Assessment of knowledge and disposal practices of unused and expired household medicines in a community in Liberia

Abstract

Background

Expansion of pharmaceutical industries and improved availability of pharmaceuticals across the world have contributed to an increase in drug usage and accumulation in homes. Improper disposal of expired and unused medications has several consequences such as environmental pollution, and childhood poisoning.

Objectives

The aim of the study was to assess the knowledge on disposal as well as disposal practices of unused and expired household medicines in the Parker Corner Road Community in Brewerville, Liberia.

Methods

This study was a cross-sectional survey conducted among 162 residents of Parker Corner Road Community using face-to-face interviews. Outcomes measured were knowledge of disposal as well as disposal practices of unused and expired household medicines. The data collected were analysed using descriptive statistics.

Results

Majority of respondents (55.6%) were female and 23.5% had university education. 71% of the respondents reported that they had not received any information on safe disposal practices while 64.2% admitted that they often did not read and follow disposal instructions. The most popular disposal practices were disposal of the drugs along with household waste (61.1%) and flushing them down the toilets or sinks (25.3%). Majority of the respondents (82.1%) were aware of the health effects arising from improper disposal of unused and expired medicines while 64.2% usually read medicine disposal instruction on the package. Only about 3% of them knew of expired medication take-back system and 33.3% knew nothing about medication expiration date.

Conclusion

The study revealed insufficient knowledge as well as inappropriate disposal practices of unused and expired medicines among residents of Parker Corner Road Community in Brewerville. There is need to organize a public enlightenment programme on safe, appropriate use, as well as disposal of unused and expired medicines.

1. Introduction

The growth of the pharmaceutical industry and better access to medications all contribute to a rise in drug use and accumulation in households throughout the world. As a result, many studies have been conducted on the various types of unwanted medications, their quantities held in households, and their disposal habits.^1,2 In Liberia, there are existing guidelines focused on the proper disposal of outdated pharmaceuticals in community pharmacies but there are no guidelines to govern the disposal practices of expired and unused prescriptions among community inhabitants.

Non-prescription or over-the-counter (OTC) medications are not often only available in pharmacies, but also in supermarkets and other places in various countries. Self-medication might involve taking left-over pharmaceuticals from past treatment courses, drugs obtained from relatives or friends which often leads to improper storage of unused drugs, expired drugs and potential dumping of the drugs in households.³ Due to an increase in disease incidence and prevalence, healthcare practitioners tend to prescribe and dispense various kinds of medicines to end-users.³ However, factors such as poor adherence to medication, discontinuation of medication, adverse effects, inappropriate prescription, feeling healthy, dose changes, non-adherence, and medicines reaching expiration date have contributed to potential build-up of expired and unused medicines in some households.⁴

Improper disposal of expired and unused medications has several consequences such as environmental pollution, childhood poisoning, negative impact on wildlife, and development of drug-resistant microorganisms.⁵ Throwing household expired medicines into the garbage cans or the sewage system can cause environmental hazards that may have implications on public health since some of the medicines consist of potentially harmful ingredients that may accumulate in the environment.⁶ When unused medicines are dumped in the environment with municipal rubbish, the active chemicals in the medicines pose harm to the environment and human health because they may be released into the air when the waste is burned or seep into the ground in the presence of water.

Proper disposal of pharmaceuticals should be well known among end-users. However, environmentally unsafe medication disposal practices are common in several regions of the world. For example, in Indonesia, it was found that >50% of the patients flushed their medicines down the toilet and <1% returned unused medication to the pharmacy.⁷ Other studies carried out in China,⁸ India,⁹ and Ghana¹⁰ also found that the most common method of disposing of unused medication was throwing in the garbage, which ended up in landfills. These challenges and practice of improper pharmaceutical waste disposal has been well documented in a systematic review carried out among East African countries including Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda despite the fact that there are measures for disposal in these countries.² The accumulation of unused and expired medicines in households and their disposal practices are serious global challenges that need to be investigated. There has been no study regarding the disposal practices of unwanted pharmaceutical products conducted in Liberia. The results of these studies are necessary for developing effective measures to increase public awareness of medication disposal and the harms associated with its improper practices. This study thus evaluated the disposal knowledge, awareness and disposal practices of unused and expired medicines among inhabitants of the Parker Corner Road Community in Brewerville, Liberia.

