Awareness towards Disposal of Unused Medication in District Shaheed Benazirabad Sindh

Aims: The purpose of this study was to examine level of awareness about proper disposal of unused medicine. It is a growing problem. People directly dispose unused medicines into waste or flush into sink. Finally, these improperly disposed medicines mix with wastewater leach out into sea water, ground water, drinking water and effect human and other forms of life and develop microbial resistance and accidental poising and various societal repercussion. Confusion exists in people about proper disposal of unused medicine. Despite of already available guidelines people very rarely follow proper disposal methods. Particularly in developing countries situation is very alarming. It is well established fact that knowledge and level of awareness play pivotal role for practice of proper disposal methods. Original Research Article Kaloi et al.; JPRI, 33(54B): 41-49, 2021; Article no.JPRI.76130 42 Study Design: This study was a descriptive cross-sectional study. Methodology: This study was conducted in Nawab Shah and its vicinities: Sakrand, Kaziahamed, Bachalpur, during September 2019 to May 2020. The number of participants were included in the study according Slovin's Formula. The simple random sampling method was used to select participants. The level of awareness about proper disposal of unused medicine of 400 participants was assessed through a well-designed questionnaire. The questionnaires were distributed to the participants at their homes with the help of volunteers. The descriptive statistics were analyzed through latest version of MS excel 2016. Results: Out of 400, 320 (80%) of the participants admitted have no knowledge for proper disposal of unused medicines. 185 (46.25%) of the participants viewed throwing unused medicines into waste was correct. Whereas 176 (44%) of the participants believed improperly thrown medicines has no effect on environment. Conclusion: The level of knowledge about proper disposal of unused medicine was found very low in study participants. It is suggested government should incorporate guidelines about the harmful effects of improper disposal of unused medicines in curriculum at primary level of education.


INTRODUCTION
Due to relieve of symptoms or progress of illness, alteration in dosage form or medicines reaching the expiry date, are few of the many reasons for which medicines goes unused [1-3]Medicines are called unused when they are not fully consumed [4].The quantity of unused medicine is not only an economical burden [5] but it become inexorable threat to human and whole ecosystem, if disposed improperly [6]. The hefty quantities of unused medicines [7] at home create disposal problems [8] whereas many of the medicine consumers are not aware of proper disposal methods as a consequence unused medicines are improperly disposed[9-11] . These improperly disposed medicines comprise on various classes of medicines[12-16] after improper disposal these medicines get into the environment [17,18] .
According to WHO guidelines improper disposal of unused medicines is unsafe and it is environmentally Harmful [19]. The improperly disposed medicines may result accidental poisoning [20] anti-microbial resistance and genetic effects on human and innumerable effects on aquatic life [21][22][23][24][25][26][27]. However currently waste water treatment plants are available but latest studies have shown they are not efficient in removing or degrading active pharmaceutical ingredients (APIs).During treatment processes many (APIs) even leach out again into environment. There have been substantial evidences of presence of traces of medicines in ground, and surface water [28][29][30] .Interestingly the pharmaceuticals which were detected in water ways were numerous and belonged to various classes of pharmaceuticals such as anticonvulsant, antibiotics painkillers, and synthetic hormones [31][32][33] .
The improper disposal of unused medicine is due to lack of awareness and proper guidelines [34] It is a global problem. Although in developing countries problem is escalating and is not well documented [35,36] on the other hand in developed countries for instance, Canada Australia, and United Kingdom has drug return programs at national level [37]. Besides this the FDA advocates best way for disposal of unused medicines are drug take back programs but in case, lack of such services mixing prescription drugs with an undesirable substance or flushing certain listed medicines is however allowed [38] . Despite of presence of such guidelines people practice improper disposal methods [39][40][41] Whereas medicine user are seldomly informed about proper disposal methods. [42][43][44].The available scientific literature agrees that the improper disposal of unused medicine is unequivocally due to lack of knowledge and awareness about proper disposal of unused medicine [45,46] . The objective of this study was to examine how people dispose unused medicines and document the level of awareness about proper disposal of unused drug in residents of Shaheed Benazir Abad Sindh.

Study Design
This study was a descriptive cross-sectional study. The number of participants were included in the study according Slovin's Formula. The simple random sampling method was used to include study participants.

Participants
We assessed the practice and level of awareness about proper disposal of unused medicine of 400 participants through a welldesigned questionnaire [9]. The purpose of the study was introduced to the participants. The questionnaires were distributed to the participants at their homes with the help of volunteers.
After filling questionnaires participants returned these questionnaires to volunteers and later were assessed. This research was conducted during September 2019 to May 2020 mostly in homes and public places in the following cities and their vicinities: Nawab shah, Jam sahib, Sakrand, Kaziahamed, Bachalpur and Daultpur.

Procedure
Each participant was given a questionnaire, which in beginning stated purpose of the study and later participants were asked to answer the questions regarding surveys objective. Questionnaire states as-The objective of this study is to know how many people practice proper disposal of unused medicine. If you are willing to answer the questions please give true and genuine answer of the following questions.
Participants were asked to answer following questions. (1) Do you have any unused medicine at home? (2) What is the name and dosage form of unused medicine at home? (3) Why you left taking medicine? (4) What do you do with unused medicine? (5) How you dispose unused medicine? (6) Do you know proper disposal methods? (7) Do you know disposing unused medicine into waste is harmful? (8) Do you know disposing unused medicines into waste has any effect on environment? (9). Some questions were open ended so as participants can write their own insights. Descriptive statistics were analyzed through latest version of MS excel 2016.

