A cross-sectional survey of the Maltese general public on medication wastage

Medication waste and disposal behaviors among Iranian households: A Cross-sectional study

Improper use and disposal of medications pose substantial risks to both public health and the environment. Although medication take-back programs are recognized as effective solutions to address these concerns, public awareness remains low, and such programs are currently unavailable in Iran. The study, conducted between February and May 2024, used a validated 40-item questionnaire to assess the Knowledge, Attitudes, and Practices (KAP) of households regarding the disposal of unused and expired medications. The study revealed moderate knowledge levels (median = 58.82, interquartile range [IQR] = 88.2) and relatively positive attitudes (median = 85.71, IQR = 51.7) among participants. However, a notable discrepancy was observed between positive attitudes and actual practice, with 51.1% of households reporting disposal of unused medications in household waste. A weak negative correlation was found between older age and knowledge score (r = -0.129, p = 0.001), and a very weak negative correlation was observed between older age and attitude score (r = -0.078, p = 0.049). Higher knowledge scores were observed among participants with middle monthly incomes, those with post-secondary education (including Secondary education and students), and those living in three-member households. More positive attitudes were associated with Post-secondary education and households consisting of three or four members. To improve medication disposal practices, public health interventions should focus on raising awareness about the environmental and health risks of improper disposal and promoting proper disposal methods. This includes organizing community medication collection events and advocating for the establishment of nationwide medication take-back programs. The negative correlation between age and knowledge suggests that these interventions should specifically target older adults and individuals with lower levels of education.

Patients' knowledge, attitude, and practices toward unused medications in Qatar: A cross-sectional survey

Background

Global evidence has linked unused medications and their inappropriate disposal to adverse health, economic, environmental, and ethical impacts. However, such evidence is scarce in Qatar. This study explored patients' knowledge and attitude toward unused medications and their practices toward medication supply and disposal (KAP) in Qatar.Materials and methods.

Study design

A cross-sectional survey using a pretested questionnaire was performed between February 2020 and October 2020. Descriptive statistics, Man Whitney U, and Kruskal-Wallis Rank-Sum tests were applied. The Chi square test assessed the association between socio-demographic characteristics and KAP scores. Characteristics that were found significantly associated with KAP (i.e., p-values <0.05) were further included as predictor variables in the multiple linear regression model.

Results

All items pertaining to patients' knowledge were found to be good (mean score > 3), except for "awareness of unwanted medication return policy" (mean score < 3), i.e., the lowest level of patient agreement (31 %) (median (M) = 3, Interquartile Range (IQR) = 3). Their attitude was generally good (mean score > 3). Conversely, their practice toward medication supply was poor (mean score < 3). Possible future use was the most reported reason (79 %) for keeping medications at home, and home trash was the most widely disposing place of unused ones (76 %). Knowledge was significantly higher among non-laborers and other occupations than among patients with no work (p < 0.001) and (p = 0.005), respectively. The attitude was significantly lower among patients with healthcare providers (HCPs) in their household than among those without (p = 0.001). Practices were also significantly lower among those aged 40-49 years and those with HCPs in their household than those aged 18-29 years (p = 0.012) and those without HCPs, (p < 0.001), respectively.

Conclusions

Overall, patients' knowledge and attitude toward unused medications seem good, while their practices toward medication supply and disposal are bad. To mitigate the health, economic, and environmental impacts of unused medications, interventions including rationalizing drug supply, use, disposal, prescribing, manufacturing, and promotion are recommended.

Medicine storage, wastage, and associated determinants among urban households: a systematic review and meta-analysis of household surveys

Background

Irrational household storage of medicines is a world-wide problem, which triggers medicine wastage as well as its associated harms. This study aimed to include all available evidences from literature to perform a focused examination of the prevalence and factors associated with medicine storage and wastage among urban households. This systematic review and meta-analysis mapped the existing literature on the burden, outcomes, and affective socio-economic factors of medicine storage among urban households. In addition, this study estimated pooled effect sizes for storage and wastage rates.

Methods

Household surveys evaluating modality, size, costs, and affective factors of medicines storage at home were searched in PubMed, EMBASE, OVID, SCOPUS, ProQuest, and Google scholar databases in 2019. Random effect meta-analysis and subgroup analysis were used to pool effect sizes for medicine storage and wastage prevalence among different geographical regions.