2. Materials and methods

2.1. Study area

The study was conducted in Brewerville City which is approximately 13.6 km from the capital Monrovia, Liberia. The country is the oldest African republic, founded in 1847 and has a population of 5,066,949 million people, according to the World Population Review.¹¹ The specific community where this study was carried out was Parker Corner Road Community.

2.2. Study design

This study was carried out from July to September 2021 using a descriptive cross-sectional design.

2.3. Sample size

The sample size was calculated using the Raosoft® sample calculator with the estimated population size of 4000.¹¹ The final calculated sample size was 300.

2.4. Sampling technique

Convenient sampling was used to sample the permanent residents of the Parker Corner Road Community while simple random sampling was used to select the willing participants. A list of all permanent residents was made and a number allocated to each. A total of 300 random numbers from the total number of residents were generated via computer generated codes. Each generated number associated with each household was visited and the study objectives were explained after which informed consent was sought. Residents who consented were interviewed while those who did not consent were excluded.

2.5. Inclusion and exclusion criteria

Permanent residents of the community aged at least 18 years of age, who have used over-the-counter medications and who gave consent to participate were included while those who had prescription medications and who did not give consent were excluded. The reasons for exclusion of those with prescription-only medications were because participants on prescription drugs may be more hesitant to disclose their medication usage due to privacy concerns or social stigma and excluding them may help protect their privacy and reduce potential discomfort. Also, prescription-only medications are usually supplied for a specific duration and the tendency of having them around homes or expired is relatively low.

2.6. Validity and reliability of data collection instrument

A 21-item semi-structured questionnaire was used to collect data. This questionnaire was adapted from a study by Gidey et al., (2020).¹²The questionnaire has been attached in Appendix I. The instrument included information on socio-demographic characteristics, knowledge of disposal of unused and expired medicines as well as their individual practices. The questionnaire was pre-tested among 10 residents and the reliability using Cronbach alpha was at least 75%. The pretested data were excluded from the final analysis.

2.7. Protocol

Two-day training was conducted for the data collectors before commencement of the study on the modalities required to be followed for the interviews to be conducted with the permanent residents. After the data researchers showed mastery of how data was meant to be collected, a face-to-face interview was conducted to collect data from the permanent residents of the Parker Corner Road Community. Each interview lasted for an average duration of 10 min.

2.8. Data analysis

Descriptive statistics was used to analyse all data and presented using descriptive statistics using Statistical Package for Social Sciences (SPSS) version 25.

3. Results

Participants that consented to participate in this study were 162 out of which 90 (55.56%) were females making a response rate of 54%. The reason for the low response rate was that participants were not available in their places of residence during the visit by the researchers. Also, some of the participants did not give consent to participate in the study. Other than 5.6% of them, they had at least primary education (Table 1). Majority of the respondents (82.1%, 133) were aware of the environmental and human health effects arising from improper disposal of unused and expired medicines, while 64.2% (104) usually did not read medicine disposal instruction on the package. >3% (5) of the respondents were aware of the expired medication take-back system but mentioned that such practice is not being enforced (Table 2). Sixty (37%) respondents were aware that unused and expired medicines need to be disposed of safely and properly while >70% (119) of the respondents felt that unused and expired drugs are waste and should be disposed of like ordinary waste. <67% (108) were cognizant of the expiration date of drugs and stressed the importance of reading the expiration date before buying while 33.3% (54) of the respondents knew nothing about a medication expiration date (Table 2). More than three quarters of the respondents (75.3%, 122) believed that it is the responsibility of the pharmacists to inform the public about the proper disposal of unused or expired medication while 22.2% of the respondents believed that any matter concerning unused or expired medication should be reported by doctors. The rest opted for nurses. Regarding the knowledge about the right method required to dispose of unused or expired medication, <50% of the participants agreed that flushing the unwanted drugs down the toilet is the correct and safe practice while 32.7% of the respondents believed that disposing of the unwanted medication along with municipal solid waste is the preferred and safe method (Fig. 1). Ninety-nine respondents (61.1%) reported that they mix unwanted or unused drugs with household waste for disposal, while 25.5% of the respondents flushed the unwanted drugs down a toilet. <4% reported that they donate the drugs to friends while 9.9% stated that they return the drugs to the pharmacy stores. Regarding the reasons why expired drugs are found in homes, >28% (46) of the respondents indicated that they discontinued taking the drugs after feeling well while 25.9% (42) stated that they discontinued taking the medicine due to its side effect. <25% (40) reported that the taste of the medicine prevented them from taking it while the rest (21%, 34) reported that they stopped taking the medications after another medication was prescribed to them.