RESULTS AND DISCUSSION
In this study majority of the participants were male, and were between 16 to 70 years of age. The mean age of participants was 30.26 years. Majority of the participants were unmarried. Majority of the participants had at least Primary level of education, Many of the participants were unemployed (Table 1).
The participants were asked do they know or have any knowledge about proper disposal of unused medicine. In this regard 80 (20%) of the participants showed have knowledge about proper disposal of unused medicine, whereas 320 (80%) of the participants expressed had no knowledge about proper disposal of unused medicine (Table 2).  To view how much participants were aware of the harmful nature of medicines, The participants were asked about effect of improperly thrown medicine on environment regarding this, 28 (7%) of the participant expressed they don't know whether it effects or not .Whereas 176 (44%) expressed it has no effect on environment while 196(49%) believed have effect on environment ( Table 3).
The study participants were also asked, whether disposing or throwing unused medicine into waste is correct or incorrect, in their view. Regarding this 24 (6%) of the participant were not sure whether it was correct or incorrect. Whereas 185 (46.25%) viewed doing so was correct and 191 (47.75%) of the participants viewed doing so was incorrect (Table 4).
In this survey-based study participants were asked about disposal practices of unused medicine. Regarding this 60 (15%) of the participants expressed they disposed unused medicine into dustbin and 132 (33%) expressed have disposed unused medicine outside of home. Whereas 208 (52%) of the participants disposed unused medicine into waste ( ) had medicines such as antiemetic, antimalarials, antacid, antipyretic and multivitamins the names of these medicines were written below as 'others' to save the space (Table 6).
Furthermore, it was asked from participants about reasons why they did not completely use their medicines completely. Regarding this 112 (28%) of the participants expressed they didn't use due to laziness and 124 (31%) reasoned health not improved and 164 (41%) reasoned as health improved due to these reason they have not used their medicines. (Table 7).
To see how many participants, have unused medicines at home, it was asked from participants for having or not having unused medicines at home regarding this 138 (34.5%) of the participant expressed they have no unused medicine at home whereas 262 (65.5%) of the participants showed have unused medicines at home (Table 8).   (Table 2) which is also consistent with the above studies. This may be due to lack of government policies and lack of educational trainings and awareness campaigns because we saw countries, such as Sweden where pharmaceutical companies and government together conduct awareness campaigns, as a consequence populace has strikingly higher level of awareness 80% versus 20% of our study [49].
The perception about the effects of improperly disposed medicine on environment, cited by previous study was found 73% [15] . Similarly another study conducted in Kabul showed 98% of the participant had strikingly higher level of perception about harmful effects of unused medicine on environment [9].The results of our study showed very low level of perception about effect of unused medicine on environment as compared to above studies in our study only 49% of the participants believed improperly disposed medicine effect environment while 44% of the participants showed it has no effect on environment, even 7% had no idea whether improperly disposed medicine effect environment or not (Table 3). Many of the participants even viewed throwing unused medicine into waste was correct (Table 4). These findings indicate that participants were For disposal practices of unused medicine previous studies showed 79.1% of the participants disposed unused medicines outside of home [50]. In a similar study 53.84 % of the participants disposed unused medicines in the waste [51]. The results of our study showed 52% of the participants disposed unused medicine in the waste, and 33% disposed outside of home only 15% of the participants disposed into dustbins, yet participants had not expressed whether during disposal they had followed FDAs guidelines or not which is unclear ( Table 5). The results of our study confirms the previous studies. However previous studies showed participants return unused medicines to pharmacies 23%, 42% respectively [49,52]. Strangely none of our study participants retuned unused medicines to the pharmacies. It implies whatever participants had unused medicine was disposed by improper means.
Regarding classes of unused medicine at home, previous studies found analgesics 35.9%, antibiotics 34.8% were found as unused medicines at home [43,[53][54][55]The results of our study showed that participants had unused medicine such as 19.09% analgesics, 15.65% antibiotics and 13.74% antidiarrheal (Table 6), which confirms the presence of various classes of unused medicines at home including antibiotics.
Studies in past have investigated finally why medicines are left unused, in this regard past studies showed reasons behind leftover unused medicines were such as, nonadherence, improvement in health, [2, 42,56] . Our results confirm the above studies (Table 7).
The results of our study showed that 65.5% of the participants have unused medicines at their homes. Regarding this previous study found 88%, of participants had unused medicines at home. Similarly, another study showed 78 % presence of unused medicines [57][58][59]. The results of our study are however lower than previous studies (Table 8).The presence of unused medicines at home pose danger to human and whole environment at large [9,60].

CONCLUSION
The study participants lacked knowledge about likely side effects of disposing unused medicines improperly and storing them at home. Many participants not only improperly disposed but also accepted doing so was a suitable method. The FDA and WHO guideline are hardly known and seldomly practiced. It is suggested government should incorporate guidelines about the odds of improper disposal of unused medicines in curriculum at primary level of education this will help in to reduce the escalating problem.

LIMITATIONS
Our study had some limitations firstly the study is cross-sectional analytical study which simply portray an existing problem it neither show cause nor can elucidate effects. This nature of the study makes it limited to relations only. But the important aspect of our study is that it has shown a large fraction of the participants have unused medicine which are improperly disposed and none of the participants were found returning unused medicine to the pharmacies which illustrates an startling situation in this regard dire measures are needed to be taken. Moreover, this study may serve as first ever study conducted at national level with a large sample size that can help and provide other researchers a solid framework to speculate more comprehensively. This study will also provide insights to health officials and policy makers in future.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).