Results

From the 2604 initial records, 20 studies were selected for systematic review and 16 articles were selected for meta-analysis. An overall pooled-prevalence of medicine storage and real wastage rate was 77 and 15%, respectively. In this regard, some significant differences were observed between geographical regions. Southwest Asia region had the highest storage and wastage rates. The most common classes of medicines found in households belonged to the Infective agents for systemic (17.4%) and the Nervous system (16.4%). Moreover, income, education, age, the presence of chronic illness, female gender, and insurance coverage were found to be associated with higher home storage. The most commonly used method of disposal was throwing them in the garbage.

Conclusions

Factors beyond medical needs were also found to be associated with medicine storage, which urges effective strategies in the supply and demand side of the medicine consumption chain. The first necessary step to mitigate home storage is establishing an adequate legislation and strict enforcement of regulations on dispensing, prescription, and marketing of medicines. Patient’s pressure on excessive prescription, irrational storage, and use of medicines deserve efficient community-centered programs, in order to increase awareness on these issues. So, hazardous consequences of inappropriate disposal should be mitigated by different take back programs, particularly in low and middle income countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11100-4.

Lack of Awareness of the Impact of Improperly Disposed Of Medications and Associated Factors: A Cross-Sectional Survey in Indonesian Households

Introduction: Disposal of unused medications through environmentally unsafe routes is common in Indonesia. The lack of awareness of the impact of improperly disposed of medications is a significant contributing factor. The objectives of this study were to identify factors associated with lack of awareness of the impact of improperly disposed of unused medications and to assess the associations of awareness with medication disposal practices among the general population in Indonesia.

Patients and methods: An observational cross-sectional survey was conducted using nonprobability sampling in Bandung, Indonesia, from November 2017 to January 2018 among respondents who were older than 18 years, had used any medication in the past, were literate, and had signed an informed consent document. Disposal practices and awareness regarding the impact of improperly disposed of unused medications were collected using an online- and a paper-based pre-validated questionnaire. The paper-based questionnaires were distributed to respondents in public places such as city center, markets, and religious places. Binary logistic regression was performed to assess associations of sociodemographic and other related factors with a lack of awareness. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported.

Results: Of 497 participating respondents, 433 and 64 respondents filled an online- or a paper-based questionnaire, respectively. Most respondents were female, aged between 18 and 30 years, and students/university students. Of 497 respondents, more than half (53.1%) were not aware that improper medication disposal could harm the environment and population health. Most respondents (79.5%) had never received information about proper medication disposal practices. The education level, the number of stored medications at home, and previous education about medication disposal practices were significantly associated with awareness of proper practices. In the multivariate analysis, only those with previous education about medication disposal practices were less likely to report a lack of awareness (OR: 0.043; 95% CI: 0.02–0.09). Respondents with a lack of awareness tended to dispose of their unused medications in the garbage or shared them with friends or relatives.

Conclusion: There is a clear need to increase awareness of the importance of proper medication disposal practices, in particular among the student population of Bandung city, Indonesia. Healthcare providers can play an important role by educating this specific population on the proper disposal of unused medications.

The 'Necessity-Concerns Framework' as a means of understanding non-adherence by applying polynomial regression in three chronic conditions

OBJECTIVE

The 'Necessity-Concerns Framework' is an important framework which can support healthcare professionals in targeting patients' medication beliefs and decisions on adherence. Our aim was to determine how the interdependence of 'necessity' and 'concerns' beliefs for medication adherence compares across three chronic conditions.

METHODS

Patients diagnosed with asthma, cardiovascular conditions or diabetes attending out-patient clinics completed a self-administered questionnaire. The questionnaire gathered information regarding demographics, medication adherence using the 'Tool for Adherence Behaviour Screening', presence of unused medication in households and medication beliefs using the 'Beliefs about Medicines Questionnaire-Specific'. Polynomial regression was applied to determine the multidimensional interdependence of 'necessity' and 'concerns' beliefs for adherence. P-values ≤ 0.05 were taken to be significant.

