceived risk of counterfeit drugs (β = -0.16, B = 0.19,
t(425) = -3.26, p = 0.001, R2 = 0.02, F(1, 425) = 10.61,
p < 0.001). us, surprisingly, consumers who are more
aware of SFMs tend to associate the phenomenon with
lower risks than those who claim not to be aware of the
problem. A 100-point increase in consumers’ knowledge
is linked to a 16-point reduction in the risks they associ-
ate with consuming SFMs. But this variable explains only
two percent of the variance in risk perceptions.
H3c predicted a negative link between consumers’
knowledge and intentions to purchase or use SFMs. A
significant relationship was found but in the reverse
direction (β = 0.25, B = 0.07, t(425) = 5.22, p < 0.001,
R2 = 0.06, F(1, 425) = 27.22, p < 0.001). us, contrary to
our expectations, people aware of SFMs are more willing
to purchase and consume such products than those who
are not.
Subjective norm, attitude, risk perception, andpurchase
intention
e study found support for H4a, which predicted
a positive relationship between consumers’ subjec-
tive norm toward purchasing SFMs and their over-
all attitude toward the sale and consumption of
counterfeit drugs (β = 0.60, B = 7.18, t(425) = 14.47,
p < 0.001, R2 = 0.33, F(1, 425) = 208.23, p < 0.001). us ,
consumers who think their friends and loved ones will
approve of them consuming SFMs tend to have an over-
all favorable attitude toward such medicines than peo-
ple who think their loved ones will disapprove of such a
practice. Subjective norm explains 33% of the variance
in consumer attitudes. A 100-point increase in subjec-
tive norm is associated with a 60-point reduction in
risk perception.
Additionally, the study found support for H4b, which
predicted a negative relationship between consum-
ers’ subjective norm toward purchasing SFMs and their
risk perceptions (β = -0.60, B = -2.27, t(425) = -15.35,
p < 0.001, R2 = 0.36, F(1, 425) = 235.62, p < 0.001). us,
consumers who think their friends and loved ones will
approve of them consuming SFMs tend to perceive
lower risks than those who think their loved ones will
disapprove of such a practice. e relationship between
subjective norm and risk perception is such that, for
example, a 100-point increase in subjective norm is asso-
ciated with a 60-point reduction in risk perception.
H4c predicted a positive relationship between con-
sumers’ subjective norm toward purchasing SFMs and
their purchase intentions. is was supported (β = 0.58,
B = , 0.53, t(425) = 14.61, p < 0.001, R2 = 0.33, F(1,
425) = 213.58, p < 0.001). Hence, consumers who think
their friends and loved ones will disapprove of their deci-
sion to SFMs are more likely to say they do not intend
to purchase such medicines. Moreover, subjective norm
explains a third of the variance in consumers’ purchase
intentions regarding fake medicines.
Risk aversion, consumer attitude, risk perception,
andpurchase intention
Our hypothesis (H5a) regarding risk aversion and con-
sumers’ attitude toward the purchase of SFMs was sup-
ported (β = -0.45, B = -7.64, t(425) = -10.45, p < 0.001,
R2 = 0.20, F(1, 425) = 109.18, p = < 0.001). i s variable
explains 20 percent of the variance in consumer attitudes
toward purchasing SFMs. e relationship is such that a
100-point increase in aversion is linked with a 45-point
decline in attitudes toward SFMs. H5b predicted a posi-
tive relationship between risk aversion and consumers’
risk associated with counterfeit medicine consumption.
e analysis found support for this hypothesis (β = 0.49,
B = 2.52, t(425) = 11.61, p < 0.001, R2 = 0.24, F(1,
425) = 134.78, p < 0.001). Risk aversion explains only 24
percent of the variance in the risk consumers associated
with consuming SFMs. Our test of H5c also found sup-
port for the hypothesis that there is an inverse relation-
ship between consumers’ risk aversion and the intentions
to purchase SFMs (β = -0.50, B = -0.61, t(425) = -11.89,
p < 0.001, R2 = 0.25, F(1, 425) = 141.26, p < 0.001).
