Knowledge and Practices on Home Medication Storage and Disposal in Syria: A Population-Based, Cross-Sectional Study

doi:10.21203/rs.3.rs-4714675/v1

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Research Article

Knowledge and Practices on Home Medication Storage and Disposal in Syria: A Population-Based, Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4714675/v1

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published 06 Sep, 2024

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Background

Medications are commonly found in every household. Improper storage can alter their effectiveness and usability, while inappropriate disposal negatively impacts the environment. This study aimed to evaluate the attitudes and practices of Syrian individuals regarding the appropriate storage and disposal of home medications.

Method

A cross-sectional study was conducted from September 22 to October 20, 2023, using an online survey distributed via social media apps (WhatsApp, Facebook, and Telegram) in Syria. The questionnaire, adapted from a similar study in Saudi Arabia, was translated to Arabic using the forward-backward translation technique. A convenience sampling technique was used. Validity and reliability were confirmed through a pilot study with 50 participants (Cronbach's alpha = 0.7). Inclusion criteria were participants over eighteen with expired or unused medications at home. Descriptive statistics, Chi-square tests, and binary logistic regression analysis were performed using SPSS version 27, with statistical significance defined as p < 0.05.

Results

A total of 2,217 responses were collected. The findings revealed that 87% of respondents dispose of expired medications in the garbage, and 95% keep medications in their original containers. Additionally, 30% consult pharmacists for storage instructions, and 64% read the storage information on medication leaflets. There was no significant difference in responses between medical professionals and the general population.

Conclusion

This study highlights a significant lack of awareness among the Syrian public regarding the proper storage and disposal of medications. Enhanced public education and awareness programs are essential to improve these practices.

Medication Safety

Medication Disposal

Home Medication Storage

Syria

Pharmaceutical preparations known as medications are frequently used and kept in households all around the world [1]. While medications play a vital role in life preservation, they can also have negative side effects if misused and abused [2]. Studies conducted both domestically and internationally reveal that most patients store their prescriptions improperly at home. This practice heightens the risk of unintended consequences, including improper self-medication, accidental overdoses, and prescription drug misuse [3]. The safe disposal of unused, unwanted, or expired medications, particularly by consumers, is a significant global concern. Many developed nations have initiatives to address the disposal of leftover medications, with strong support from both the government and the pharmaceutical industry for projects like the National Return and Disposal of Unwanted Medicines Project [4]. In the United Kingdom, around 653 million prescriptions were dispensed annually in 1999,and 1074 million were in 2009, This increase can result from a rise in the variety of available pharmaceuticals or the expanded utilization of previously available medications [5]. Medicine waste refers to both expired and partially or completely unused medications, For the safe and appropriate use of pharmaceuticals, including vitamins and vitamin supplements, careful storage in homes is crucial, Medication should be kept in the physical conditions necessary for maximum efficacy, which includes proper storage(6). Various analgesics, anticonvulsants, anti-epileptics, antibiotics, painkillers, and synthetic hormones are among the pharmaceuticals that are frequently found in freshwater environments, as these substances are difficult to remove with conventional wastewater treatment processes [4]. Disposing of discarded medications through environmentally unfavorable routes, such as the sink, toilet, or trash can, significantly contributes to groundwater and water contamination and the overall environmental presence of pharmaceutically active compounds [4]. The US Food and Drug Administration (FDA) regulates the appropriate disposal of unused and expired medications in accordance with agreements between neighborhood pharmacies and the local police force, These organizations offer advice on how to get rid of outdated and unwanted drugs by burning them, taking them back to nearby pharmacies and over-the-counter medications sellers (OTCMs), or flushing them down the toilet (for drugs on the FDA flush list) [7]. The practice of discarding leftover medications has since expanded to become a global issue that is attracting the interest of governments, medical professionals, pharmaceutical companies, and the general public [4]. In certain other nations, the practice of flushing drugs down the sewage system still exists, only by implementing procedures for appropriately discarding unused and expired medications can the presence of pharmaceuticals in the environment be reduced [7]. Programs to dispose of leftover medications are available in many developed nations, one such initiative is the National Return and Disposal of Unwanted Medicines Project, which has the full backing of both the government and the pharmaceutical industry [2]. The leaflet that is often attached to each drug contains detailed recommendations for the proper way to store a medicine. No prior research has examined how medications are stored in Syria, and there are no explicit guidelines, regarding the storage and disposal of home medications. This study aimed to evaluate the attitudes and practices of Syrian individuals regarding the appropriate way of disposing and storing medications.