Table 1.

Demographic characteristic of respondents (N = 162).

Variables	Frequency	Percent (%)
Gender of respondents
Male	72	44.44
Female	90	55.56
Age of respondents
18–24 years	24	14.81
25–31 years	45	27.78
32–38 years	54	33.33
≥39 years	39	24.07
Range: 18–51 years
Educational level of respondents
No formal education	9	5.56
Primary	45	27.78
Secondary	49	30.24
Tertiary	38	23.46

Table 2.

Respondents' knowledge of the disposal of unused and expired medications.

S/N	Question	Response (%)
		Yes	No	Not sure
1.	Do you know about any drug-take-back system?	3.1	32.1	64.8
2.	Do you know that improper disposal of medicines can affect the environment and human health?	82.1	17.9	–
3.	Do you read medicines disposal instructions?	35.8	64.2	–
4.	Have you ever been told about the safe and proper way to dispose of expired and unused medicines?	27.0	73.0	–
5.	Do you check the expiration date of the medicine before buying it?	66.7	22.2	11.1

Fig. 1.

Respondents' knowledge about the proper disposal method of unwanted and expired medicines.

Regarding the prevalence of unused or expired medication at homes, >50% of the participants stated that they have unwanted drugs in their home while all the participants agreed to have more information on medication take-back programs (Table 3).

Table 3.

The presence of expired or unused medicines in Respondents' homes in the study area.

S/N	Question	Responses (%)
		Yes	No	Not sure
1	Do you normally have unused or expired medicines in your home?	56.2	43.8	–
2.	Do you presently have expired or unwanted medications in your home medicine store?	34.0	14.8	51.2
3.	Have you been told to return expired or unused medicines to a designated authority?	11.1	46.3	42.6
4.	Do you want to hear more about the medication take-back policy	100	–	–

The participants also indicated that the major classes of medicines usually found in their homes as leftover drugs were antibiotics (76%), non-steroidal anti-inflammatory drugs (NSAIDS) (22%) and anti-hypertensive drugs (16%). They also stated that tablets (78.4%), capsules (9.9%), lotions (5%) and syrups (6.8%) as the common dosage form of medications found in their homes. All of the participants agreed with the organization of a program that will collect expired and unwanted medicines from homes and consumers should be more conscious of the hazards associated with the unsafe disposal of expired and unwanted medicine.

Ninety percent (146) also agreed that there is a need to produce a guideline for expired and unwanted medication handling at homes. >45% (74) recommended a robust awareness program by the government while 33.3% (54) suggested patients' education by healthcare providers (Fig. 2).

Fig. 2.

Respondents' suggestions for improved awareness.

4. Discussion

This study assessed the knowledge, awareness and disposal practices of unused and expired household medicines among the residents of Parker Corner Road Community in Liberia. The results showed poor knowledge as well as poor medicines disposal practices among the study respondents.

4.1. Knowledge of disposal of expired medicines

This study revealed that about 65% of the participants could not read medicines' disposal instructions. This finding goes along with a similar study conducted in Tanzania where 72% could not read medicines' disposal instructions.¹³ This shows that public awareness of drug disposal instructions is low in this study area as adherence to drug disposal instruction depends on the education of the consumers by healthcare providers and awareness by the government.¹⁴

In this study, >82% of the participants knew that improper disposal of unused and expired medicines can negatively affect the environment and human health. This finding is similar to the study conducted in Zambia where 55.1% of the participants were aware of the negative impact improper disposal of expired medicines has on the environment.⁴ Similar households' assessment was done in Indonesia and the result was the opposite in that 264 (53.1%) of the participants were unaware.⁷ Unused pharmaceutical products that are not properly stored and disposed of may have negative implications. Improperly disposed drugs can lead to overuse and accidental poisonings, posing major health risks.¹⁵

