Influence of Sex and Gender on Knowledge of Generic Medicines Among Older Patients and Caregivers

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Gender-related factors may influence attitudes towards GMs, but data on older adults are scarce. This study aimed to explore sex and gender differences in knowledge and opinions about GMs among older patients and their caregivers. Methods SurFE is a cross-sectional multicenter survey conducted in Italy (April-May 2023) that enrolled non-institutionalized individuals aged ≥ 65 years and their caregivers. Participants completed a questionnaire assessing knowledge, attitudes, and perceptions of GMs, and sociodemographic and health-related information. We collected data on gender-specific factors and, using a validated methodology, developed a composite gender score. Results Among the 471 participants (312 patients and 159 caregivers), no differences related to biological sex were observed. According to the gender score, patients with male gender characteristics were less likely to believe that generic medicines are made with lower-quality substances. Additionally, both female patients and male caregivers were more likely to consider GMs equivalent to brand-name medications. Logistic regression analysis showed that female caregivers were significantly more likely to believe that GMs are produced with lower-quality substances (OR = 2.06, 95% CI 1.01–4.21, p = 0.047). No other significant associations between sex, gender, and beliefs about GMs were found. Conclusions Gender-related factors may have a greater impact on shaping beliefs about GMs than biological sex. Further research is required to explore the potential role of other sociodemographic or clinical factors to better understand and address barriers to the use of GMs. Gender medicine older adults caregivers sex differences gender Figures Figure 1 Figure 2 Key summary points Aim : Explore sex and gender differences in knowledge and opinions about generic medicines amongst older adults Findings: No significant difference according to biological sex. Patients with male gender characteristics were less likely to believe that generic medicines are made with lower-quality substances while caregivers with female gender were significantly more likely to believe the opposite. Message: Gender-related factors may have a greater impact on shaping beliefs about generic medicines than biological sex. INTRODUCTION A generic medicine (GM) is a drug designed to match an existing brand-name medicine in all of its different characteristics such as dosage form, safety, strength, method of administration, quality, performance, and intended purpose[ 1 ]. These similarities form the basis of bioequivalence, which means that a GM works in the same way and provides the same clinical benefit as the brand-name medicine. GMs can effectively treat many of today’s illnesses and offer the opportunity to substantially reduce costs for healthcare budgets and patients[ 2 – 4 ]. Indeed, GMs are bioequivalent but approximately 10–80% less expensive than brand-name medicines[ 5 ]. However, the use of GMs is still scarce due to the limited knowledge and the negative perception of patients towards their quality, efficacy, and safety[ 6 ]. Sex- and gender-related factors may significantly influence patients’ health literacy[ 7 , 8 ] and behaviours, including attitudes towards GMs. Sex differences refer to biological diversity between males and females resulting from specific genetic characteristics and hormone profiles, while gender differences refer to a socio-cultural construct involving domains such as identity, social roles, relations, and institutionalized gender[ 9 ]. These differences have gained considerable attention in recent years and are increasingly investigating in medical research. Previous studies on GMs mainly focused on sex differences in patients’ knowledge and opinions. Some studies suggest a tendency to scepticism towards GMs in females[ 10 – 12 ], while others found no evidence of any influence of sex on patients’ knowledge and preferences in regards to generic/branded medicines[ 13 , 14 ]. Moreover, the available studies mainly involved young adult individuals[ 10 , 13 ]. Nonetheless, data on knowledge and perceptions of GM among older adults, who are the main medication users, are scarce and differences by gender and sex influencing the approach towards GM have been poorly investigated and remain unclear, particularly in old age. This study aimed to explore sex and gender differences in knowledge and opinions about GM in a sample of older patients and caregivers. MATERIALS AND METHODS Study design and population The “ Survey sulle conoscenze e preferenze di pazienti anziani e caregivers in materia di farmaco equivalente - Survey on knowledge and preferences of older patients and their caregivers regarding generic medications ” (SurFE) study is a cross-sectional multicenter survey promoted by the ministerial institute “Italia Longeva” and the Italian Society of Gerontology and Geriatrics, involving several geriatric services in Italy. The survey enrolled non-institutionalized individuals aged 65 years or older or their caregivers from 15 inpatient and outpatient geriatric and internal medicine clinics across Italy from April 19 th to May 20 th , 2023. Patients with a diagnosis of a major neurocognitive disorder or with a moderate-severe cognitive impairment, according to routinely administered screening tests, or those who did not personally collect their medications from pharmacies, were excluded from the study. For these patients, we proposed their caregivers (if any) to participate in the study. The study protocol has been approved by the Ethics Committee of the coordinating center (Comitato Etico Area Vasta Emilia Centro della Regione Emilia-Romagna, protocol number 309/2023/Oss/AOUFe) and by the local Ethics Committees of the participating centers. The study complies with the guidelines of the Declaration of Helsinki, and each involved individual provided written consent to participate in the research. Data collection and sharing were conducted in line with national data protection laws, and the privacy of participants was guaranteed by anonymized data. Data collection The recruited sample was asked to fill in a questionnaire (see Supplementary material, Supplementary Questionnaire 1) on the knowledge and attitudes toward GMs, developed after a systematic literature review and composed of structured questions and validated scales (Generic Medicines Scale)[15]. The following data were collected: Sociodemographic data including age, sex, area of residence, marital status, and educational background. Health-related information, including the presence of multimorbidity, polypharmacy, autonomy in daily life activities and experiences with home medication delivery. Gender: information on factors with gender-specific features was collected based on the framework proposed by Pelletier et al . [16]. In particular, we considered the following variables: marital status, cohabiting, educational level, employment status, personal monthly income, household's primary earner status, primary role in house chores, number of hours involved in house chores, caregiving role, and self-reported stress (measured on a scale from 1 to 10). From these factors, we created a composite gender score through a two-step procedure, according with a validated methodology [16]. In the first step, we performed a binary logistic regression with sex as the outcome (male sex as the reference category) and all the above-listed gender-related independent variables. In the second step, we repeated a binary logistic regression with sex (outcome) as a