Study design and sample size

During the period 22 September to 20 October 2023, we distributed an online-based survey in Syria using social media apps (WhatsApp, Facebook, and telegram). This research was a cross-sectional study. Based on prior research conducted in Saudi Arabia (1), a questionnaire was translated from the English language to Arabic, using the forward backward translation technique. The conceptual translation was prioritized during the translation process over the literal (word-for-word) translation.

All responses were anonymous and contained no identifying information; the data was only accessible to the main investigator. A convenience sampling technique was used to pick the sample population. Before disseminating the questionnaire, we assessed its usability and technical functionality on thirty participants in an experimental survey. The questionnaire's validity and reliability were then confirmed by testing it on 50 participants as part of a pilot study; Cronbach's alpha was 0.7. Inclusion criteria were for participants to be older than eighteen and have any expired or unused medications in their residences. Calculator.net's sample size estimator, accessible at “https://www.calculator.net/sample-size-calculator.html”, was used to determine the sample size. Based on UN estimates, the population of Syria is predicted to surpass 18 million in 2019. We used that information to undertake an analysis of statistical power in order to determine the sample size. A sample size of 385 with a 50% design effect, a 0.05 margin of error, and a 95% confidence level was recommended. Our sample size was 2217 in total.

Measures

The questionnaire consisted of 22 questions divided into 2 sections:

1. Socio-demographic characteristics: This covers 9 questions about age, gender, the governorate of origin, living place (urban or rural), employment status, financial status, educational level, having kids < 6 years, belonging to the medical field.

2. Knowledge and practice towards storing and disposing of medications: This section includes 13 questions about the way/place in which drugs are stored at home, whether the original containers of the prescriptions are changed or not, and whether the expiry date is written on the new container. Participants were questioned in certain questions if they are aware of the kinds of pharmaceutical preparations or dosage forms that need to be refrigerated, as well as whether they check the expiration date of the medications they have stored before using them and on a regular basis. They were also questioned about how they dispose of both unused, unexpired and expired drugs. The full Arabic and English version of the questionnaire can be found in Supplementary file. 1

Ethical approval

This study was conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval for this research was obtained from the Ethics Committee of Syrian Private University and Al-Baath University. Prior to participation, all respondents were provided with detailed information about the study's purpose, and their rights as participants. Informed consent was obtained electronically from all participants before they began the survey. Participation was voluntary, and participants could withdraw from the study at any time without any consequences. All responses were anonymous, and no identifying information was collected. The data was stored securely and was accessible only to the main investigator.

Statistical analysis

The statistical analysis for this study involved multiple steps to ensure a thorough examination of the data. Descriptive statistics were calculated to determine mean values and standard deviations (±SD) for continuous variables. Categorical variables were summarized using frequencies and percentages. To analyze variations in medication storage and disposal practices among different demographic groups, Chi-square tests were utilized. This allowed for the identification of significant differences across groups. Additionally, binary logistic regression analysis was conducted to pinpoint specific factors that predict medication storage and disposal behaviors. All analyses were performed using SPSS software, version 27. Statistical significance was defined as p < 0.05. Results were presented with 95% confidence intervals (CIs).

Sociodemographic characteristics of the respondents

A total sample size of 2217, 1753 (79%) were female. Most respondents 1246 (56%) were in the 21-30 years age group. 798 (35.9%) lived in northern Syria. The majority of the participants lived in cities 1805 (81%). Regarding the respondents' educational levels, 1767 (80%) were University students. Participants who work or study in the healthcare system were 1090 (49%). Only 464 (21%) reported that they have children under 6 years old. 1051 (47%) participants reported their financial status as moderate. 925 (42%) participants were students who were unemployed, 347 (16%) participants were unemployed, and 337 (15%) participants worked full-time jobs. (Table 1)

Table 1: Participants’ sociodemographic characteristics.

