7.

Article

Knowledge and Disposal Practice

of Leftover and Expired Medicine:
A Cross-Sectional Study from
Nursing and Pharmacy Students’
Perspectives

Adel Bashatah and Syed Wajid

https://doi.org/10.3390/ijerph17062068
 International Journal of
Environmental Research
and Public Health

Article
Knowledge and Disposal Practice of Leftover and
Expired Medicine: A Cross-Sectional Study from
Nursing and Pharmacy Students’ Perspectives
Adel Bashatah 1, * and Syed Wajid 2
1 Department of Nursing Administration and Education, College of Nursing, King Saud University,
Riyadh 11362, Saudi Arabia
2 Department Clinical Pharmacy, Drug and Poison Information Centre, College of Pharmacy, King Saud
University, Riyadh 11451, Saudi Arabia; wali@ksu.edu.sa
* Correspondence: abashatah@KSU.EDU.SA; Tel.: +96-650-547-3496




Received: 16 February 2020; Accepted: 18 March 2020; Published: 20 March 2020


Abstract: The objective of the present study was to investigate the knowledge and practices concerning
unused and expired medicine among pharmacy and nursing students at King Saud University, Riyadh,
Saudi Arabia. A cross-sectional study design was used. The study used a validated paper-based,
self-administered questionnaire. Statistical analyses were performed using SPSS, Version 24. The
response rate was 70.4% (n = 352). The results indicated that 57.4% of pharmacy students and 53.4% of
nursing students check the expiry date of medicine before procuring, and 37.6% of pharmacy students
and 52.5% of nursing students keep unused medicine until it expires. With regard to disposal, 78.9% of
pharmacy students and 80.5% of nursing students reported discarding expired medicine in household
garbage or flushing it down a sink or toilet. Only a small percentage returns leftover medicine to a
medical store. There was a statistically significant difference between pharmacy and nursing students
in regard to checking the expiry date of medicine before procuring (p = 0.01), and keeping unused
medicine until it expires (p = 0.03). The study concluded that the majority of respondents dispose of
medicine unsafely. The findings suggest that creating awareness regarding proper medicine disposal
procedures among university health care students in Saudi Arabia is needed.

Keywords: Expired; Medicine; Unused; Nurses; Pharmacist; Saudi Arabia

1. Introduction
Universally, the correct disposal of medicine poses a challenge and is receiving increasing
attention [1–5]. A lack of knowledge about proper disposal of unused medicine can lead to serious
consequences, such as an accumulation of toxins and chemicals from the medicine into the environment,
unintentional overdose, and prescription drug abuse [6]. A number of countries have established
guidelines for disposing of leftover or expired medication [7–12].
A study by AlAzm et al in 2017, carried out in King Abdul-Aziz Medical City (KAMC), Jeddah,
found that a large majority of subjects (80%) never received any information about the safe disposal of
medication from their health care providers; 73% discarded leftover medication in the trash, while
14% returned it to a pharmacy [13]. A study in 2003 investigating the use and disposal of medication
among Saudi families reported that most of the subjects stored or discarded unused medicine [14].
Fletcher found that a lack of education, older age, and receiving multiple medications were factors
associated with inappropriate drug use, which could lead to medication waste in the environment [15].
Reports have confirmed a lack of knowledge among health care professionals about the significant
risks of unused or expired medicine, including diversion, abuse, and accidental overdose [16]. A study