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
Income,attitude towardSFMs, risk perception,
andpurchase intention
To test our hypothesis (H6a) regarding consumers’
income level and their attitudes toward SFMs, we con-
ducted a one-way ANOVA test. We found a signifi-
cant difference among consumers of certain income
groups (F(4, 422) = 2.41, p < 0.05). Additional post-hoc
tests found that consumers who earn less than $20,000
had more favorable attitudes toward counterfeit drugs
(m = 22.69, sd = 11.72) than those who earn between
$20,000 and $50,000 (m = 19.18, sd = 9.36, p < 0.05).
Also, the $20,000 and $50,000 (m = 19.18, s d = 9.36)
income bracket group had less favorable views on SFMs
that those earning $80,000 and $100,000 (m = 23.59,
sd = 13.17, p < 0.05). We found no difference for the
other income groups.
To test our hypothesis (H6b) regarding the income
and SFMs risk perception, we conducted a one-way
ANOVA. e analysis found no significant differences
in risk perception (F(4,422) = 1.32, p > 0.05). Hyp othesis
2c regarding the income and SFMs purchase intention
also found an insignificant relationship between income
levels and SFMs purchase intention (F(4, 422) = 1.23,
p > 0.05).
Age, attitude towardSFMs, risk perception, andpurchase
intention
A series of regression tests were conducted to address
our research questions regarding age and the follow-
ing outcomes: attitudes, risk perceptions, and purchase
intentions. First, regarding RQ1a, consumers’ attitude
toward SFMs were found to differ by age (β = -0.17,
B = -1.44, t(425) = -3.44, p = 0.001, R2 = 0.03, F(1,
425) = 11.82, p = 0.001). us, older people tend not to
like SFMs.
Second, regarding RQ1b, age was positively associ-
ated with SFMs risk perceptions (β = 0.21, B = 0.55,
t(425) = 4.40, p < 0.001, R2 = 0.04, F(1, 425) = 19.34,
p = 0.001). us, older people associate SFMs with
higher risks than younger consumers do.
Our test regarding RQ1c, returned a significant nega-
tive association between consumers’ age and their
intentions to purchase SFMs (β = -0.19, B = -0.12,
t(425) = -4.02, p < 0.001, R2 = 0.04, F(1, 425) = 16.14,
p = 0.001). at is, younger consumers are more likely
to consume SFMs than older people.
Overall model predicting consumer attitudes, risk
perception, andbehavior intention
We conducted a series of multiple regressions to test
the combined effect of age, knowledge, ethical judg-
ment, risk aversion, and subjective norm on risk
perceptions, attitude toward counterfeit medicine con-
sumption, and purchase intentions (R.Q. 2a – 2c). See
Table1 for how these predictors correlate to each other.
First, a multiple linear regression was calculated to pre-
dict consumer attitudes toward “counterfeit medicine”
consumption based on their age, knowledge, ethical judg-
ment, risk aversion, subjective norm, and perceived ben-
efit. (Income does not significantly improve the model;
we have, therefore, excluded it from the results for par-
simony.) e overall model (Model 2) explains more
than a two-thirds of the variance in consumer attitude
toward SFMs (F(6, 420) = 162.30, p < 0.001, R2 = 0.70). As
the standardized betas show in Table2, controlling for
all other factors, perceived benefit is positively associ-
ated with attitudes, and is the most significant predictor
of consumer attitudes toward SFMs. is is followed by
subjective norm, risk aversion, and self-reported knowl-
edge of the substandard and falsified medicines problem.
Age and consumers’ ethical judgments about buying or
selling SFMs are not significant factors in the predictive
model (p = 0.44 and 0.50, respectively).