function only of the variables that showed a significant association at the first step, i.e. marital status, occupation, earnings compared to the partner, primary role in house chores, number of hours involved in house chores, and self-reported stress. For each participant, the gender score was computed from the sum of the independent variables’ beta-coefficients related to the conditional probability of being female. The sample was then categorized based on the score’s tertiles so that the highest, middle, and lowest tertiles included individuals with female, neutral, and male gender characteristics, respectively (Supplementary Figure 1). Attitudes and knowledge about GMs, including question about participants’ awareness and usage of GMs and reasons for choosing or avoiding these medications. The questions assessed how frequently participants are offered generic alternatives in pharmacies, their knowledge of the characteristics, efficacy, and safety of generics compared to brand-name medication, and their willingness to select GMs based on cost differences. Additionally, participants were asked about their perceptions of medication costs and attitudes towards generic drugs among different demographic groups. Their beliefs and potential misconceptions regarding the effectiveness, quality, and safety of generic medications were also evaluated through a series of targeted statements. Statistical Analysis All analyses were conducted separately for patients and caregivers. Within each subgroup, the characteristics of participants and questionnaire responses were compared as a function of biological sex (males and females) and gender (males, neutral, females)[17]. Categorical variables are presented as counts and percentages, while continuous quantitative variables are expressed as mean ± standard deviation or median (interquartile range), as appropriate. The normal distribution of continuous variables was assessed using the Shapiro–Wilk test. Quantitative variables were compared between groups using the Student's t-test or ANOVA for normally distributed data, and the Mann–Whitney U test or Kruskal–Wallis test for non-parametric data. Categorical variables were analysed using the Chi-square test. We conducted ordinal regression analyses to assess the influence of sex and gender on patients' and caregivers' beliefs about GMs. The models were adjusted for age, education level, and region of residence in Italy. The results of the regression models are expressed as Odds Ratios (OR) and 95% Confidence Intervals (95% CI). For all analyses, statistical significance was set as a p-value <0.05. SPSS software (version 29) was used for the statistical analysis. RESULTS A total of 471 people were enrolled in the study, including 312 patients (168 females, 53.8%) and 159 caregivers (111 females, 69.8%). The characteristics of the sample are displayed in Table 1 . Most patients were older than 80, while caregivers were frequently younger than 70 years old. Male patients were more frequently married, lived with their partner or families, and had a higher monthly income than their female counterparts. According to the gender score, 73 (23.4%) patients reported characteristics traditionally ascribed to females and 96 (30.8%) to males; similarly, 58 (35.6%) caregivers reported characteristics traditionally ascribed to females and 32 (19.6%) to males. Table 1 Characteristics of the sample, divided by participant status (patient or caregiver) and sex Patients (n = 312) Caregivers (n = 159) Variable Male (n = 144) Female (n = 168) p-value Male (n = 48) Female (n = 111) p-value Age, years 0.760 0.588 ≤ 70 22 (15.3%) 27 (16.1%) 34 (70.8%) 85 (76.6%) 71–80 58 (40.3%) 71 (42.3%) 4 (8.3%) 12 (10.8%) > 80 64 (44.4%) 69 (41.1%) 9 (18.8%) 13 (11.7%) Italy’s region 0.223 0.876 North 60 (41.7%) 64 (38.1%) 18 (37.5%) 37 (33.3%) Centrum 55 (38.2%) 56 (33.3%) 10 (20.8%) 24 (21.6%) South and islands 29 (20.1%) 48 (28.6%) 20 (41.7%) 50 (45.0%) Marital status < 0.001 0.738 Widow/widower 25 (17.4%) 60 (35.7%) 5 (10.4%) 15 (13.5%) Married 101 (70.1%) 80 (47.6%) 31 (64.6%) 69 (62.2%) Single 10 (6.9%) 9 (5.4%) 8 (16.7%) 13 (11.7%) Education 0.298 0.103 Elementary 48 (33.3%) 70 (41.7%) 5 (10.4%) 15 (13.5%) Middle school or higher 90 (62.5%) 84 (50.0%) 40 (83.3%) 93 (83.8%) Living arrangement < 0.001 0.939 Alone 26 (18.1%) 52 (31.0%) 6 (12.5%) 15 (13.5%) With a partner or family 113 (78.5%) 105 (62.5%) 41 (85.4%) 91 (82.0%) Income 0.015 0.505 1000–2000 46 (31.9%) 43 (25.6%) 18 (37.5%) 36 (32.4%) > 2000 26 (18.1%) 16 (9.5%) 9 (18.8%) 15 (13.5%) When asked about their level of agreement on various issues regarding GMs, males were more inclined to state that GMs are to be used for less severe conditions and are, in general, less effective, while females believed GMs to be produced with lower-quality substances. Among patients and caregivers, males were more likely than females to consider GMs identical to brand-name medicines (Fig. 1 ). These differences were not statistically significant (Fig. 1 ). Several significant differences emerged when focusing on gender rather than biological sex (Fig. 2 ). Regarding the clinical use of GMs, patients with a male gender score and caregivers with a neutral gender score were significantly more likely to believe that GMs are to be used for less severe conditions (p = 0.03 and p = 0.002, respectively). Differently from caregivers with a female gender score, patients with a male gender score were less likely to consider GMs to be produced with lower-quality substances (p < 0.001). Additionally, patients with a neutral gender score and caregivers with a male gender score were significantly more likely to believe that GMs’ cost is lower than that of brand-name medicines because of their reduced efficacy (p < 0.001). Moreover, significantly more patients with a female gender score compared to those with neutral and male gender scores were aware of the equivalence between GMs and brand-name drugs. Conversely, among caregivers, significantly more individuals with a male gender score believed in the equivalence between GMs and brand-name medicines. For a detailed breakdown of the percentages of agreement and disagreement on the survey contents, categorized by biological sex and gender score, refer to Supplementary Table 1. Results from the logistic regression analysis, after adjustment for potential confounders, showed that female caregivers were more likely to think that GMs are produced with lower-quality substances (OR = 2.06, 95% CI 1.01–4.21, p = 0.047), while no other significant associations were observed between sex and gender and knowledge and/or different beliefs regarding GMs (see Supplementary Table 2 and Supplementary Table 3). DISCUSSION The present study investigated sex and gender differences in relation to knowledge of GMs, with a focus on older patients and their caregivers. Overall, participants largely believed that GMs are comparable to their brand-name counterparts. However, a significant number of both patients and caregivers held negative views, particularly concerning the effectiveness of generic medicines. While sex and gender-related factors did not significantly impact on the knowledge of older patients and caregivers about GMs, gender-related aspects appeared to influence some beliefs about generic medicines more than biological sex alone. In recent literature, several studies have explored sex differences in patients’ opinions and use of GMs, reporting conflicting results. Indeed, some authors describe higher health literacy levels[ 18 – 20 ] and a higher prevalence of use of GMs among female individuals[ 21 ]. Yet, some other works suggest that females might have a more negative perception of