RESULTS

Confirmatory polynomial regression rejected the differential score model in all three groups. For each condition, exploratory polynomial regression found that linear terms indicated the best fitting model for predicting adherence. In all groups, adherence increased as necessity beliefs increased and concerns decreased. Patients suffering from cardiovascular conditions and diabetes with low necessity and low concerns beliefs reported higher medication adherence compared to those with high necessity and high concerns beliefs.

DISCUSSION

Alleviating patients' concerns can enhance medication adherence and potentially curb the issue of medication wastage.

Adherence to oral anticancer chemotherapies and estimation of the economic burden associated with unused medicines

Background The list of oral and expensive chemotherapy agents has lengthened over the last few years and has created unique medication adherence concerns. In a real-life setting, patients often do not take their medications as prescribed. This pattern is associated with poor outcomes and increased health care costs. Objectives To estimate the adherence to oral anticancer chemotherapies and to determine the economic burden of unused medicines due to patients' death. Setting Alsace (France). Method This retrospective study was carried out by using ERASME, an Insurance Healthcare database. Main outcome measures Adherence was calculated using medication possession ratio and economic impact using prescription refill data. Results 10,734 patients were treated with oral anticancer medicines (cytotoxic agents, hormonal and targeted therapies). Averaged adherence of 0.86 was observed although it varied significantly between subclasses (cytotoxic agents: 0.69 ± 0.14, hormonal therapy: 0.91 ± 0.17 and targeted therapy: 0.79 ± 0.17). 1631 patients died during the study period. The expenses related to unused chemotherapies amounted to €152,175. Conclusions Our data showed that overall adherence to oral anticancer medicines was above the acceptable limit of adherence of 80% with a marked graduation in values between cytotoxic agents, hormonal and targeted therapies. These statistical significant differences in medication possession ratio could be related to the intrinsic toxicity of the three subclasses of molecules, their tolerance and adverse effects. To limit the cost associated with unused medicines, interventions such as dispensing expensive oral anticancer chemotherapies per unit over shorter periods and not only on monthly intervals could be implement.

Mixed-methods approach to determine adherence, knowledge and behavioral determinants associated with medication wastage

BACKGROUND

While literature quantifying medication wastage and assessing public's knowledge and practices about medication disposal is substantial, less attention is given to the public's knowledge and behavior pertaining to medication wastage prevention. This study aimed to determine the public's knowledge of medication wastage, any association between knowledge and adherence, and behavioral determinants potentially leading to wastage.

METHODS

A mixed-method explanatory sequential approach was adopted with a quantitative survey followed by qualitative semi-structured interviews. Maltese residents ≥18 years attending social/educational events were recruited in this mixed-methods study. Participants completed a structured questionnaire comprising: 1) demographics; 2) medication adherence using 'Tool for Adherence Behaviour Screening' dichotomized into 'good adherence'/'suboptimal adherence'; 3) eight knowledge statements each carrying one point (total, 0 = lowest; 8 = highest); 4) and whether they had unused medication at home. Chi-square analysis determined associations between demographics and adherence, and having unused medication. Multiple regression was performed to predict knowledge based on demographics, adherence, having regular medication and having unused medication, p  ≤0.05. Questionnaire respondents expressing interest in participating in semi-structured face-to-face interviews, based on the Theoretical Domains Framework (TDF), were recruited consecutively until data saturation. Interviews were audio-recorded, transcribed and analyzed using the Framework Approach.

RESULTS

Of the 524 individuals attending 14 events, 80.5% completed the questionnaire (mean age±standard deviation (SD): 65 ± 13 years). Thirty-one percent (n = 130/422) of respondents reported having unused medication and 18.8% (58/309 taking chronic medication) classified as 'optimal' adherence. Mean ± SD knowledge score was 4.7 ± 1.5. Knowledge and adherence were not significantly related. Most prevalent TDF domains influencing wastage emerging from 15 interviews were knowledge, beliefs about consequences and behavioral regulation.

CONCLUSION

Public's knowledge about medication wastage and adherence were inadequate, necessitating implementation of tailored educational interventions based on behavioral determinants recognized within this study. Identified inadequate behavior around disposal mandates inclusion of environmental/social planning issues when developing policies.