Item		N (%)
Gender	Female	1753(79)
Gender	Male	464(21)
Age groups	18-20 years	487(22)
	21-30 years	1246(56)
	31-40 years	265(12)
	40 years or older	219(10)
Living area	Eastern Syria	34(1.5)
	Northern Syria	798(35.9)
	Middle Syria	641(28.9)
	Southern Syria	602(27.1)
	Western Syria	142(6.4)
Area of living	Urban	1805(81)
Area of living	Rural	412(19)
Education level	No formal education	12(1)
	Primary school	28(1)
	Secondary school	61(3)
	High school	198(9)
	University	1767(80)
	Postgraduate	151(7)
Work	Part time job	265(12)
	Full-time job	337(15)
	Student	925(42)
	Student+ part-time job	259(12)
	Student+ full-time job	84(4)
	Unemployed	347(16)
Do you belong to the medical field	Yes	1090(49)
Do you belong to the medical field	No	1127(51)
Do you have any kids <6?	Yes	464(21)
Do you have any kids <6?	No	1753(79)
Income	Low	342(15)
	Moderate	1051(47)
	Good	741(33)
	High	83(4)

Knowledge and practices of participants regarding medications storage.

Among study participants, 2102 (95%) kept medications in their original container, 2073 (94%) said that they check the expiration date before using the medications, 1596 (72%) check the expiration date periodically, 1414 (64%) read the storing instructions of medications written on the leaflet, 672 (30%) asked the pharmacist about the storing instructions and 869 (39%) wrote the expiration date on the new container. (Table 2)

Table 2. Participants’ medication storage behaviors.

Behavior		N (%)
Keeping medication in original container	Yes	2102(95)
Keeping medication in original container	No	115(5)
Checking the expiration date before using the medications	Yes	2073(94)
Checking the expiration date before using the medications	No	144(6)
Checking the expiration date of stored medications periodically	Yes	1596(72)
	No	621(28)
Reading the storing instructions of medications written on the leaflet	Yes	1414(64)
	No	803(36)
Asking the pharmacist about the storing instructions	Yes	672(30)
Asking the pharmacist about the storing instructions	No	1545(70)
Writing the expiration date on the new container	Yes	869(39)
Writing the expiration date on the new container	No	1348(61)

The most common classes of medications that participants kept at home were painkillers and antipyretics 2107 (95%). When they were asked about the ways they dispose unused medications, the most common answers were storing it for future use and throwing it in the garbage, as reported by 986 (44.4%) and 974 (43.9%) participants, respectively. The main way to dispose expired medications was throwing it in the garbage, as reported by 2012 (90.7%) participants.

Regarding places where medications were stored, 622 (28%) were stored in bedroom, 570 (25.7%) in kitchen and 1231 (55.5%) in cabinet. When participants were asked about the way they carried medications in case of traveling, more than half of them reported that they carry it in handbag 1495 (67.4%). Regarding dosage forms that should be stored in the refrigerator, suppository was the most commonly reported by 1716 (77.4%) participants. (Table 3)

Table 3: Participants’ knowledge and practices regarding the storage of medications.