GMs[ 12 ] and show lower trust in generic substitution[ 10 , 11 ]. In our study, in the older population, females did not seem to have a more negative opinion of GMs than males, in alignment with other studies that did not find any sex-related differences in opinions towards GMs in terms of perceived efficacy as well as in preference for branded medicines and/or refusal of generic substitution[ 13 – 15 , 22 – 27 ]. Nonetheless, age may have variable effects on consumers’ opinions concerning GMs, with older age being associated with both negative and positive views[ 12 , 26 , 28 ]. Some data suggest that older adults are less likely to receive information on GMs[13) and more frequently refuse generic substitution[10) or report a preference for branded molecules[ 25 , 29 ]. Consistently, people in advanced age may have lower health literacy[ 20 , 30 ] and, therefore, we cannot exclude that sex-related differences may have been blunted in our sample of older individuals due to an overall less positive attitude towards GMs. To the best of our knowledge, this is the first study applying the concept of socio-cultural gender to explore gender-related differences in consumers’ knowledge of GMs. Gender differences were analysed using a gender score that integrated several variables such as household primary earner status, employment status, work hours, caregiving responsibilities, marital status, personal income, education level, and stress levels that can captures difference nuances related to gender-biased cultural influences on GMs’ perceptions and beliefs. Indeed, these factors were chosen based on their prior association with opinions on GMs[ 26 , 28 ] and when considering gender, we observed slightly different knowledge patterns, with individuals of neutral and female gender being less informed. Both female patients and caregivers were more likely to perceive GMs as being produced with lower-quality substances. This opinion may be related to a higher aversion to risk. Females often exhibit greater caution in health-related decisions, leading them to be more skeptical of generic alternatives and view them as potentially less safe[ 31 ]. In contrast, male caregivers are more inclined to believe that GMs are equivalent to brand-name medications. This perspective can be attributed to their greater focus on cost-effectiveness and a more rational approach to healthcare decisions[ 31 , 32 ]. Male people may be more likely to evaluate GMs based on cost-effectiveness and more rational approach to healthcare decisions rather than subjective perceptions. Furthermore, patients, having a greater emotional investment in their medications, may experience health decisions more personally and subjectively. Caregivers, on the other hand, may approach these decisions with greater objectivity and the different sources of information accessed by patients and caregivers can influence their perceptions in varying ways. Direct experiences with medications, such adverse reaction for example, may have a more significant impact on patients' opinions compared to the secondary observations of caregivers. Lastly, differences in the level of education and awareness regarding generic drugs between the two groups may further shape their opinions in distinct ways. Indeed, when adjusting the analyses for some key sociodemographic factors, such as age, education, and region of residence, these differences were not more significant, supporting a primary influence of sociocultural context in the attitude towards GMs in the older population. Moreover, available data suggest that opinions and use of GMs can also be influenced by factors such as patients’ health status, illness perception[ 15 ], drug category[ 14 ], financial problems and prescription coverage[ 33 ], and health care professionals’ opinions[ 26 ]. Patients' opinions on GMs can significantly affect treatment adherence, persistence, and overall healthcare costs. Understanding the factors that shape consumers' knowledge and attitudes toward generic medicines is essential for designing targeted educational programs and communications strategies or campaigns concerning GMs. Limitations and strengths of the study This study has some limitations. First, although a large sample of real-world older adults was involved, our study included primarily older individuals from outpatient clinics or acute care units who may not be representative of the general older population. Second, non-binary individuals and or transexual persons were poorly represented in our sample, and we were unable to investigate knowledge and opinions on GMs in this specific subgroup. Finally, the statistical power for analysing data related to caregivers was limited, which may affect the robustness of our findings for this specific population. Despite these limitations, the study has notable strengths. It engaged a significant number of older adults, providing valuable insights into this important demographic. The use of a validated gender score allowed for a nuanced analysis of gender-related factors influencing attitudes and knowledge about GMs. Additionally, the comprehensive assessment of both attitudes and knowledge regarding GMs offers a thorough understanding of the subject matter. CONCLUSIONS Among older patients and their caregivers, knowledge and opinions about GMs were not significantly influenced by sex or gender-related factors. While most participants viewed GMs as comparable to brand-name drugs, some negative perceptions persisted, particularly concerning the quality and effectiveness of GMs. These findings suggest that attitudes towards GMs in older populations may be determined more by individual experiences and overall health literacy. However, gender-related factors may have a greater impact on shaping beliefs about GMs than biological sex alone in both patients and their caregivers. Future research should explore the potential role of other sociodemographic or clinical factors that may influence gender-related factors and impact on the use of GM among older adults and their caregiver to better understand and address potential barriers. Declarations Authorship Confirmation/Contribution Statement: Conceptualization : Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Caterina Trevisan, Giulia Rivasi Data collection: Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Federica D’Ignazio, Giulia Rivasi Data curation : Caterina Trevisan Formal Analysis : Chiara Ceolin, Francesco Salis Supervision : Caterina Trevisan Visualization : Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Giulia Rivasi Writing – original draft : Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Federica D’Ignazio, Giulia Rivasi Writing – review & editing : Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Giulia Rivasi, Caterina Trevisan Author Disclosure Statement , Conflicts of interest/Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. Data availability statement : All data generated or analyzed during this study are included in this published article (and its supplementary information files). Ethics approval statement : This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the coordinating center (Comitato Etico Area Vasta Emilia Centro della Regione Emilia-Romagna, protocol number 309/2023/Oss/AOUFe) and by the local Ethics Committees of the participating centers. Patient consent statement : Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper. Funding: The SurFe study was promoted by Italia Longeva (https://www.italialongeva.it/) and supported by Egualia. Permission to reproduce material from other sources : not applicable. Clinical trial registration : not applicable. Acknowledgements. The complete list of the SurFe working group (in alphabetical order) is: Stefano Andreoli, Giada Arena, Giorgio Basile, Giuseppe Bellelli, Federica Bellone, Leonardo Bencivenga, Roberto Bernabei Anna Bertocco, Davide Maria Biancone, Enrico Brunetti, Maria Modestina Bulla, Maria Lucia Bursi, Stefano Cacciatore, Marco Capacci, Cristina Cargiolli, Stefano Caruso, Chiara Ceolin, Ludovica Ceolin, Giuseppina ConiglioAndrea Corbani, Antonio D’Errico, Federica D’Ignazio, Rosa De Felice, Maria Cristina Ferrara, Elvira Filicetti, Panaiotis Finamore, Tommaso Finco, Beatrice Fumagalli, Thelma Geneletti, Alessia Ghidini, Rossella Giordano, Giulia Gorla, Claudio Guarneri, Giovanni Lazzaro, Elisa Lenotti, Elena Levati, Myriam Macaluso, Leonarda Maltese, Davide Montini, Chukwuma Okoye, Graziano Onder, , Ilaria Parrotta, Giulia Pasolini, Chiara Petrucci, Roberto Presta, Antonella Risoli, Rengo Giuseppe, Giulia Rivasi, Priscilla Romagnoli, Francesco Salis, Ottavio Scarano, Pierfederico Scaroni, Luca Soraci, Caterina Trevisan, Ungar Andrea, Virdis Agostino, Maria Beatrice Zazzara, Alberto Zucchelli. 