The participants stated reasons for having expired and unused medications in their homes such as discontinued use after feeling well, drug side effect, unpleasant taste of the medicine, and regimen change. This is in agreement with other studies where similar reasons including improvement in medical condition, change of medicines by prescriber, keeping for future use, and intolerable medicine side effect.^12,16 Although these reasons might appear reasonable to the participants, they can carry associated risks. The presence of leftover, unused, or expired medications at home poses a potential danger in terms of environmental contamination, largely stemming from a lack of awareness regarding proper medicine disposal methods.¹⁷ Consequently, it is essential to promote awareness through suitable means. Majority of the participants of this study reported that it is the responsibility of the pharmacists to inform the public about the proper disposal of unused or expired medications. This finding is consistent with a study carried out in a specialist hospital in Ethiopia in which 60.7% of the participants believed that an awareness campaign about the proper disposal of unused and expired medicine should be led by pharmacists.¹² Pharmacists have a major role in providing proper information concerning safe disposal of medications. Some of these roles include educating patients about the potential risks associated with keeping unused or expired medications at home, emphasizing the importance of proper disposal.¹⁸ They can provide guidance on safe disposal options, such as local take-back programs, which prevent environmental harm and the diversion of controlled substances.¹⁹ Pharmacists can also ensure compliance with regulations, staying informed about federal and state guidelines, and often collaborate with other organizations to promote responsible medication disposal practices, protecting public health and the environment.¹⁹

4.2. Expired drugs disposal practices of participants

A large proportion of this study participants reported that they mix unwanted or unused drugs with household waste for disposal. These results are in agreement with the results of a study conducted in Nigeria where 74% of the participants specified that they usually dispose of their unused and expired medicines along with household solid waste.²⁰ Additionally in Brazil, 47% of the participants stated that the disposal of unused and expired medicines is done along with domestic waste.²¹

It is interesting to note that 9.9% of the participants returned the unused or expired medicines to the pharmacy while 3.7% of the participants donated the expired or unused medicines to friends and relatives. This was similar to respondents' actions toward unwanted medicine in studies carried out in Zambia where >60% and 30.4% of the participants indicated that they mainly disposed of expired unused medicines in household garbage and flushed into toilets/sinks respectively.⁴ Also, in Eastern Ethiopia, 53.2% of the participants threw expired or unused medicines in household garbage bin, 23.9% flushed into toilets/sinks, 1.9% donated to friends or relatives and 1.0% returned to the pharmacy.²² Improper disposal of medicines in the United States had led to detection of various medications such as acetaminophen, verapamil, and estradiol in rivers due to incorrect disposal of unused and expired medication.²³ This practice is dangerous and has been reported to hamper fish sexual development and feminization,²⁴ lead to antibiotics resistance,²⁵ and also genetically impact human life on the long term basis.²⁶ This highlights the need of proper medicines disposal guidelines among community dwellers in African countries.

More than half of the participants indicated the presence of unwanted medicines in homes. This result is similar to the results obtained from studies conducted in Indonesia,⁷ India,²⁷ Zambia,⁴ and Ethiopia,²² where 95.5%, 58.3%, 100%, and 66.2% participants confirmed having unused and expired medicines at home respectively. The variability found in the response rates in these studies can be linked with the level of awareness in the study areas.

Majority of the participants were eager to hear more about the drug take-back system. This is a clear indication that the majority of the respondents were not aware of the medication take-back program. This result is comparable to the study conducted in the households of Dhaka Metropolitan, Bangladesh in which 72% of respondents were willing to participate in the medicines take-back program.²⁸ Similarly, in Tanzania²⁹ and Ethiopia,³⁰ 96% and 78% of the participants, who did not know about the medicines take-back system, expressed willingness to participate in the program after the principle was explained to them respectively. Medication take-back programs have been reported to be an effective measure in the proper recycling of medications in developed countries^31,32 and if implemented could help reduce medication waste burden in developing countries.