Item		N (%)
Common classes of medications in the house	Pain killers+ antipyretics	2107(27)
	Cough syrups	1072(14)
	Vitamins and supplements	1419(18)
	Antibiotics	943(12)
	Antiacids	625(8)
	Antidiabetic agents	331(4)
	Antihypertensive	522(7)
	Anti-hyperlipidemic	242(3)
	Others	419(5)
The way of disposing unused medications	Keep it at home until expiration	23(1)
	Store it for future use	986(36)
	Throw it in the garbage	974(36)
	Give it to a friend or relative	427(16)
	Return it to the pharmacy	313(11)
The way of disposing the expired medications	Throw it in the garbage	2012(87)
	Throw it in the toilet	118(5)
	Return it to the pharmacy	81(3)
	Buried in the soil	90(4)
	Burn it	25(1)
Store medications in	Cabinet	1231(46)
	No box	131(5)
	Open box	303(11)
	Bag	206(8)
	Locked box	407(15)
	Others	424(16)
Place for storing medications	Refrigerator	490(31)
	Bedroom	622(21)
	Kitchen	570(19)
	Living room	488(16)
	Car	14(0.4)
	Others	373(12)
Medications that should be stored in the refrigerator	Suppositories	1716(27)
	Insulin	381(6)
	Syrups	887(14)
	Eye drops	591(9)
	Injectable medication	365(6)
	Ear drops	245(4)
	Ointments	497(8)
	Antibiotics	290(5)
	Tab+ caps	6(0.1)
	Hormones	102(2)
	Creams	367(6)
	Iron and folic acid tablets	157(2)
	Vitamins tablets	315(5)
	Others	320(5)
The way of carrying the medications in case of traveling	In handbag	1495(67)
	With luggage	290(13)
	In a bag inside the airplane cabin	51(2)
	I do not carry medications during travel	217(10)
	Buy new medications from designated country	164(8)

Correlations between participants characteristics and their practices regarding the storge of medications

Using chi-square test, results showed a statistically significant difference between males and females in checking the expiration date before using the medications, of which 1653 (94%) females answered “yes” (p-value < 0.01), checking the expiration date of stored medications periodically, of which 1291 (74%) females answered “yes” (p-value < 0.001), reading the storing instructions of medications written on the leaflet, of which 1159 (66%) females answered “yes” (p-value < 0.0001), asking the pharmacist about the storing instructions, of which 158 (34%) males answered “yes” (p-value < 0.05) and writing the expiration date on the new container, of which 711 (41%) females answered “yes” (p-value < 0.05). (Table 4)

Table 4: Participants’ medication storage practices stratified by gender.

Behavior	Gender		P value
Behavior	Male N (%)	Female N (%)	P value
Keeping medication in original container			0.354
Yes	436(94)	1666(95)
No	28(6)	87(5)
Checking the expiration date before using the medications			0.0033*
Yes	420(91)	1653(94)
No	44(9)	100(6)
Checking the expiration date of stored medications periodically			0.0007*
Yes	305(66)	1291(74)
No	159(34)	462(26)
Reading the storing instructions of medications written on the leaflet			<0.0001*
Yes	255(55)	1159(66)
No	209(45)	594(34)
Asking the pharmacist about the storing instructions			0.0487*
Yes	158(34)	514(29)
No	306(66)	1239(71)
Writing the expiration date on the new container			0.0107*
Yes	158(34)	711(41)
No	306(66)	1042(59)

Results showed a statistically significant difference between different age groups in checking the expiration date of stored medications periodically, of which 221 (83%) participants in the age group 31–40 years old answered “yes” (p-value < 0.0001), reading the storing instructions of medications written on the leaflet, of which 188 (71%) participants in the age group 31–40 years old answered “yes” (p-value < 0.01), asking the pharmacist about the storing instructions, of which 165 (34%) participants in the age group 18–20 years old and 90 (34%) participants in the age group 31–40 years old answered “yes” (p-value < 0.05) and writing the expiration date on the new container, of which 104 (47%) participants in the age group above 40 years old answered “yes” (p-value < 0.0001). (Table 5)

Table 5: Participants’ medication storage practices stratified by age.