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Front Public Heal. 2022 Aug;10:944103. doi: 10.3389/fpubh.2022.944103. Kesselheim AS, Gagne JJ, Franklin JM, Eddings W, Fulchino LA, Avorn J, et al. Variations in Patients’ Perceptions and Use of Generic Drugs: Results of a National Survey. J Gen Intern Med. 2016 Jun;31(6):609–14. doi: 10.1007/s11606-016-3612-7. Orlando V, Mucherino S, Guarino I, Guerriero F, Trama U, Menditto E. Gender Differences in Medication Use: A Drug Utilization Study Based on Real World Data. Int J Environ Res Public Health. 2020 Jun;17(11). doi: 10.3390/ijerph17113926. Federman AD, Halm EA, Zhu C, Hochman T, Siu AL. Association of income and prescription drug coverage with generic medication use among older adults with hypertension. Vol. 12, American Journal of Managed Care. 2006. p. 611–8. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5328311","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375886328,"identity":"7e55154d-0e51-4c3b-be86-a4b2c7da1606","order_by":0,"name":"Chiara Ceolin","email":"","orcid":"","institution":"University of Padova: Universita degli Studi di Padova","correspondingAuthor":false,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Ceolin","suffix":""},{"id":375886329,"identity":"4dbbcc9d-9734-4c16-9ff5-fe4b43959f9e","order_by":1,"name":"Francesco Salis","email":"","orcid":"","institution":"University of Cagliari: Universita degli Studi Di Cagliari","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Salis","suffix":""},{"id":375886330,"identity":"333bb040-95f7-464d-a5ab-1b6608243f83","order_by":2,"name":"Myriam Macaluso","email":"","orcid":"","institution":"Università Cattolica del Sacro Cuore: Universita Cattolica del Sacro Cuore","correspondingAuthor":false,"prefix":"","firstName":"Myriam","middleName":"","lastName":"Macaluso","suffix":""},{"id":375886331,"identity":"4d9f5f75-b3c8-4b56-ae4b-093b9abad383","order_by":3,"name":"Elena Levati","email":"","orcid":"","institution":"Università Cattolica del Sacro Cuore: Universita Cattolica del Sacro Cuore","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Levati","suffix":""},{"id":375886332,"identity":"86fa973b-9887-46a3-89fe-e4851ff1ce3c","order_by":4,"name":"Maria Beatrice 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Gemelli","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"Beatrice","lastName":"Zazzara","suffix":""},{"id":375886333,"identity":"170ef006-5ec1-439d-9aa5-ed8d2b641dc7","order_by":5,"name":"Graziano Onder","email":"","orcid":"","institution":"Università Cattolica del Sacro Cuore: Universita Cattolica del Sacro Cuore","correspondingAuthor":false,"prefix":"","firstName":"Graziano","middleName":"","lastName":"Onder","suffix":""},{"id":375886334,"identity":"609a9ce5-f9db-4564-b26a-b87d314e494d","order_by":6,"name":"Roberto Bernabei","email":"","orcid":"","institution":"Italia Longeva","correspondingAuthor":false,"prefix":"","firstName":"Roberto","middleName":"","lastName":"Bernabei","suffix":""},{"id":375886335,"identity":"791f3bb7-f32b-4fa0-a983-a7d5e91c8353","order_by":7,"name":"Caterina Trevisan","email":"","orcid":"","institution":"University of Ferrara: Universita degli Studi di Ferrara","correspondingAuthor":false,"prefix":"","firstName":"Caterina","middleName":"","lastName":"Trevisan","suffix":""},{"id":375886336,"identity":"74f5c7fa-6e6e-42cc-8fed-f16d502d7625","order_by":8,"name":"Federica D'Ignazio","email":"","orcid":"","institution":"Università Cattolica del Sacro Cuore: Universita Cattolica del Sacro Cuore","correspondingAuthor":false,"prefix":"","firstName":"Federica","middleName":"","lastName":"D'Ignazio","suffix":""},{"id":375886337,"identity":"26f992b5-5da5-488c-8426-c62821f470ab","order_by":9,"name":"Gilia Rivasi","email":"","orcid":"","institution":"Università degli Studi di Firenze: Universita degli Studi di Firenze","correspondingAuthor":false,"prefix":"","firstName":"Gilia","middleName":"","lastName":"Rivasi","suffix":""}],"badges":[],"createdAt":"2024-10-24 21:16:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5328311/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5328311/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71481235,"identity":"7657b766-31e3-44bb-ac4c-ee6e6d5756ef","added_by":"auto","created_at":"2024-12-16 06:01:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2649987,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAgreement with statements regarding equivalent medications of male and female patients and caregivers.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNotes\u003c/em\u003e. Level of agreement was defined as concurring with the statements regarding generic medicines. No significant sex-related differences were found in these comparisons.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5328311/v1/856ddfbffee27f2546eec019.png"},{"id":71481230,"identity":"fe33d72b-567d-4be0-a41a-774be58c9d35","added_by":"auto","created_at":"2024-12-16 06:01:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4477547,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAgreement with statements concerning the equivalence of medications across male, female, and neutral genders among patients and caregivers.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNotes\u003c/em\u003e: Level of agreement was defined as concurring with the statements regarding generic medicines. *p\u0026lt;0.05; **p\u0026lt;0.01; ***p\u0026lt;0.001\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5328311/v1/711642d1ba7b47ed92620225.png"},{"id":71517468,"identity":"1a17e93c-786f-4920-82bc-57d8b9513c66","added_by":"auto","created_at":"2024-12-16 11:10:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6844790,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5328311/v1/384074f9-b243-4301-ad76-2fdc5bf5816f.pdf"},{"id":71482472,"identity":"4f7821db-5806-4e3b-b6f5-fbf36d43535e","added_by":"auto","created_at":"2024-12-16 06:09:32","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":69504,"visible":true,"origin":"","legend":"","description":"","filename":"SurFEgendersupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-5328311/v1/f84dbcbeb31e4e1485414556.docx"}],"financialInterests":"","formattedTitle":"Influence of Sex and Gender on Knowledge of Generic Medicines Among Older Patients and Caregivers","fulltext":[{"header":"Key summary points","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAim\u003c/strong\u003e:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExplore sex and gender differences in knowledge and opinions about generic medicines amongst older adults\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli style=\"font-weight: bold;\"\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo significant difference according to biological sex.