Int. J. Environ. Res. Public Health 2020, 17, 2068; doi:10.3390/ijerph17062068 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 2068 2 of 8

by Raja et al among health care professionals reported partial knowledge about proper drug disposal
and a lack of safe disposal practices [5].
The literature has also shown that health care students acquire information about drug use and
disposal from a range of sources, including health care practitioners, curricula, media, teachers, and
medicine package inserts. Knowledge about proper drug practice formed prior to graduation may
affect medicine disposal practices later during employment [5].
The clinical benefits resulting from collaboration among health care professionals, such as
pharmacists and nurses, have been proven by many studies [12,17,18]. Nurse practitioner and
pharmacist consultations in family practice resulted in major improvements in the correct use of
medication [5,17]. Fletcher reported that nurse practitioner and pharmacist counseling is important in
improving the appropriate use of medication [15].
While a number of studies exist about safe drug disposal knowledge and practice, much of the
early work is limited to the general public, both in Saudi Arabia and in other countries [2–5]. There is a
shortage of research on the knowledge and practice of drug disposal among health care students, such
as pharmacy and nursing students, who are on the ‘front lines’ in the health care setting. A review of
the literature found no studies carried out in Saudi Arabia that investigated pharmacy and nursing
students’ knowledge and disposal practices regarding unused and expired medicine. Therefore, the
present study, conducted among pharmacy and nursing students from King Saud University Colleges
of Pharmacy and Nursing in Saudi Arabia, will add to the investigative literature.

2. Methods

2.1. Study Design, Area, and Setting

This study was conducted for a period of 3 months, from January to March 2019, at the College of
Pharmacy and the College of Nursing, King Saud University, Riyadh, Saudi Arabia. The study included
senior-level students of nursing and pharmacy (4th, 5th and 6th year pharmacy and nursing students).
Data collection was carried out with a paper-based, printed questionnaire through a self-administration
procedure using convenience sampling. Convenience sampling is a non-probability technique in which
study subjects are selected based on certain criteria, such as availability at a given time, willingness to
participate, accessibility, and geographical proximity to the researchers [19]. The study was approved
by the ethics committee of the College of Medicine at King Saud University (E-19-4279).
The study tool was prepared after conducting an extensive review of questionnaires used in
previous studies that evaluated the disposal of expired and unused medication [4,5]. Reliability of
the questionnaire was assessed in a pilot study conducted among a sample of 10 randomly selected
pharmacy and nursing students. Cronbach’s alpha coefficient was 0.70, which indicated that the
questionnaire could be used in this study. Slight modifications to the survey language were made, and
the questionnaire was amended to be suitable for Saudi students in Saudi Arabia. The questionnaire
consisted of 10 items divided into two parts and included both multiple choice and binary answers.
Part A contained demographic questions, including age, marital status, and methods for obtaining
medication. Part B addressed students’ knowledge and habits regarding unused and expired medicine.

2.2. Data Collection Procedure

The study population included nursing and pharmacy students who were regular students at
the colleges and willing to participate in the survey. A researcher who was appointed to collect
the data visited the students in their classrooms during lecture periods. A brief talk was given to
explain the purpose of study and to ensure the students of confidentiality in their responses. Written
informed consent was obtained from the students. Participants were given enough time to complete
the questionnaire. Data collection was conducted using convenience sampling and performed in such
a way that all of the pharmacy and nursing students would be included. Students with incomplete
answers to more than a half of the study questionnaires were considered as incomplete responses
Int. J. Environ. Res. Public Health 2020, 17, 2068 3 of 8

and therefore excluded from the study, and students who missed 2 or 3 questions in the survey were
considered as a treatable response and therefore included in the study. Students who did not return
questionnaires were considered non-respondents.

2.3. Statistical Analyses

The data were entered and coded, and descriptive statistics were calculated for all survey items.
All statistical analyses were conducted using SPSS Version 24 (SPSS Inc., Chicago, IL, USA). The results
are expressed as numbers and percentages presented in the forms of tables and graphs. In addition,
the associations between variables were determined by performing chi-square tests. A p-value < 0.05
was considered a statistically significant difference in all analyses.