Medication and Medication Wastage: Short-Term and Long-Term Effects of an Educational Intervention Among School Children

Background. Education should support the gradual development of students’ necessary abilities to empower them in participating in decision-making together with health care professionals. Aim. The aim of this study was (1) to evaluate baseline knowledge regarding medication and medication wastage among primary school children and (2) to determine the short- and long-term effects of an educational intervention. Methods. Ten primary state schools around Malta were invited to participate; 5 accepted participation (3 control and 2 intervention). Children aged 9 to 12 years attending the sixth grade completed a self-reported questionnaire containing 20 questions, with total scores ranging from 0 to 20. Students from the intervention classes filled in a questionnaire pre and post an educational seminar. All students answered the questionnaire again after 8 months. ANOVA (analysis of variance) with repeated measures was used to compare difference between preintervention and postintervention mean scores. Results. Overall, 40.8% (160/392) of children participated. Mean ± SD age was 10 ± 0.4years; 52.5% (n = 84) were boys. Average preintervention knowledge score for all 5 schools was 11.5 ± 3.6, with 43.1% (n = 69) obtaining responses ≥13 (median). A repeated-measures ANOVA with a Greenhouse-Geisser correction determined that mean knowledge scores differed significantly between preintervention and postintervention (F[1, 81.000] = 75.190, P < .0005). Intervention students retained a significant increase in knowledge scores at 8 months (P = .026). Discussion and Conclusion. The significantly improved knowledge score following the educational intervention both in the short- and long-term demonstrated the success of the intervention. These findings provide a basis for the introduction of education about medication and medication wastage in schools.

Analysis of Disposed Unused Medications at a Village Community Pharmacy

Background: The aim of this study was to determine the type, quantity, and cost of medications being disposed of by clients in a specifically-set pharmaceutical disposal bin at a village community pharmacy. Methods: Medicines placed in a medication disposal bin by clients were examined during a nine-month period from April to December 2018. The data recorded included the active ingredient, trade name, dose, dosage form, disposed quantity, and the actual expiry date on the pack. The medications were classified according to ATC (Anatomical Therapeutic Chemical Classification System) code, and the cost of the amount wasted was calculated using the pharmacy’s price list. Descriptive statistics were used to analyze the data. Results: A total of 411 medications were collected, amounting to a total cost of approximately €2600. The largest group of medications belonged to the alimentary group, and this also represented the group with the highest monetary value. The number of months that medicinal products were retained by patients beyond the expiry date ranged from 1 to 232. Conclusion: This small study provides a glimpse of what clients dispose of in a medication bin when this is readily available in their community pharmacy, a simple measure which, if adopted on a national level, could aid in ensuring the appropriate disposal of wasted medication.

Medication wasted - Contents and costs of medicines ending up in household garbage

BACKGROUND

Despite potentially considerable implications for public health, the environment and public funds, medicine waste is an under-researched topic. This study aims to analyse medicines drawn from household garbage in Vienna (Austria) and to assess possible financial implications for public payers.

METHODS

Four pharmaceutical waste samples collected by the Vienna Municipal Waste Department between April 2015 and January 2016 were investigated with regard to their content. The value of medicines was assessed at ex-factory, reimbursement and pharmacy retail price levels, and the portion of costs attributable to the social health insurance was determined. Data were extrapolated for Vienna and Austria.

RESULTS

The waste sample contained 1089 items, of which 42% were excluded (non-pharmaceuticals, non-Austrian origin and non-attributable medicines). A total of 637 items were further analysed. Approximately 18% of these medicines were full packs. 36% of the medicines wasted had not yet expired. Nearly two out of three medicines wasted were prescription-only medicines. The majority were medicines related to the 'alimentary tract and metabolism' (ATC code A), the 'nervous system' (ATC code N) and the 'respiratory system' (ATC code R). The medicines wasted had a total value of € 1965, € 2987 and € 4207, expressed at ex-factory, reimbursement and pharmacy retail price levels, respectively. Extrapolated for Vienna, at least € 37.65 million in terms of expenditure for public payers were wasted in household garbage, corresponding to € 21 per inhabitant.

CONCLUSION

This study showed that in Vienna some medicines end up partially used or even completely unused in household garbage, including prescription-only medicines, non-expired medicines and medicines for chronic diseases. While there might be different reasons for medicines being wasted, the findings suggest possible adherence challenges as one issue to be addressed.