\u0026nbsp;Patients with male gender characteristics were less likely to believe that generic medicines are made with lower-quality substances while caregivers with female gender were significantly more likely to believe the opposite.\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli style=\"font-weight: bold;\"\u003e\u003cstrong\u003eMessage:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eGender-related factors may have a greater impact on shaping beliefs about generic medicines than biological sex.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eA generic medicine (GM) is a drug designed to match an existing brand-name medicine in all of its different characteristics such as dosage form, safety, strength, method of administration, quality, performance, and intended purpose[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These similarities form the basis of bioequivalence, which means that a GM works in the same way and provides the same clinical benefit as the brand-name medicine.\u003c/p\u003e \u003cp\u003eGMs can effectively treat many of today\u0026rsquo;s illnesses and offer the opportunity to substantially reduce costs for healthcare budgets and patients[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Indeed, GMs are bioequivalent but approximately 10\u0026ndash;80% less expensive than brand-name medicines[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, the use of GMs is still scarce due to the limited knowledge and the negative perception of patients towards their quality, efficacy, and safety[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Sex- and gender-related factors may significantly influence patients\u0026rsquo; health literacy[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and behaviours, including attitudes towards GMs. Sex differences refer to biological diversity between males and females resulting from specific genetic characteristics and hormone profiles, while gender differences refer to a socio-cultural construct involving domains such as identity, social roles, relations, and institutionalized gender[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These differences have gained considerable attention in recent years and are increasingly investigating in medical research. Previous studies on GMs mainly focused on sex differences in patients\u0026rsquo; knowledge and opinions. Some studies suggest a tendency to scepticism towards GMs in females[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while others found no evidence of any influence of sex on patients\u0026rsquo; knowledge and preferences in regards to generic/branded medicines[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, the available studies mainly involved young adult individuals[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nonetheless, data on knowledge and perceptions of GM among older adults, who are the main medication users, are scarce and differences by gender and sex influencing the approach towards GM have been poorly investigated and remain unclear, particularly in old age.\u003c/p\u003e \u003cp\u003eThis study aimed to explore sex and gender differences in knowledge and opinions about GM in a sample of older patients and caregivers.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cem\u003eStudy design and population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u0026ldquo;\u003cem\u003eSurvey sulle conoscenze e preferenze di pazienti anziani e caregivers in materia di farmaco equivalente - Survey on knowledge and preferences of older patients and their caregivers regarding generic medications\u003c/em\u003e\u0026rdquo; (SurFE) study is a cross-sectional multicenter survey promoted by the ministerial institute \u0026ldquo;Italia Longeva\u0026rdquo; and the Italian Society of Gerontology and Geriatrics, involving several geriatric services in Italy. The survey enrolled non-institutionalized individuals aged 65 years or older or their caregivers from 15 inpatient and outpatient geriatric and internal medicine clinics across Italy from April 19\u003csup\u003eth\u003c/sup\u003e to May 20\u003csup\u003eth\u003c/sup\u003e, 2023. Patients with a diagnosis of a major neurocognitive disorder or with a moderate-severe cognitive impairment, according to routinely administered screening tests, or those who did not personally collect their medications from pharmacies, were excluded from the study. For these patients, we proposed their caregivers (if any) to participate in the study. The study protocol has been approved by the Ethics Committee of the coordinating center (Comitato Etico Area Vasta Emilia Centro della Regione Emilia-Romagna, protocol number 309/2023/Oss/AOUFe) and by the local Ethics Committees of the participating centers. The study complies with the guidelines of the Declaration of Helsinki, and each involved individual provided written consent to participate in the research. Data collection and sharing were conducted in line with national data protection laws, and the privacy of participants was guaranteed by anonymized data.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe recruited sample was asked to fill in a questionnaire (see Supplementary material, Supplementary Questionnaire 1) on the knowledge and attitudes toward GMs, developed after a systematic literature review and composed of structured questions and validated scales (Generic Medicines Scale)[15]. The following data were collected:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSociodemographic data including age, sex, area of residence, marital status, and educational background.\u003c/li\u003e\n \u003cli\u003eHealth-related information, including the presence of multimorbidity, polypharmacy, autonomy in daily life activities and experiences with home medication delivery.\u003c/li\u003e\n \u003cli\u003eGender: information on factors with gender-specific features was collected based on the framework proposed by Pelletier \u003cem\u003eet al\u003c/em\u003e. [16]. In particular, we considered the following variables: marital status, cohabiting, educational level, employment status, personal monthly income, household\u0026apos;s primary earner status, primary role in house chores, number of hours involved in house chores, caregiving role, and self-reported stress (measured on a scale from 1 to 10). From these factors, we created a composite gender score through a two-step procedure, according with a validated methodology [16]. In the first step, we performed a binary logistic regression with sex as the outcome (male sex as the reference category) and all the above-listed gender-related independent variables. In the second step, we repeated a binary logistic regression with sex (outcome) as a function only of the variables that showed a significant association at the first step, i.e. marital status, occupation, earnings compared to the partner, primary role in house chores, number of hours involved in house chores, and self-reported stress. For each participant, the gender score was computed from the sum of the independent variables\u0026rsquo; beta-coefficients related to the conditional probability of being female. The sample was then categorized based on the score\u0026rsquo;s tertiles so that the highest, middle, and lowest tertiles included individuals with female, neutral, and male gender characteristics, respectively (Supplementary Figure 1). \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAttitudes and knowledge about GMs, including question about participants\u0026rsquo; awareness and usage of GMs and reasons for choosing or avoiding these medications. The questions assessed how frequently participants are offered generic alternatives in pharmacies, their knowledge of the characteristics, efficacy, and safety of generics compared to brand-name medication, and their willingness to select GMs based on cost differences. Additionally, participants were asked about their perceptions of medication costs and attitudes towards generic drugs among different demographic groups. Their beliefs and potential misconceptions regarding the effectiveness, quality, and safety of generic medications were also evaluated through a series of targeted statements.