Journal of Cardiovascular Disease Research

ISSN: 0975-3583,0976-2833 VOL14, ISSUE 12, 2023

Original Research
To Ascertain The Level Of Awareness And Adherence To Proper Disposal
Methods For Leftover And Expired Medication Among Nursing And
Dental Students
1Dr. Rana Arun Gopal Krishan Pal , 2Dr. Aarushi Sharma, 3Dr.Raj Kumar Wasan, 4
Varinder Kaur
1
MD Pathology, Professor, Department Of Pathology, Genesis Institute Of Dental Sciences And Research,
Ferozepur, Punjab, India.
2
BDS
3
Ph.D. Microbiology, Professor, Department Of Microbiology, Genesis Institute Of Dental Sciences And
Research, Ferozepur, Punjab, India.
4
Msc Lecturer, Department Of Microbiology, Genesis Institute Of Dental Sciences And Research, Ferozepur,
Punjab, India.

Corresponding Author:Dr. Raj Kumar Wasan

Email Id: [email protected]

Received: 27 November, 2023 Accepted: 27 December, 2023

ABSTRACT
Aim: To ascertain the level of awareness and adherence to proper disposal methods for leftover and expired medication among
nursing and dental students.
Material and methods: The study included senior level students of nursing and dental (2nd, 3rd and 4th year dental and nursing
students). 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. 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.
Results: Of the participants, 65% of dental students and 60% of nursing students reported that they check the expiry date of
medicine before procuring it from the pharmacy, while 25% of dental students and 17.5% of nursing students said they do not
check it. A small percentage of both groups (10% and 22.2%, respectively) said they did not know. Nearly half of dental
students (51.2%) and over half of nursing students (67.5%) threw away leftover medicines in household garbage, while 3.7%
and 2.5%, respectively, flushed unused medicine down the sink or toilet. A large majority of both dental (77.5%) and nursing
(91.2%) students said they discard expired medication in household garbage, while 11.2% and 5 %, 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. More than half (72.5%) of dental students and a majority (70%) 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.
Conclusions: The results of this study demonstrate the need for improvement in practices by Indian 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.
Keywords: Disposal, Leftover, Expired, medication, Nursing, Dental

Introduction
The prevalence of many illnesses among the general population is heightened as a result of an unhealthy lifestyle.
It is often seen that once a patient experiences the presence of any health disorders, it necessitates the
administration of various pharmaceutical interventions for their therapeutic management. Pharmaceutical
interventions serve a multifaceted role in the realm of healthcare, including not only the treatment of diseases, but
also encompassing diagnostic and preventive measures. However, it is worth noting that drug adherence has
emerged as a widespread issue on a worldwide scale. Noncompliance with treatment may result in patients not
using all prescribed medications, leading to the accumulation of unused or expired pharmaceuticals inside their
households [1]. Other factors contributing to pharmaceutical waste include discontinuation of pharmacological
treatment owing to improved symptoms, transitioning to other therapies or regimens, and excessive prescribing
by physicians in response to patient or medical representative requests [2]. It is important to provide information
to the general public on appropriate protocols for the disposal of unused or expired pharmaceuticals within
household settings. The dissemination of knowledge to the general population on the several ways of dumping