Behavior	Age				P value
Behavior	18-20 N (%)	21-30 N (%)	31-40 N (%)	>40 N (%)	P value
Keeping medication in original container					0.132
Yes	465 (95)	1170 (94)	257 (97)	210 (96)
No	22 (5)	76 (6)	8 (3)	9 (4)
Checking the expiration date before using the medications					0.845
Yes	458 (94)	1165 (94)	248 (94)	202 (92)
No	29 (6)	81 (6)	17 (6)	17 (8)
Checking the expiration date of stored medications periodically					<0.0001*
Yes	334 (69)	870 (70)	221 (83)	171 (78)
No	153 (31)	376 (30)	44 (17)	48 (22)
Reading the storing instructions of medications written on the leaflet					0.0049*
Yes	313 (64)	761 (61)	188 (71)	152 (69)
No	174 (36)	485 (39)	77 (29)	67 (31)
Asking the pharmacist about the storing instructions					0.0197*
Yes	165 (34)	344 (28)	90 (34)	73 (33)
No	322 (66)	902 (72)	175 (66)	146 (67)
Writing the expiration date on the new container					<0.0001*
Yes	214 (44)	433 (35)	118 (45)	104 (47)
No	273 (56)	813 (65)	147 (55)	115 (53)

Results showed a statistically significant difference between different educational levels in reading the storing instructions of medications written on the leaflet, of which 148 (75%) participants in high schools answered “yes” (p-value < 0.01), asking the pharmacist about the storing instructions, of which 15 (54%) participants in primary schools answered “yes” (p-value < 0.0001) and writing the expiration date on the new container, of which 18 (64%) participants in primary schools answered “yes” (p-value < 0.01). (Table 6)

Table 6: Participants’ medication storage practices stratified by education level.

Cases	Education level N (%)						P value
Cases	No formal education	Primary school	Secondary school	High school	University	Postgraduate	P value
Keeping medication in original container							0.479
Yes	12 (100)	28 (100)	59 (97)	189 (95)	1668 (94)	146 (97)
No	0 (0.00)	0 (0.00	2 (3)	9 (5)	99 (6)	5 (3)
Checking the expiration date before using the medications							0.545
Yes	12 (100)	27 (96)	55 (90)	185 (93)	1649 (93)	145 (96)
No	0 (0.00)	1 (4)	6 (10)	13 (7)	118 (7)	6 (4)
Checking the expiration date of stored medications periodically							0.203
Yes	6 (50)	20 (71)	49 (80)	151 (76)	1260 (71)	110 (73)
No	6 (50)	8 (29)	12 (20)	47 (24)	507 (29)	41 (27)
Reading the storing instructions of medications written on the leaflet							0.0037*
Yes	4 (33)	17 (61)	43 (70)	148 (75)	1108 (63)	94 (62)
No	8 (67)	11 (39)	18 (30)	50 (25)	659 (37)	57 (38)
Asking the pharmacist about the storing instructions							<0.0001*
Yes	5 (42)	15 (54)	31 (51)	79 (40)	505 (29)	37 (25)
No	7 (58)	13 (46)	30 (49)	119 (60)	1262 (71)	114 (75)
Writing the expiration date on the new container							0.0011*
Yes	4 (33)	18 (64)	30 (49)	97 (49)	664 (38)	56 (37)
No	8 (67)	10 (36)	31 (51)	101 (51)	1103 (62)	95 (63)

Results showed that there is no statistically significant difference in any variable between people who work or study in the medical field and people who do not (p-value > 0.05). (Table 7)

Table 7: Participants’ medication storage practices stratified by whether they work in the medical field.

Behavior	Do you have any work in the medical field		P value
	Yes N (%)	No N (%)
Keeping medication in original container			0.105
Yes	1025 (94)	1077 (96)
No	65 (6)	50 (4)
Checking the expiration date before using the medications			0.512
Yes	1023 (94)	1050(93)
No	67 (6)	77 (7)
Checking the expiration date of stored medications periodically			0.195
Yes	771 (71)	825 (73)
No	319 (29)	302 (27)
Reading the storing instructions of medications written on the leaflet			0.074
Yes	675 (62)	739 (66)
No	415 (38)	388 (34)
Asking the pharmacist about the storing instructions			0.292
Yes	319 (29)	353 (31)
No	771 (71)	774 (69)
Writing the expiration date on the new container			0.064
Yes	406 (37)	463 (41)
No	684 (63)	664 (59)