Second, a multiple linear regression was calculated to
predict consumers’ perception of the risks associated
with counterfeit medicine consumption based on age,
knowledge, ethical judgment, risk aversion, subjective
norm, and perceived benefit of SFMs. e overall model
(Model 2) explains more than half of the variance in the
risk consumers associate with SFMs (F(6, 420) = 76.07,
p < 0.001, R2 = 0.52). From Table 3, controlling for the
other factors, the standardized coefficients show that
Table 1 Correlation matrix of all predictors
a Correlation is signicant at the 0.05 level (2‑tailed). N = 427
b Correlation is signicant at the 0.01 level (2‑tailed)
Age Knowledge Subjective
Norm Ethical
Judgment Risk Aversion
Age
r 1
Sig
Knowledge
r ‑.027 1
Sig .584
Subjective Norm
r ‑.083 .125b1
Sig .088 .010
Ethical Judgment
r .103a‑.091 ‑.601b1
Sig .034 .061 .000
Risk Aversion
r .099a‑.163b‑.422b.432b1
Sig .042 .001 .000 .000
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
subjective norm is the most significant predictor of the
risk individuals associate with counterfeit medicine con-
sumption. is was followed by perceived benefits, risk
aversion, ethical judgment, and age. Self-reported knowl-
edge does not significantly improve the model (p = 0.16).
ird, we run a multiple linear regression to predict
consumers’ intention to purchase SFMs based on age,
knowledge, ethical judgment, risk aversion, subjective
norm, and perceived benefit. e overall model (Model
2) explains about 56 percent of the variance in the con-
sumers’ intention to purchase SFMs (F(6, 420) = 87.31,
p < 0.001, R2 = 0.56). As seen in Table4, the standardized
betas indicate that (controlling for all other factors), per-
ceived benefit is the best predictor (with a positive asso-
ciation) of consumers’ purchase intention, followed by
subjective norm, risk aversion, and age (in that order).
Ethical judgment (p = 0.11) and knowledge (p = 0.11)
has no significant effect after controlling for all the other
predictors.
Finally, based on the theory of planned behavior’s prop-
osition that subjective norms, attitudes, and perceptions
influence individuals’ behavioral intentions [26, 27], the
Table 2 Summary of hierarchical regression analysis for variables predicting attitude toward counterfeit medicine consumption
(N = 427)
For subjective norm, a high score implies a belief that friends and loved ones will approve of them consuming SFMs. A high score on ethical judgment implies a belief
that counterfeit medicine sale and consumption is unethical
Model Unstandardized Coecients Standardized
Coecients t Sig
B S.E. B β
1 (Constant) 40.777 5.786 7.048 .000
Age ‑1.435 .417 ‑.165 ‑3.439 .001
F = 11.82 .001
R2 = .03
2(Constant) 10.691 4.610 2.319 .021
Age ‑.182 .238 ‑.021 ‑.766 .444
Knowledge .350 .114 .087 3.070 .002
Subjective Norm 2.775 .447 .222 6.208 < .001
Ethical Judgment ‑.364 .543 ‑.023 ‑.670 .503
Risk Aversion ‑1.792 .526 ‑.106 ‑3.406 < .001
Perceived Benefit 3.035 .163 .609 18.676 < .001
F = 162.30 < .001
R2 = .70 < .001
Table 3 Summary of hierarchical regression analysis for variables predicting perceived counterfeit medicine risk (N = 427)
Model Unstandardized Coecients Standardized Coecients t Sig
B S.E. B β
1 (Constant) 10.617 1.747 6.078 .000
Age .554 .126 .209 4.398 .000
F = 19.34
R2 = .04
2(Constant) 12.449 1.770 7.032 < .001
Age .264 .091 .100 2.895 .004
Knowledge .020 .044 .016 .448 .655
Subjective Norm ‑1.132 .172 ‑.297 ‑6.594 < .001
Ethical Judgment .614 .209 .129 2.941 .003
Risk Aversion 1.000 .202 .194 4.952 < .001
Perceived Benefit ‑.441 .062 ‑.290 ‑7.059 < .001
F = 76.07 < .001
R2 = .52 < .001
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
researchers estimated a predictive model for consumers’
intentions to patronize SFMs. e predictors include age,
knowledge, subjective norm, ethical judgment, risk aver-
sion, attitude, risk perception, and perceived benefit. e
final model explains 65 percent of the variance in the con-
sumers’ intention to purchase SFMs (F(8, 418) = 98.98,
p < 0.001, R2 = 0.65). Age (p = 0.11), knowledge (p = 0.69),
and ethical judgment (p = 0.31) have no significant effects
on individuals’ intention to consume SFMs. Interestingly,
also, perceived value/benefit does not have a significant
effect on intentions (p = 0.51). Controlling for all other
factors, consumers attitudes is the largest predictor of
their behavioral intentions (β = 0.51, p < 0.001), followed
by perceived risks (β = -0.13, p = 0.002), risk aversion
(β = -0.12, p < 0.001) and subjective norms (β = -0.12,
p < 0.009).