Redispensing of medicines unused by patients: a qualitative study among stakeholders

Background Medication waste has undesirable economic and environmental consequences. This waste is partly unavoidable, but might be reduced by redispensing medicines unused by patients. However, there is little knowledge of stakeholders' views on the redispensing. Objective To identify the stakeholders' views on the redispensing of medicines unused by patients. Setting Dutch healthcare system. Method Semi-structured interviews were conducted with 19 Dutch stakeholders from September 2014 until April 2015. The interview guide included two themes: medication waste and redispensing of unused medicines. The latter included qualitative-, legal- and financial aspects and stakeholder involvement, with specific attention to the patient. Interview transcripts were subjected to thematic content analysis. Main outcome measure Requirements related to the redispensing of unused medicines. Results All stakeholders considered the redispensing of medicines desirable if the implementation is feasible and the requirements for the safe redispensing are met. All of them pointed out that the product quality of redispensed medicines should be guaranteed and that it should be clear who is responsible for the quality of redispensed medicines. The stakeholders stated that transparent communication to patients is essential to guarantee trust in the redispensing system and that patients should be willing to use redispensed medicines. Moreover, the redispensing system's benefits should outweigh the costs and a minimal economic value of medicines suitable for redispensing should be determined. Conclusion Redispensing unused medicines could decrease medication waste if several requirements are met. For successful implementation of a redispensing system, all relevant stakeholders should be involved and cooperate as a joint-force.

Disposal practices of unused and expired pharmaceuticals among general public in Kabul

BACKGROUND

Most of the medicine users remain unaware about the disposal of unused or expired medicines. The aim of this study was to know the disposal practices of unused and expired medicines among the general public in Kabul.

METHODS

This was a descriptive, cross-sectional survey, conducted through face-to-face interviews using prevalidated structured questionnaire. Returned questionnaires were double-checked for accuracy. Statistical Package for Social Science (SPSS) version 23 was used for statistical analysis.

RESULTS

Total of 301 valid questionnaires were returned with a response rate of 100% in which 73.4% men and 26.6% women participated. More than half of the respondents were university graduates. Interestingly, 83.4% of the interviewees purchased medicines on the prescription of which 47.2% were university graduates, while 14.6% purchased medicine over the counter. Among the respondents, 46.5/100 purchased antibiotics and the remaining purchased NSAIDs, anti-hypertensive and anti-diabetic medicines. Significantly, 97/100 checked the expiry date of medicine before buying. Majority (95.3%) of the respondents' stored medicines at home. 77.7% of the respondents discarded the expired medicines in household trash. Majority of respondents held government responsible for creation of awareness for proper medicine disposal. Almost entire sample (98%) felt that improper disposal of unused and expired medicines can affect the environment and health.

CONCLUSION

Gaps exist in practices, therefore robust, safe and cost-effective pharmaceutical waste management program supported with media campaign is needed. Healthcare practitioners and community pharmacists should offer training to educate customers on standard medicine disposal practices.

A focus group based study of the perspectives of the Maltese population and healthcare professionals on medication wastage

Background The World Health Organization states that globally more than half of all medication is inappropriately prescribed, dispensed or sold with a need to implement wastage reduction strategies. Developing processes which include behaviour change theories, such as the Theoretical Domains Framework (TDF), significantly impacts the positive implementation of evidence into healthcare practice. Objective To describe and understand the beliefs and behaviours regarding medication wastage of the Maltese public and healthcare professionals (HCPs) and to explore potential solutions.

SETTING

Malta. Method Five 90 min audio recorded focus groups (2 public and 3 HCPs) were conducted with a purposive sample who responded to a previous survey study and were willing to participate in focus groups in Malta. The guide was based upon the TDF with interview questions derived from findings of the questionnaire phase. Focus groups were audio recorded and transcribed verbatim. Analysis was carried using the framework approach. Main outcome measure Beliefs and behaviours regarding medication wastage and potential solutions to reduce medication wastage. Results A total of eleven pharmacists, six doctors and six members of the public consented to participate. Focus groups conducted with HCPs and the general public identified the following four key themes aligned with the TDF domains to address proposed solutions to minimise medication wastage: (1) practitioner effects; (2) patients effects; (3) political effects; (4) societal effects. Conclusion This study has employed a theoretical framework to obtain a better understanding of facilitators which require attention as part of strategic development.