Using logistic regression, results showed that males (OR: 0.58, 95%CI: 0.40-0.84) were less likely to check the expiration date before using the medications. Participants who aged 31-40 years (OR: 0.46, 95% CI: 0.31-0.68), above 40 years (OR: 0.55, 95%CI: 0.37-0.82) and males (OR: 0.68, 95%CI: 0.54-0.85) were less likely to check the expiration date of stored medications periodically. On the other hand, uneducated participants (OR: 3.59, 95%CI: 1.05-12.30) and those who had children below 6 years old (OR: 1.29, 95%CI: 1.01-1.67) were more likely to check. These two groups were also more likely to read the storing instructions of medications written on the leaflet (OR: 4.59, 95%CI: 1.28-16.42) and (OR: 1.26, 95%CI: 1.00- 1.58), respectively. While males (OR: 0.61, 95%CI: 0.50-0.76) and participants in high schools (OR: 0.58, 95%CI: 0.36-0.93) were less likely to read it.

Males (OR: 1.26, 95%CI: 1.01-1.57) and those who had children below 6 years old (OR:1.32, 95%CI: 1.05-1.65) were more likely to ask the pharmacist about the storing instructions. On the other hand, participants in elementary schools (OR: 0.28, 95%CI: 0.12-0.67), secondary schools (OR: 0.34, 95%CI: 0.18-0.65) and high schools (OR: 0.53, 95%CI: 0.33-0.86) were less likely to ask the pharmacist. Males (OR: 0.75, 95%CI: 0.60-0.93) and participants in elementary schools (OR: 0.40, 95%CI: 0.17-0.94) were less likely to write the expiration date on the new container. While participants who aged 21-30 years (OR: 1.41, 95%CI: 1.13-1.75) were more likely to write the expiration date. (Table 8)

Table 8: Predictors of different medication storage practices.

Item

Keeping medication in original container

Checking the expiration date

before using the medications

Checking the expiration date of stored

medications periodically

Reading the storing

instructions of medications

written on the leaflet

Asking the pharmacist about the storing instructions

Writing the expiration date on the new container

Gender

Female

Male

0.81

(0.52-1.26)

0.58

(0.40-0.84)*

0.68

(0.54-0.85)*

0.61

(0.50-0.76)*

1.26

(1.01-1.57)*

0.75

(0.60-0.93)*

Age group

18-20

21-30

1.38

(0.84-2.27)

1.46

(0.73-1.79)

0.93

(0.73-1.17)

1.09

(0.87-1.37)

1.23

(0.98-1.56)

1.41

(1.13-1.75)*

31-40

0.72

(0.30-1.68)

1.31

(0.68-2.49)

0.46

(0.31-0.68)*

0.77

(0.55-1.09)

1.11

(0.79-1.55)

1.00

(0.73-1.37)

>40

1.09

(0.49-2.44)

1.45

(0.77-2.75)

0.55

(0.37-0.82)*

0.70

(0.49-1.01)

1.16

(0.81-1.67)

0.90

(0.65-1.27)

Education level

No formal education

1.11

(0.00-0)

2.31

(0.00-0)

3.59

(1.05-12.30)*

4.59

(1.28-16.42)*

0.47

(0.13-1.61)

1.57

(0.44-5.55)

Primary school

1.13

(0.00-0)

0.89

(0.10-7.80)

1.38

(0.55-3.48)

1.35

(0.57-3.16)

0.28

(0.12-0.67)*

0.40

(0.17-0.94)*

Secondary school

1.08

(0.20-5.84)

2.70

(0.82-8.86)

0.73

(0.35-1.54)

0.77

(0.40-1.47)

0.34

(0.18-0.65)*

0.68

(0.37-1.25)

High school

1.52

(0.48-4.73)

1.90

(0.69-5.23)

0.79

(0.47-1.31)

0.58

(0.36-0.93)*

0.53

(0.33-0.86)*

0.69

(0.44-1.07)

University

1.65

(0.65-4.16)

1.86

(0.79-4.36)

0.90

(0.61-1.33)

0.90

(0.63-1.28)

0.81

(0.55-1.21)

0.95

(0.67-1.07)