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expired or unwanted pharmaceuticals has significant importance. There exists a dearth of understanding pertaining
to the suitable methodologies for the disposal of unwanted, leftover, or expired prescriptions. Consequently, some
patients choose to dispose off their pharmaceuticals in household waste receptacles and via flushing them down
toilets or sinks. This practice subsequently leads to the contamination of drinking water and the environment [3].
Improper disposal of drugs yields numerous ramifications, with the primary ones encompassing the contamination
of community drinking water sources, resulting in health hazards. Additionally, the presence of antineoplastic
drugs in water can pose a threat to aquatic life. Insecure landfills can expose expired drugs to manual scavengers
and children, potentially leading to adverse consequences. Furthermore, pilferage from waste drugs may
contribute to the diversion of expired and unused drugs back into the market, facilitating their misuse and resale.
The presence of expired pharmaceuticals might potentially lead to diverse or unanticipated adverse drug reactions,
while the cremation of unused medications in open containers can result in the emission of hazardous pollutants
into the atmosphere [4]. It has been substantiated via reports that there exists a deficiency in the understanding of
health care personnel about the notable hazards associated with unused or expired medication, including diversion,
misuse, and accidental overdose. According to research conducted by Raja et al, health care personnel had only a
limited understanding of appropriate methods for drug disposal and showed a deficiency in implementing safe
disposal practices [5]. The existing body of research has also shown that students in the field of healthcare get
knowledge on drug use and disposal from several sources, such as healthcare professionals, educational curricula,
media outlets, instructors, and medication package inserts. The acquisition of knowledge about appropriate drug
handling and disposal practises before to graduation may have an impact on the subsequent disposal practices of
medications throughout one's work [5]. Numerous studies have provided empirical evidence to support the
assertion that the cooperation between healthcare professionals, including chemists and nurses, yields significant
therapeutic advantages [6]. The inclusion of nurse practitioner and chemist visits within the context of family
practice has been shown to provide significant enhancements in medication adherence [7]. Numerous studies have
been conducted on the subject of safe drug disposal knowledge and practice. However, it is worth noting that a
significant portion of the initial research primarily focuses on the general people, including Indians as well as
other nationals [2]. There exists a paucity of studies pertaining to the understanding and implementation of drug
disposal practices among healthcare students, namely those enrolled in dentistry and nursing programs, who play
a pivotal role in the frontline delivery of healthcare services.

Material and methods

This study was conducted for a period of 6 months, from February to July 2023. The study included senior-level
students of nursing and dentistry (2nd, 3rd and 4th year dental 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 [8].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]. Slight
modifications to the survey language were made, and the questionnaire was amended to be suitable for dental and
nursing students. 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.

Methodology
The study population included nursing and dental students who were regular students at the colleges and willing
to participate in the survey. A student 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 dental and nursing students would be included. Students with incomplete
answers to more than a half of the study questionnaires were considered as incomplete responses 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.

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 25.0 (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.

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Results
A total of 210 questionnaires were distributed during the study period, and the response rate was(n = 160, 76.19%)
noted. Of all participating subjects, 80 (50%) were dental students, and 80 (50%) were nursing students. The
marital status of majority of students was single. Most of the respondents were between 19 and 24 years of age.
Nearly 82.5% of dental students and 56.2 % nursing students reported that they were storing unused medicine in
their home. Almost a quarter percent (71.2%) of dental students, and 76.1% of nursing students purchased
medicine over the counter. Details are presented in Table 1

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

Participant Classifications Dental (n =80) Nursing (n =80) p-Value

N % N %

Age (years)
19–23 71 88.7 68 85
24–26 08 10 04 5
0.001
27–30 01 1.2 08 10

Marital status:

Single 54 67.5 72 90 0.005

Married 26 32.5 8 10

Does any quantity of purchased medicine

remain unused in your home *?

Yes 66 82.5 45 56.2

No 14 17.5 35 43.7

Ways of purchasing medicine:

Purchased using a prescription 57 71.2 61 76.2

Purchased without a prescription 11 13.7 14 17.5 0.001
(OTC)
Received from a friend /colleague 12 15 5 6.2

Of the participants, 65% of dental students and 60% of nursing students reported that they check the expiry date
of medicine before procuring it from the pharmacy, while 25% of dental students and 17.5% of nursing students
said they do not check it. A small percentage of both groups(10% and 22.5%, respectively) said they did not know.
Nearly half of dental students (51.2%) and over half of nursing students (67.5%) threw away leftover medicines
in household garbage, while 3.7% and 2.5%, respectively, flushed unused medicine down the sink or toilet. A
large majority of both dental (77.5%) and nursing (91.2%) students said they discard expired medication in
household garbage, while 11.2% and 5 %, 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. More than half (72.5%) of dental students and a majority (70%) 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, 7.5% and 15% of dental and nursing students, respectively, believed
that pharmacists bear the responsibility for this awareness. Large majorities of both groups (91.2% and 96.2%)
accepted that inappropriate disposal of unused and expired medicine can affect the environment and health.
Detailed information is presented in Table 2.