Discussion
To the best of our knowledge, this study is the first to
examine the social and psychological predictors of con-
sumer attitudes toward SFMs in the United States.
Our results are therefore useful for further inquiry and
practice. e research is based on the view that beyond
product packaging—which is an unreliable marker of
authenticity [25]—social, psychological, and norma-
tive considerations can help understand how consumers
relate to counterfeit products—in this case, medicines.
As a first step toward understanding how consumers
think about counterfeit drugs, this research examined
how factors such as knowledge, income, age, ethical judg-
ment, risk aversion, subjective norm (or normative sus-
ceptibility) help explain (a) what consumers think about
SFMs, (b) the risks they associate with consuming such
medication, as well as (c) their intentions to purchase.
Based on existing research [29, 31], one would expect
that having prior knowledge of SFMs will valence peo-
ple’s attitudes toward the problem. However, our hypoth-
esis testing suggests that self-reported knowledge of the
SFMs challenge is associated with favorable consumer
attitudes and purchase intentions. ree possible reasons
might explain this result. First, as earlier studies [39, 42]
found in non-pharmaceutical contexts, being aware of,
knowing about, or having consumed counterfeit prod-
ucts in the past, is not necessarily associated with unfa-
vorable attitudes toward such products. It is, therefore,
plausible that for the consumers, statements such as “I
can recognize counterfeit medicines among other genu-
ine brands,” “I am aware of counterfeit medicines,” and
“Some characteristics of counterfeit medicines come to
my mind quickly” serve as proxies for personal experi-
ence with SFMs. us, the finding that self-reported
knowledge is positively associated with attitude toward
counterfeit drugs and purchase intentions (but negatively
associated with risk perception) aligns with earlier stud-
ies on individuals past counterfeit products consumption
and attitudes [42, 46]. A second explanation for these
results comes from the risk perception and decision sci-
ence literature: familiarity and habituation. When people
see risky phenomena or hazards as familiar or known (as
opposed to novel), they discount how dangerous those
phenomena are despite that the objective level of the risk
remains the same (see Slovic [61]).
Further, risk perception mediates consumers’ evalua-
tions of counterfeit products [37]. In other words, being
aware of SFMs may not lead to unfavorable attitudes if we
Table 4 Summary of hierarchical regression analysis for variables predicting SFMs purchase intentions (N = 427)
Model Unstandardized Coecients Standardized Coecients t Sig
B S.E. B β
1 (Constant) 3.478 .419 8.304 .000
Age ‑.121 .030 ‑.191 ‑4.017 .000
F = 16.14 .000
R2 = .04
2(Constant) 2.481 .407 6.090 < .001
Age ‑.046 .021 ‑.072 ‑2.173 .030
Knowledge .016 .010 .055 1.590 .113
Subjective Norm .239 .040 .263 6.059 < .001
Ethical Judgment ‑.077 .048 ‑.068 ‑1.605 .109
Risk Aversion ‑.247 .046 ‑.201 ‑5.309 < .001
Perceived Benefit .139 .014 .383 9.662 < .001
F = 87.31 < .001
R2 = .56 < .001
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
conceptualize knowledge as familiarity. us, to “know
something” is to be “familiar with it,” and familiarity has
a discounting effect on risk perception. A third possible
explanation is that consumer knowledge serves as a proxy
for self-efficacy, which attenuates consumer attitudes [33,
46]. ese hypotheses are all fertile grounds for further
testing.