3. Results
In total, 500 questionnaires were distributed during the study period, and the response rate was
(n = 352, 70.4%). Of all participating subjects, 161 (45.3%) were pharmacy students, and 191 (54.6%)
were nursing students. The majority of students (92.6%) were single. Most of the respondents were
between 18 and 22 years of age. Nearly 59.2% of pharmacy students and 70.5% nursing students
reported that they were storing unused medicine in their home. Slightly more than half (51.5%) of
pharmacy students, and 36.1% of nursing students purchased medicine over the counter. Details are
presented in Table 1.

Table 1. Demographics, storage, and procurement of medicine.

Pharmacy (n = 161) Nursing (n = 191)

Participant Classifications p-Value
N % N %
Age (years)
18–22 113 70.8 169 88.8
23–26 46 28.7 14 7.2 p < 0.001
27–30 2 1.2 8 4.1
Marital status
Single 147 91.3 179 93.7
p < 0.05
Married 14 8.7 12 6.3
Does any quantity of purchased medicine
remain unused in your home *?
Yes 96 59.2 134 70.5
p < 0.001
No 64 39.5 55 28.9
Ways of purchasing medicine
Purchased using a prescription 117 72.7 170 89.5
Purchased without a prescription (OTC) 83 51.5 69 36.1
Received from a friend /colleague 23 14.8 15 7.9 p < 0.001
Obtained / purchased on the advice of a
27 16.7 31 16.3
relative
* Missing responses.

Of the participants, 57.4% of pharmacy students and 53.4% of nursing students reported that they
check the expiry date of medicine before procuring it from the pharmacy, while 22.8% of pharmacy
students and 35.6% of nursing students said they do not check it. A small percentage of both groups
(18% and 9.5%, respectively) said they did not know.
Nearly half of pharmacy students (47.2%) and over half of nursing students (61.2%) threw away
leftover medicines in household garbage, while 6.8% and 5.3%, respectively, flushed unused medicine
down the sink or toilet. A large majority of both pharmacy (68.3%) and nursing (74.2%) students said
they discard expired medication in household garbage, while 10.6% and 6.3%, respectively, flushed
expired medicine down the toilet or sink. Interestingly, only a small percentage of both groups said
they return leftover or expired medicine to the medical store or pharmacy.
Int. J. Environ. Res. Public Health 2020, 17, 2068 4 of 8

More than half (64.6%) of pharmacy students and a majority (81.6%) of nursing students agreed
that the responsibility for creating awareness of proper disposal methods for leftover and expired
medicine lies with the Ministry of Health. Additionally, 19.9% and 16.3% of pharmacy and nursing
students, respectively, believed that pharmacists bear the responsibility for this awareness. Large
majorities of both groups (91.9% and 81.8%) accepted that inappropriate disposal of unused and
expired medicine can affect the environment and health. Detailed information is presented in Table 2.

Table 2. Knowledge and practice regarding unused and expired medicine among Saudi pharmacy and
nursing students.

Characteristics Pharmacy n(%) Nursing n(%)

Do you check the expiry date of medicine before procuring? *
Yes 92 (57.4) 102 (53.4)
No 37 (22.8) 68 (35.6)
Don not know 29 (18) 18 (9.5)
What do you do with unused medicine?
Throw away in household garbage 77(47.2) 117(61.2)
Donate to hospital 18 (11.2) 9 (4.7)
Give to friends or relatives 25 (15.5) 39 (20.5)
Return to medical store 11 (6.8) 9 (4.7)
Keep at home until expired 60 (37.6) 100 (52.5)
Flush in toilet or sink 11 (6.8) 10 (5.3)
What do you do with expired medicine?
Throw away in household garbage 110 (68.3) 141 (74.2)
Flush in toilet or sink 17 (10.6) 12 (6.3)
Give to friends or relatives 8 (5.0) 4 (2.1)
Return to medical store 13 (8.1) 5 (2.6)
Don not know 13 (8.1) 27 (14.2)
Who is responsible for creating awareness of the proper
disposal of unused and expired medicine?
Ministry of Health 104 (64.6) 155 (81.6)
Pharmaceutical industry 19 (11.8) 20 (10.5)
Pharmacist 32 (19.9) 31 (16.3)
General public 21 (13) 28 (14.7)
Improper disposal of unused and expired medicine can affect
the environment and health.*
Yes 132 (81.8) 174 (91.9)
No 29 (18.1) 16 (8.7)
* Missing responses.