The major classes of medicines identified by the study participants to be usually found in their homes as leftover drugs were majorly antibiotics followed by NSAIDS and anti-hypertensive drugs. This is slightly similar what findings from a study in Northern Ethiopia where the classes of drugs found were mostly NSAIDS followed by antibiotics and anti-hypertensives.³⁰ Another study in Saudi Arabia also revealed a slightly different order of leftover medicines to include NSAIDS, antibiotics and antacids.³³ These classes of leftover medicines could be due to the prevalent conditions in the study area such as pain, infections and hypertensive cases. However, the excess expired medications may also be due to the participants' inclination to self-medication which is common practice among the residents of Liberia.

When it comes to storing unwanted or expired medications, patients and family members need clear instructions on how to dispose of them.³⁴ In this study, 90% of the respondents suggested the need for a guideline for expired and unwanted medication handling at homes. These findings are consistent with a study in Ethiopia where over 96% of the participants called for an outreach awareness program about how proper disposal of unused or expired medicines should be initiated.¹²

Lack of proper disposal of medications shown by the study participants could be due to a range of sociocultural and educational factors. Firstly, a significant reason is the lack of awareness and education about the potential risks associated with improper disposal. Some individuals may not fully understand the environmental and safety implications of throwing medications in the trash or flushing them down the toilet. This knowledge gap can lead to improper disposal practices.³⁵

Secondly, cultural beliefs and practices can play a significant role. In some cultures, there might be a reluctance to dispose of medications, even if they are expired or no longer needed. This is often influenced by beliefs about waste or the perceived value of keeping medications.³⁶ Cultural norms can sometimes override recommended disposal methods.

Thirdly, individuals may avoid proper medication disposal due to the stigma associated with certain medical conditions or medications such as mental health or psychotropic medications.³⁷ They fear that disposing of these medications could reveal sensitive information about their health and, as a result, not dispose of them properly.

Medication hoarding is another issue where people stockpile medications, making them reluctant to dispose of them. This behaviour can be influenced by concerns about future unaffordability, access to specific medications.³⁸

Furthermore, even when individuals are aware of proper disposal methods, they may not have easy access to appropriate disposal options. This could be due to geographical limitations, limited pharmacy take-back programs, or a lack of knowledge about nearby disposal locations.³⁹

To address these challenges, certain practical actions to improve knowledge of medicines disposal can be carried out such as implementing educational campaigns and community outreach programs that consider sociocultural factors and are tailored to specific populations. This can be done via various media channels, community workshops and seminars featuring healthcare experts. These efforts should emphasize the importance of proper medication disposal, provide clear instructions, and make accessible disposal options widely available to promote responsible medication management and disposal practices.

Furthermore, incorporation of drug disposal education into school curricula, collaboration with environmental organizations, and participation in national prescription drug take-back events can further boost awareness.

5. Limitations of study

This research assessed the knowledge on disposal as well as disposal practices of unused and expired household medicines among residents in one Community in Liberia which could imply that the findings are not generalizable to other communities in Liberia. There was also a response rate of 54% showing a relatively small sample size. However, the findings have provided valuable insight that could be built upon in further studies. This study was carried out among a relatively young population and the findings might be different from an older population. Future studies might also explore the area. Also, inferential statistics exploring the influence of participant demographics on knowledge of disposal practices was not assessed in this study. This could be explored in future studies.

6. Conclusion

The study revealed poor knowledge and awareness of unwanted/expired medicines disposal among majority of participants. The medication disposal practices found in the study were disposing along with household waste and flushing the unwanted medicines in toilets and sinks. It is therefore expedient that government-driven public awareness campaigns on the safe disposal practices of unused medicines be carried out.

Ethics approval and consent to participate

This study was conducted following an approval from National Research Ethics Board of Liberia (NREBL, approval number NREB/2021/2356). All participants were explained all essential information before obtaining an informed consent. All procedures, including the informed consent process, were conducted in accordance with the Helsinki Declaration of 1975, as revised in 2008.

Consent for publication

Not applicable.

Funding

No funding was obtained for the conduct of this research.

Authors' contributions

P.E and J.T designed and conceptualised the study. J.T collected data, analysed the data, and drafted the manuscript. E.O conducted critical reviews and revisions of drafts of the manuscript. P.E, J.T and E.O revised manuscript for intellectual content and approved the final version of the manuscript.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Supplementary material

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.