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted separately for patients and caregivers. Within each subgroup, the characteristics of participants and questionnaire responses were compared as a function of biological sex (males and females) and gender (males, neutral, females)[17]. Categorical variables are presented as counts and percentages, while continuous quantitative variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range), as appropriate. The normal distribution of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. Quantitative variables were compared between groups using the Student\u0026apos;s t-test or ANOVA for normally distributed data, and the Mann\u0026ndash;Whitney U test or Kruskal\u0026ndash;Wallis test for non-parametric data. Categorical variables were analysed using the Chi-square test. We conducted ordinal regression analyses to assess the influence of sex and gender on patients\u0026apos; and caregivers\u0026apos; beliefs about GMs. The models were adjusted for age, education level, and region of residence in Italy. The results of the regression models are expressed as Odds Ratios (OR) and 95% Confidence Intervals (95% CI). For all analyses, statistical significance was set as a p-value \u0026lt;0.05. SPSS software (version 29) was used for the statistical analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 471 people were enrolled in the study, including 312 patients (168 females, 53.8%) and 159 caregivers (111 females, 69.8%). The characteristics of the sample are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients were older than 80, while caregivers were frequently younger than 70 years old. Male patients were more frequently married, lived with their partner or families, and had a higher monthly income than their female counterparts. According to the gender score, 73 (23.4%) patients reported characteristics traditionally ascribed to females and 96 (30.8%) to males; similarly, 58 (35.6%) caregivers reported characteristics traditionally ascribed to females and 32 (19.6%) to males.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the sample, divided by participant status (patient or caregiver) and sex\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;312)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eCaregivers\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;168)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (15.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (70.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e85 (76.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e71\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (40.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (41.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eItaly\u0026rsquo;s region\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (38.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e37 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentrum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (20.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth and islands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (20.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.738\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow/widower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e101 (70.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80 (47.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31 (64.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69 (62.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e93 (83.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving arrangement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (31.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith a partner or family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113 (78.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41 (85.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e91 (82.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1000\u0026ndash;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43 (25.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen asked about their level of agreement on various issues regarding GMs, males were more inclined to state that GMs are to be used for less severe conditions and are, in general, less effective, while females believed GMs to be produced with lower-quality substances. Among patients and caregivers, males were more likely than females to consider GMs identical to brand-name medicines (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These differences were not statistically significant (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSeveral significant differences emerged when focusing on gender rather than biological sex (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Regarding the clinical use of GMs, patients with a male gender score and caregivers with a neutral gender score were significantly more likely to believe that GMs are to be used for less severe conditions (p\u0026thinsp;=\u0026thinsp;0.03 and p\u0026thinsp;=\u0026thinsp;0.002, respectively). Differently from caregivers with a female gender score, patients with a male gender score were less likely to consider GMs to be produced with lower-quality substances (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, patients with a neutral gender score and caregivers with a male gender score were significantly more likely to believe that GMs\u0026rsquo; cost is lower than that of brand-name medicines because of their reduced efficacy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moreover, significantly more patients with a female gender score compared to those with neutral and male gender scores were aware of the equivalence between GMs and brand-name drugs. Conversely, among caregivers, significantly more individuals with a male gender score believed in the equivalence between GMs and brand-name medicines. For a detailed breakdown of the percentages of agreement and disagreement on the survey contents, categorized by biological sex and gender score, refer to Supplementary Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eResults from the logistic regression analysis, after adjustment for potential confounders, showed that female caregivers were more likely to think that GMs are produced with lower-quality substances (OR\u0026thinsp;=\u0026thinsp;2.06, 95% CI 1.01\u0026ndash;4.21, p\u0026thinsp;=\u0026thinsp;0.047), while no other significant associations were observed between sex and gender and knowledge and/or different beliefs regarding GMs (see Supplementary Table\u0026nbsp;2 and Supplementary Table\u0026nbsp;3).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study investigated sex and gender differences in relation to knowledge of GMs, with a focus on older patients and their caregivers. Overall, participants largely believed that GMs are comparable to their brand-name counterparts. However, a significant number of both patients and caregivers held negative views, particularly concerning the effectiveness of generic medicines. While sex and gender-related factors did not significantly impact on the knowledge of older patients and caregivers about GMs, gender-related aspects appeared to influence some beliefs about generic medicines more than biological sex alone.