The most common classess of drugs purchased by respondents were painkillers, followed by
antibiotics. The detailed information was given in Figure 1. There was a statistically significant
difference between pharmacy and nursing students regarding checking the expiry date of medicine
before procuring (p = 0.010), unused medicine being stored at home (p = 0.030), and awareness
that improper disposal can affect the environment (p = 0.007). There was no statistically significant
difference in the belief that the pharmaceutical industry and the general public are responsible for
Int. J. Environ. Res. Public Health 2020, 17, 2068 5 of 8

creating awareness of proper disposal of unused and expired medicines (< 0.05). Details are presented
in Table 3.

Chart Title
160
140
120
100
80
60
40
20
0
Painkillers Antibiotic Anti-hypertensive Anti-diabetic Miscellaneous
drugs

Pharmacy Nursing

Figure 1. Most common classes of drugs purchased by respondents.

Table 3. Association between study participants’ responses in selected variables.

Variables Pharmacy n(%) Nursing n(%) p-Value

Do you check the expiry date of the medicine before procuring?
Yes 92 (58.2) 102 (54)
p < 0.010
No 37 (23.4) 68 (36.)
Don not know 29 (18.4) 19 (10.1)
Does any quantity of purchased medicine remain unused in your
home?
Yes 96 (60) 135 (71.1)
p < 0.030
No 64 (40) 55 (28.9)
Improper disposal of unused and expired medicine can affect the
environment and health.
Yes 132 (82) 174 (91.6)
p < 0.007
No 29 (18) 16 (8.4)
Who is responsible for creating awareness of the proper disposal
of unused and expired medicine?
Ministry of Health
Yes 104 (64.6) 156 (82.1)
p < 0.001
No 57 (35.4) 34 (17.9)
Pharmaceutical industry
Yes 19 (11.8) 20 (10.5)
p < 0.701
No 142 (88.2) 170 (89.5)
Pharmacist
Yes 32 (19.9) 31 (16.3)
p < 0.387
No 129 (80.1) 159 (83.7)
General public
Yes 21 (13) 28 (14.7)
p < 0.648
No 140 (87) 162 (85.3)
Int. J. Environ. Res. Public Health 2020, 17, 2068 6 of 8