Postgraduate

Do you have any kids <6 years

Yes

0.94

(0.58-1.52)

1.38

(0.86-2.21)

1.29

(1.01-1.67)*

1.26

(1.00-1.58)*

1.32

(1.05-1.65)*

0.98

(0.79-1.22)

Do you have any work in the medical field

Yes

0.75

(0.51-1.11)

1.25

(0.88-1.78)

0.92

(0.76-1.13)

0.89

(0.74-1.07)

0.99

(0.81-1.21)

0.88

(0.73-1.06)

*P<0.05

This research studied the Syrian public awareness and practices regarding the appropriate way of disposing and storing medications.

Our study has shown that only a minority ask the pharmacist about proper storing instructions, this practice should be reinforced and encouraged among the public, and the role of pharmacists regarding this issue should be improved. Studies have shown that many pharmacists do not provide adequate instruction on medication disposal [8,9], so it is essential for healthcare providers, especially pharmacists, to have a greater role in educating people. Most participants opted to throw medications away when expired (87%), while (36%) did so when unused, which confirms results from numerous previous studies conducted in the Middle East [3,6,8,10,11]. There is a good proportion of our sample who chose to keep medications for later usage after being done with their prescription (36%), that can be attributed to self-medication practices without referring to healthcare providers, which is common among the Middle Eastern region [12,13].

Our study found that participants who are females, aged older than 30, received secondary or high school education were more likely to verify expiry dates and read medication storage instructions. This tendency may be explained by the fact that many of these participants were likely mothers, given that most women in this age group tend to be married [14] and have children to care for. As such, they may be more attentive to details related to their children's health, as has been observed in previous studies conducted in Turkey [15].

Participants aged 21-30, primarily university students, were less inclined to inquire about proper storage instructions or to note expiration dates on new containers. This trend might be attributed to the fact that 80% of our participants had university education, possibly leading them to believe they did not need additional guidance. Conversely, individuals with only primary education demonstrated a higher likelihood of seeking such information. This group perhaps recognized the importance of receiving accurate instructions from professionals. According to respondents, the refrigerator was the most frequently utilized place to store prescriptions and suppositories are the most important drugs to keep in there. While traveling, the majority of our participants store their medications in their handbags . which is in line with what was found in a similar study conducted in Saudi Arabia [1]. In a study conducted in Sweden, 73% of participants returned their unwanted medications to the pharmacy, citing environmental concerns as their main reason. Only 13% kept their unused medications in their cupboards, and 9% threw them away in the trash [16]. While in Syria, our study shows that only a mere (11%) returned their medications to the pharmacy, and (36%) disposed of them in the trash. This suggests that either there is a lack of awareness among Syrians about the proper methods of medication disposal, or pharmacists might not be adequately informing patients about this crucial aspect. In a similar study conducted in Sudan, (47.2%) of the population stored their medication for future use [17], whereas (36%) of our study participants did so, when asked for their reasons they stated the ease of access to medication in case another family member gets sick with the same illness and other economical and availability reasons.

Our survey revealed that most participants (87%) disposed of expired prescriptions in the garbage, while in a study conducted in Northern Ethiopia found (75.2%) of participants to do the same [18]. However, this higher percentage in our study may be due to a lack of awareness about the environmental and health risks associated with disposing of expired medications. Proper medication disposal methods are crucial to prevent the harmful impact of expired pharmaceuticals on environmental and life resources. Therefore, it is crucial to enhance public education regarding this critical issue. On the contrary, (3%) returned their medications to the pharmacy and a minority (1%) burned them.