e study also reports on two demographic variables:
income and age. Contrary to studies [39, 41] that link
having a low income to favorable attitudes and SFM pur-
chase intentions, our results suggest that the relationship
between income and how consumers feel about sub-
standard and falsified medicines is mixed, and may not
be linear. While consumers who earn less than $20,000
had more favorable attitudes toward counterfeit drugs
than those who make between $20,000 and $50,000,
those who make income higher than $50,000 are no dif-
ferent from all other groups. is finding aligns with Tom
etal.’s [41] — but contrary to Bian and Moutinho’s [42]—
results on consumer attitudes toward counterfeit prod-
ucts in general. is study also found younger consumers
to be more risk-tolerant and have favorable attitudes
toward SFMs. is finding, coupled with high internet
usage among younger people, may make them more sus-
ceptible to illicit online pharmacies [62].
Also, corroborating results from earlier studies from
other counterfeit product categories [39, 40], this study
supports the hypothesized link between risk perception,
attitudes toward SFMs, and purchase intentions. us,
when consumers see counterfeit drugs as risky in terms
of long-term health implications, costs, and efficacy, they
are less likely to express intent to patronize such medi-
cines. It suggests that awareness creation that focuses on
personal risks and negative cues [36, 37] could enhance
consumer decision-making about counterfeit drugs.
While this study does not test for the mediation effect
of risk perception on attitudes and consumers’ intention
to purchase SFMs, given the pattern of results obtained
in this exploratory study, it is reasonable to expect some
form of mediation or moderation effects. Regarding per-
ceived risk versus benefit of SFMs: It is plausible that
even if consumers associate risks with “counterfeit” med-
icines, it might be worth the risk for them if they believe
the benefit outweighs the cost. However, as we illustrate,
the perceived benefit/value of SFMs does not signifi-
cantly affect consumption intent after controlling for risk
perception, attitude, and subjective norm.
In summary, in line with the general literature on
counterfeit products, consumer knowledge (albeit in an
unexpected direction), people’s expectations about what
will impress their significant others, their ethical judg-
ments about selling and consuming counterfeits, and
their risk-aversion are associated with their judgment
and decision-making about SFMs. While subjective
norm/normative susceptibility and perceived benefits
are the most significant predictors of consumer attitudes,
risk perceptions, and purchase intentions, these factors
combined explain 52 to 70 percent of the variance in the
specified outcomes. Despite contributing to our under-
standing of individuals’ attitudes toward fake medicines,
this study acknowledges that consumers cannot always
tell which drugs are counterfeit and which ones are
not, given the sophisticated nature of packaging used in
SFMs. us, given that packaging characteristics are not
reliable markers of authenticity [1, 6, 25], knowing the
factors that make consumers more receptive to counter-
feit medicine consumption is essential for advocacy and
public education.
Currently ongoing efforts include Alliance for Safe
Online Pharmacies’ Buy SafeRx; U.S. Food and Drug
Administration’s Know Your Source, Filled with Empty
Promises and BeSafeRx; and Pfizer’s Fight the Fakes [63].
Like studies on counterfeiting in other non-pharmaceuti-
cal consumption contexts (e.g., Michaelidou and Christo-
doulides [45]), beyond simply seeking to raise awareness,
these results have lessons for designing demand-side
strategies that combat the SFM concern. Beyond these
informational efforts, policymakers, advocates, and phar-
maceutical firms need campaigns that discourage the
consumption of SFMs by appealing to individuals’ desire
to impress their significant others, risk aversion, and risk
perception. Here, using a social desirability tactic that
highlights how consuming SFMs can hurt one’s social
standing, as well as emphasizing the health risk of con-
suming SFMs are demand-side strategies worth explor-
ing. eir attitudes can also be shaped by appealing to
their belief in a fair and equitable life.