4. Discussion
Globally, the improper disposal of leftover medicine poses a danger to public health and
environmental safety [20,21]. Therefore, it is important to investigate the prevalence of this practice
and to create awareness of and solutions for safe medicine disposal methods, particularly among health
care providers. This is the first study of its kind to survey university health care students in Saudi
Arabia on their knowledge and practice regarding unused and expired medication. The present study
results show that majority of the participants prefer to purchase medicines using a prescription, which
is similar to the previous study conducted among health care students and staff, in which nearly 55%
of surveyed participants purchased medicine through prescription [5]. It is believed that health care
professionals such as pharmacist and nurses work through interprofessional collaboration to dispense
medications to the patients. Additionally, a number of studies revealed that nurses and pharmacists
provide counseling and education regarding the use and administration of drugs, and to emphasize
the importance of expiry dates to patients [5,19].
The results show that a majority of pharmacy and nursing students (58.2% and 54%, respectively)
check the expiry date of medicine before purchasing it. These results are lower than the findings of a
study by Raja et al., in which 98% of nursing students checked the expiry date of medication [5]. Studies
have shown that nurses and pharmacists provide counseling and education to patients about the use of
medicine and the importance of paying attention to expiration dates [5,20]. In the present study, both
pharmacy (68.3%) and nursing (74.2%) students threw away expired medicine in household garbage.
These results are in line with those of Raja et al., in which 72% of respondents threw expired medicine
in the garbage [5]. A similar study among dental students by Aditya found that 94% of students threw
away unused medicine in the household trash [22]. This practice has been observed internationally,
irrespective of whether the subjects are the general public or health care professionals [4,5].
In the current study, more than half (52%) of nursing students and 37% of pharmacy students
stored leftover medicine. According to Raja et al., the majority of nursing students discarded leftover
medicine [5], while studies done among the general public showed that leftover medicine was stored
until it expired [17,22,23]. This could be due to the perception that it might be needed in the future [7,22].
However, some studies reported that keeping leftover or unused medicine for a longer time might
result in polypharmacy or unintentional consumption of medicine, which can lead to toxic effects in
the individuals [4,5,22]. The results also show significant differences between pharmacy and nursing
students regarding ways of purchasing medicine (p = 0.001). Additionally, results revealed that nursing
students were more knowledgeable (p = 0.001) in regards to purchasing medicine, checking the expiry
date of medicine, and safe disposal practice, compared to pharmacy students. This might be due to the
training and clinical rotation, which starts in nursing from the start of the course, while in pharmacy,
clinical rotation begins in the last or senior levels.
The majority of the participants in this study said they were aware of the dangers to the environment
from improper drug disposal. This finding is similar to those of other studies among both health
care students and the general public [5,17,22–25]. Nevertheless, a general belief persists that flushing
unused and expired medication down the toilet or sink is the best practice, particularly for liquid
medications [18,25–27], even in countries such as the United States and the United Kingdom [26,27].
The present study has several limitations. Firstly, the sample referred to in this study was small,
and the research was limited to one university in Riyadh City. Therefore, the outcomes of the current
findings can only represent the situation in the current study’s settings. In addition, to address
sampling bias due to respondents who did not respond to the survey, it is recommended that future
studies investigate the factors or reasons that prevented them from participating.

5. Recommendations
It is necessary and advisable to increase education among health care students and the general
public about proper storage and disposal of medication, both prescribed and over-the-counter. In
Int. J. Environ. Res. Public Health 2020, 17, 2068 7 of 8

Saudi Arabia and other countries, awareness on this issue is lacking. This can be accomplished by the
government, learning institutions, and in pharmacies at the point of sale.
It is recommended that the Ministry of Health issue official guidelines and policies for the safe
storage and disposal of unused and expired medication. It is also suggested that the government
establish a take-back program in partnership with medical stores and the pharmaceutical industry.
Physicians should avoid overprescribing, as this will minimize the burden of unused medication
requiring disposal. All of these approaches can play a significant role in reducing the hazards that
medicine disposal poses to environmental safety and human health [28].

6. Conclusions
The results of this study demonstrate the need for improvement in practices by Saudi health care
students regarding the disposal of leftover and expired medicine. Improper disposal of medication can
cause contamination of water supplies, introduce toxins into the environment, and risk unintentional
overdose or drug abuse. The government should issue guidelines and launch education programs on
correct disposal methods for professionals in health care settings and for the general public, as well as
establish a convenient medicine take-back program. Future studies can be conducted once these efforts
are put in place to monitor their success.

Author Contributions: Conceptualization, A.B. and S.W.; methodology, S.W.; software, S.W.; validation AND
formal analysis, S.W. and A.B.; investigation and resources, S.W.; data curation, S.W.; writing—original draft
preparation, A.B.; writing—review and editing, A.B.; visualization, A.B.; supervision, A.B.; project administration,
A.B.; funding acquisition, A.B. All authors have read and agreed to the published version of the manuscript.
Funding: This research was supported and funded by King Saud University, Riyadh Saudi Arabia.
Acknowledgments: The authors extended their appreciation to the Researcher Supporting Project, (Project
number - RSP-2019/9).) King Saud University, Riyadh, Saudi Arabia, for supporting this study.
Conflicts of Interest: The authors declare no conflicts of interest.

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