\u003c/p\u003e \u003cp\u003eIn recent literature, several studies have explored sex differences in patients\u0026rsquo; opinions and use of GMs, reporting conflicting results. Indeed, some authors describe higher health literacy levels[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and a higher prevalence of use of GMs among female individuals[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Yet, some other works suggest that females might have a more negative perception of GMs[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and show lower trust in generic substitution[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our study, in the older population, females did not seem to have a more negative opinion of GMs than males, in alignment with other studies that did not find any sex-related differences in opinions towards GMs in terms of perceived efficacy as well as in preference for branded medicines and/or refusal of generic substitution[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Nonetheless, age may have variable effects on consumers\u0026rsquo; opinions concerning GMs, with older age being associated with both negative and positive views[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Some data suggest that older adults are less likely to receive information on GMs[13) and more frequently refuse generic substitution[10) or report a preference for branded molecules[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Consistently, people in advanced age may have lower health literacy[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and, therefore, we cannot exclude that sex-related differences may have been blunted in our sample of older individuals due to an overall less positive attitude towards GMs.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first study applying the concept of socio-cultural gender to explore gender-related differences in consumers\u0026rsquo; knowledge of GMs. Gender differences were analysed using a gender score that integrated several variables such as household primary earner status, employment status, work hours, caregiving responsibilities, marital status, personal income, education level, and stress levels that can captures difference nuances related to gender-biased cultural influences on GMs\u0026rsquo; perceptions and beliefs. Indeed, these factors were chosen based on their prior association with opinions on GMs[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and when considering gender, we observed slightly different knowledge patterns, with individuals of neutral and female gender being less informed. Both female patients and caregivers were more likely to perceive GMs as being produced with lower-quality substances. This opinion may be related to a higher aversion to risk. Females often exhibit greater caution in health-related decisions, leading them to be more skeptical of generic alternatives and view them as potentially less safe[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In contrast, male caregivers are more inclined to believe that GMs are equivalent to brand-name medications. This perspective can be attributed to their greater focus on cost-effectiveness and a more rational approach to healthcare decisions[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Male people may be more likely to evaluate GMs based on cost-effectiveness and more rational approach to healthcare decisions rather than subjective perceptions. Furthermore, patients, having a greater emotional investment in their medications, may experience health decisions more personally and subjectively. Caregivers, on the other hand, may approach these decisions with greater objectivity and the different sources of information accessed by patients and caregivers can influence their perceptions in varying ways. Direct experiences with medications, such adverse reaction for example, may have a more significant impact on patients' opinions compared to the secondary observations of caregivers. Lastly, differences in the level of education and awareness regarding generic drugs between the two groups may further shape their opinions in distinct ways. Indeed, when adjusting the analyses for some key sociodemographic factors, such as age, education, and region of residence, these differences were not more significant, supporting a primary influence of sociocultural context in the attitude towards GMs in the older population. Moreover, available data suggest that opinions and use of GMs can also be influenced by factors such as patients\u0026rsquo; health status, illness perception[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], drug category[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], financial problems and prescription coverage[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and health care professionals\u0026rsquo; opinions[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Patients' opinions on GMs can significantly affect treatment adherence, persistence, and overall healthcare costs. Understanding the factors that shape consumers' knowledge and attitudes toward generic medicines is essential for designing targeted educational programs and communications strategies or campaigns concerning GMs.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strengths of the study\u003c/h2\u003e \u003cp\u003eThis study has some limitations. First, although a large sample of real-world older adults was involved, our study included primarily older individuals from outpatient clinics or acute care units who may not be representative of the general older population. Second, non-binary individuals and or transexual persons were poorly represented in our sample, and we were unable to investigate knowledge and opinions on GMs in this specific subgroup. Finally, the statistical power for analysing data related to caregivers was limited, which may affect the robustness of our findings for this specific population.\u003c/p\u003e \u003cp\u003eDespite these limitations, the study has notable strengths. It engaged a significant number of older adults, providing valuable insights into this important demographic. The use of a validated gender score allowed for a nuanced analysis of gender-related factors influencing attitudes and knowledge about GMs. Additionally, the comprehensive assessment of both attitudes and knowledge regarding GMs offers a thorough understanding of the subject matter.