Limitations ofthestudy andfuture studies
e most important limitation of the study derives from
its exploratory nature. Based on our comprehensive lit-
erature review, this research is the first to examine the
social and individual-level factors that underlie consum-
ers’ attitudes toward SFMs. Future studies should build
on the analysis to include, for example, mediation or
moderation tests. For instance, while the study examines
the relationship between risk aversion, knowledge, ethi-
cal judgments, subjective norms on attitudes, risk per-
ception, and purchase intentions, it does not assess the
complex relationship between these predictors. Subse-
quent studies could assess whether ethical judgments,
risk aversion, and subjective norms mediate or moderate
the effect of knowledge of consumer attitudes and pur-
chase intentions. Besides, considering this study’s public
health focus, we purposefully did not explore the legal
dimensions of the “counterfeit medicines” challenge.
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Ofori‑Parkuand Park BMC Public Health (2022) 22:1094
In addition, this work does not focus so much on where
individuals access SFMs. However, future studies would
benefit from distinguishing between different avenues
of SFM trafficking and access (e.g., illegal street markets,
online, legitimate pharmacies, clinics, and hospitals).
Besides, given that our analysis found a link between
risk perception and consumer attitudes, risk percep-
tions might mediate the effect of knowledge, ethics, and
people’s intrinsic need to engage in behaviors approved
by people who are important to them. ese results pre-
sent another avenue for follow-up studies. ese find-
ings suggest interesting direction pharmaceutical firms,
regulatory organizations, and consumer safety advocacy
groups can explore in their public education and brand
reputation protection campaigns. For example, regarding
the link between risk perception and attitudes, pharma-
ceutical brands and safety advocates would benefit from
using message cues that highlight risks, people’s need
to be affirmed by their significant others, and the need
for safety (and risk aversion). But, concerning creating
awareness about the problem, care should be taken to not
frame the issue in ways that enhance a false sense of self-
efficacy. Plus, based on evidence from the risk psychology
literature, we recommend framing the problem in ways
that make the “novelty” (as opposed to the “familiarity”)
of the problem salient. ese recommendations also pro-
vide fertile grounds for further empirical testing.
Abbreviations
EAASM: European Alliance for Access to Safe Medicines; OECD: Organiza‑
tion for Economic Co‑operation and Development; SFMs: Substandard and
falsified medicines; SSFFC: Substandard, spurious, falsely‑labeled, falsified, and
counterfeits; WHO: World Health Organization.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12889‑ 022‑ 13529‑7.
Additional le1.
Acknowledgements
Thanks to our anonymous reviewers for their feedback.
Authors’ contributions
SEP did an initial literature search and data analysis. SO‑P conceptualized the
study, did the literature review, data collection analysis, and discussions. The
author(s) read and approved the final manuscript.
Authors’ information
Sylvester Senyo Ofori‑Parku is an assistant professor in the School of Journal‑
ism and Communication at the University of Oregon. He studies consumer
behavior relating to ‘green’ brands and products, socio‑cultural cognition
pertaining to environmental/health risks, and corporate sustainability.
Sung Eun Park is an assistant professor of advertising and marketing com‑
munications at Webster University. Her research interests Her research interest
is in investigating the effect of visual elements of advertising in conjunction
with health communication.
Funding
Not applicable.
Availability of data and materials
The data reported in this study was part of a larger project. The dataset is
currently not publicly available because analyses for separate articles are
ongoing, but the corresponding author will make it available on reason‑
able request.
Declarations
Ethics approval and consent to participate
The study and all its protocols were approved by the IRB of The University
of Alabama. The study was carried out in accordance with ethical guidance.
Informed consent was obtained from all participants (inclusion criterion was
18 +). They were informed that their participation was voluntary, and they
could stop the study at any time without any repercussions. No personal
identifying information was collected.
Consent for publication
Not applicable.
Competing interests
No competing interest declared.
Author details
1 School of Journalism and Communication, University of Oregon, Eugene, OR,
USA. 2 School of Communication, Webster University, St. Louis, USA.
Received: 26 January 2022 Accepted: 23 May 2022
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