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Table 2. Knowledge and practice regarding unused and expired medicine among dental and nursing
students
Characteristics Dental Percentage Nursing Percentage
(%) (%)
Do you check the expiry date of medicine
before procuring?
Yes 52 65 48 60
No 20 25 14 17.5
Do not know 08 10 18 22.5
What do you do with unused medicine?
Throw away in household garbage 41 51.2 54 67.5
Donate to hospital 09 11.2 02 2.5
Give to friends or relatives 21 26.2 19 23.7
Return to medical store 04 5 02 2.5
Keep at home until expired 02 2.5 01 1.2
Flush in toilet or sink 03 3.7 02 2.5
What do you do with expired medicine?
Throw away in household garbage 62 77.5 73 91.2
Flush in toilet or sink 09 11.2 04 5
Give to friends or relatives 03 3.7 01 1.2
Return to medical store 06 7.5 02 2.5
Don not know 04 05 27 33.7
Who is responsible for creating awareness
of the proper disposal of unused and
expired medicine?
Ministry of Health 58 72.5 56 70
Pharmaceutical industry 11 13.7 07 8.7
Pharmacist 06 7.5 12 15
General public 05 6.2 05 6.2
Do you think improper disposal of unused
and expired medicine can affect the
environment and health?
Yes 73 91.2 77 96.2
No 07 8.7 03 3.7
The most common classes of drugs purchased by respondents were painkillers, followed by antibiotics. There was
a statistically significant difference between dental and nursing students regarding checking the expiry date of
medicine before procuring, unused medicine being stored at home, and awareness that improper disposal can
affect the environment. There was no statistically significant difference in the belief that the pharmaceutical
industry and the general public are responsible for creating awareness of proper disposal of unused and expired
medicines (> 0.05). Details are presented in Table 3.

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

Parameter Dental Percentag Nursing Percent p-Value
e (%) age (%)
Do you check the expiry date of the
medicine before procuring?
Yes 52 65 48 60
No 20 25 14 17.5 0.001
Do not know 08 10 18 22.5
Does any quantity of purchased
medicine remain unused in your home?
Yes 52 65 47 58.75
No 18 35 33 41.2 0.002
Improper disposal of unused and
expired medicine can affect the
environment and health.
Yes 73 91.2 77 96.2
No 07 8.7 03 3.7 0.006

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Who is responsible for creating
awareness of the proper disposal of
unused and expired medicine?
Ministry of Health
Yes 58 72.5 56 70
No 22 27.5 24 30 0.001
Pharmaceutical industry
Yes 11 13.7 07 8.7 0.24
No 69 86.3 73 91.3
Pharmacist
Yes 06 7.5 12 15 0.14
No 74 92.5 68 85
General public
Yes 05 6.2 05 6.2 0.36
No 75 93.8 75 93.8

Discussion
Globally, the improper disposal of leftover medicine poses a danger to public health and environmental safety
[9,10]. 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 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 dentists and nurses work through inter-professional 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 [5,8]. The results show that a majority of dental and nursing students (65% and 60%, 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 dental students too provide counseling and education to patients about the use of medicine and the importance
of paying attention to expiration dates [5,9]. In the present study, both dental (77.5%) and nursing (91.2%) 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 [11]. 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, 1.2% of nursing students and 2.5% of dental 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 [11,12]. This could be due to
the perception that it might be needed in the future [11]. 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 [11]. The results also show significant differences between dental and
nursing students regarding ways of purchasing medicine (p=0.001). Additionally, results revealed that nursing
students were more knowledgeable (p=0.001) in regard to purchasing medicine, checking the expiry date of
medicine, and safe disposal practice, compared to dental students. This might be due to the training and clinical
rotation, which starts in nursing from the start of the course, while in dentistry, 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 [5,11-14]. Nevertheless, a general belief persists that flushing unused and expired
medication down the toilet or sink is the best practice, particularly for liquid medications [14-16], even in countries
such as the United States and the United Kingdom [15,16]. The present study has several limitations. Firstly, the
sample referred to in this study was small and the research was limited to one university. 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.

Conclusions
The results of this study demonstrate the need for improvement in practices by Indian 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

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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.

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