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eAmong older patients and their caregivers, knowledge and opinions about GMs were not significantly influenced by sex or gender-related factors. While most participants viewed GMs as comparable to brand-name drugs, some negative perceptions persisted, particularly concerning the quality and effectiveness of GMs. These findings suggest that attitudes towards GMs in older populations may be determined more by individual experiences and overall health literacy. However, gender-related factors may have a greater impact on shaping beliefs about GMs than biological sex alone in both patients and their caregivers. Future research should explore the potential role of other sociodemographic or clinical factors that may influence gender-related factors and impact on the use of GM among older adults and their caregiver to better understand and address potential barriers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthorship Confirmation/Contribution Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConceptualization\u003c/em\u003e: Chiara Ceolin,\u0026nbsp;Francesco Salis, Maria Beatrice Zazzara, Caterina Trevisan, Giulia Rivasi\u003c/p\u003e\n\u003cp\u003eData collection:\u0026nbsp;Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Federica D\u0026rsquo;Ignazio, Giulia Rivasi\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData curation\u003c/em\u003e: Caterina Trevisan\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFormal Analysis\u003c/em\u003e: Chiara Ceolin, Francesco Salis\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSupervision\u003c/em\u003e: Caterina Trevisan\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVisualization\u003c/em\u003e:\u0026nbsp;Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Giulia Rivasi\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWriting \u0026ndash; original draft\u003c/em\u003e: Chiara Ceolin, Francesco Salis,\u0026nbsp;Maria Beatrice Zazzara, Myriam Macaluso, Elena Levati, Federica D\u0026rsquo;Ignazio, Giulia Rivasi\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWriting \u0026ndash; review \u0026amp; editing\u003c/em\u003e:\u0026nbsp;Chiara Ceolin, Francesco Salis, Maria Beatrice Zazzara, Giulia Rivasi, Caterina Trevisan\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Disclosure Statement\u003c/strong\u003e, \u003cstrong\u003eConflicts of interest/Competing interests:\u0026nbsp;\u003c/strong\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e: All data generated or analyzed during this study are included in this published article (and its supplementary information files).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval statement\u003c/strong\u003e: This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the coordinating center (Comitato Etico Area Vasta Emilia Centro della Regione Emilia-Romagna, protocol number 309/2023/Oss/AOUFe) and by the local Ethics Committees of the participating centers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent statement\u003c/strong\u003e: Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SurFe study was promoted by Italia Longeva (https://www.italialongeva.it/) and supported by Egualia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to reproduce material from other sources\u003c/strong\u003e: not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u0026nbsp;\u003c/strong\u003eThe complete list of the SurFe working group (in alphabetical order) is: Stefano Andreoli, Giada Arena, Giorgio Basile, Giuseppe Bellelli, Federica Bellone, Leonardo Bencivenga, Roberto Bernabei Anna Bertocco, Davide Maria Biancone, Enrico Brunetti, Maria Modestina Bulla, Maria Lucia Bursi, Stefano Cacciatore, Marco Capacci, Cristina Cargiolli, \u0026nbsp;Stefano Caruso, Chiara Ceolin, \u0026nbsp;Ludovica Ceolin, Giuseppina ConiglioAndrea Corbani, Antonio D\u0026rsquo;Errico, Federica D\u0026rsquo;Ignazio, Rosa De Felice, Maria Cristina Ferrara, Elvira Filicetti, Panaiotis Finamore, Tommaso Finco, Beatrice Fumagalli, Thelma Geneletti, Alessia Ghidini, Rossella Giordano, Giulia Gorla, Claudio Guarneri, Giovanni Lazzaro, Elisa Lenotti, \u0026nbsp;Elena Levati, Myriam Macaluso, Leonarda Maltese, Davide Montini, Chukwuma Okoye, Graziano Onder, , Ilaria Parrotta, Giulia Pasolini, Chiara Petrucci, Roberto Presta, Antonella Risoli, Rengo Giuseppe, Giulia Rivasi, Priscilla Romagnoli, Francesco Salis, Ottavio Scarano, Pierfederico Scaroni, Luca Soraci, Caterina Trevisan, Ungar Andrea, Virdis Agostino, Maria Beatrice Zazzara, Alberto Zucchelli.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eU.S. Food and Drug Administration. 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J Gen Intern Med. 2019;34(3). doi: 10.1007/s11606-018-4791-1.\u003c/li\u003e\n \u003cli\u003eSun S, Lu J, Wang Y, Wang Y, Wu L, Zhu S, et al. Gender differences in factors associated with the health literacy of hospitalized older patients with chronic diseases: A cross-sectional study. Front Public Heal. 2022 Aug;10:944103. doi: 10.3389/fpubh.2022.944103.\u003c/li\u003e\n \u003cli\u003eKesselheim AS, Gagne JJ, Franklin JM, Eddings W, Fulchino LA, Avorn J, et al. Variations in Patients\u0026rsquo; Perceptions and Use of Generic Drugs: Results of a National Survey. J Gen Intern Med. 2016 Jun;31(6):609\u0026ndash;14. doi: 10.1007/s11606-016-3612-7.\u003c/li\u003e\n \u003cli\u003eOrlando V, Mucherino S, Guarino I, Guerriero F, Trama U, Menditto E. Gender Differences in Medication Use: A Drug Utilization Study Based on Real World Data. Int J Environ Res Public Health. 2020 Jun;17(11). doi: 10.3390/ijerph17113926.\u003c/li\u003e\n \u003cli\u003eFederman AD, Halm EA, Zhu C, Hochman T, Siu AL. Association of income and prescription drug coverage with generic medication use among older adults with hypertension. Vol. 12, American Journal of Managed Care. 2006. p. 611\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gender medicine, older adults, caregivers, sex differences, gender","lastPublishedDoi":"10.21203/rs.3.rs-5328311/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5328311/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eGeneric medicines (GMs) are bioequivalent to brand-name drugs and more cost-effective, yet their use is limited. Gender-related factors may influence attitudes towards GMs, but data on older adults are scarce. This study aimed to explore sex and gender differences in knowledge and opinions about GMs among older patients and their caregivers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSurFE is a cross-sectional multicenter survey conducted in Italy (April-May 2023) that enrolled non-institutionalized individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years and their caregivers. Participants completed a questionnaire assessing knowledge, attitudes, and perceptions of GMs, and sociodemographic and health-related information. We collected data on gender-specific factors and, using a validated methodology, developed a composite gender score.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 471 participants (312 patients and 159 caregivers), no differences related to biological sex were observed. According to the gender score, patients with male gender characteristics were less likely to believe that generic medicines are made with lower-quality substances. Additionally, both female patients and male caregivers were more likely to consider GMs equivalent to brand-name medications. Logistic regression analysis showed that female caregivers were significantly more likely to believe that GMs are produced with lower-quality substances (OR\u0026thinsp;=\u0026thinsp;2.06, 95% CI 1.01\u0026ndash;4.21, p\u0026thinsp;=\u0026thinsp;0.047). No other significant associations between sex, gender, and beliefs about GMs were found.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eGender-related factors may have a greater impact on shaping beliefs about GMs than biological sex. Further research is required to explore the potential role of other sociodemographic or clinical factors to better understand and address barriers to the use of GMs.\u003c/p\u003e","manuscriptTitle":"Influence of Sex and Gender on Knowledge of Generic Medicines Among Older Patients and Caregivers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 06:01:26","doi":"10.21203/rs.3.rs-5328311/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5e767933-866b-496c-988d-652bc5958ab3","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T11:02:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-16 06:01:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5328311","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5328311","identity":"rs-5328311","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}