Antibiotics made up 26% of the total drugs in the Saudi Arabian study that were most frequently kept in home storage. This is explained by their common usage in treating influenza and respiratory tract infections [19]. In contrast, the majority of our study participants (95%) reported storing painkillers and antipyretics, as they are often used as a first-line treatment to alleviate symptoms without knowledge of the underlying condition. This may be due to an increase in self-medication practices rather than seeking medical advice, as the main reasons for self-medication were having mild symptoms of the illness or not being able to afford a doctor’s appointment due to the worsening economic state [20]. Discussing the appropriate storage conditions for medications stored at home, in the Saudi Arabian study, 42% of respondents stored their medications in a refrigerator [19]. whereas in our study, only 31% did so. These results may be attributed to the increased awareness among Saudi Arabian residents regarding proper storage conditions, or the lack of suitable storage facilities such as refrigerators and electricity in current circumstances in Syria. Additionally, the majority of participants in our study (77.4%) reported storing suppositories in the refrigerator, which can be explained by the nature and sensitivity of these medications to heat. Our study found that 94% of participants checked the expiration date of medications, contrasting with 59.2% in an Ethiopian survey and 59.5% in a another conducted in Nepal [2,21], possibly due to differing knowledge and awareness of expiration dates and health risks [21].

When comparing between people who work in the medical field and the general population, we found that there was no statistically significant differences between the two groups regarding their answers, which is contrary to what is expected, in general people who work in the medical field are expected to be more aware about the proper ways of storing medications, but to our surprise we found that the general population were just as aware if not even slightly more as the former group, a possible explanation is that even though the general population don’t have as much knowledge about medicine in comparison to medical field workers, they have a good amount of information out of concern for their children and families, another plausible explanation is due to the ease of access to the information readily available online from trustable sources.

Strengths and limitations of the study

This study is the first of its kind in Syria, which makes it a starting point for spreading awareness about proper ways of disposal and storage of medications in Syria, which raises a challenge to conduct more studies to raise awareness about health issues in the future. Additionally, our study sample was made up of 2417 participants which is significantly bigger than similar studies [16-19]. However, given that females made up the majority (79%) of the study population, bias in analysis and discussion is to be expected during the course of the study. Significant statistical disparities are also observed concerning the level of education, age, population distribution, having children under the age of six, work nature, and level of income. The survey was conducted online which means that people with no access to the internet were not able to participate in it, also our sample was mostly made up of three governorates.

The results of this study show that participants were aware of checking expiration dates on medications. However, it was clear that self-medication is a common practice and there is lack of awareness of proper ways of disposing medication, as a significant number of participants chose to discard unused and expired medicines by disposing of them in household garbage and down the sink. Unfortunately, this practice poses risks to both the environment and public health. Proper disposal methods are crucial to mitigate these harmful effects, which shows the importance of awareness campaigns and the vital role that pharmacists play regarding this issue. The implementation of drug takeback program in local pharmacies along with awareness campaigns can be a great step in addressing this problem.

Ethics approval and consent to participate

This study was conducted in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethics approval was obtained from ethics boards in Syrian Private University and Al-Baath University. All participants provided written informed consent prior to their participation in the study.

Consent for publication

Not applicable

Availability of data and materials

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

Competing interests

The authors declare that they have no competing interests

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors' contributions

R.S, A.W, F.A, M.S conceived and designed the study, and drafted the manuscript. S.AQ analyzed the data and created the tables. A.AK, A.AD contributed to the interpretation of the results and the literature review. M.S, M.A.A provided critical feedback and helped shape the research, analysis, and manuscript. W.I.K contributed to the manuscript revision. S.AH supervised the research project, provided guidance throughout the study, and critically reviewed the manuscript. All authors contributed to the writing of the manuscript, read, and approved the final manuscript.

Acknowledgements

We would like to thank Theqa team for their support and assistance throughout the study. Data Collection Group:

Mahmoud Salem Aloudat¹, Manar Bassam Omaira¹, Rabah Suhail Baghdadi¹, Hala Jafa², Tuka Hamasho³, George Moayad Hneino⁴,

1 Faculty of Medicine, Damascus University, Damascus, Syria.

2 Faculty of Medicine, University of Aleppo, Aleppo, Syria.

3 Faculty of Medicine, Hama University, Hama, Syria.

4 Faculty of Medicine, Tishreen University, Latakia, Syria.

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Knowledge and Practices on Home Medication Storage and Disposal in Syria: A Population-Based, Cross-Sectional Study

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