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Summary
Obsolete health commodities such as expired or unused medicines, used sharps and soiled bandages are part of the Health care waste (HCW) and these are generated in places that where patientcare is occurring including facilities such as hospitals, clinics and homes where patients self administer their chronic medicines and self-injecting with insulin therapy or self management of wounds occurs. HCW if not handled properly in every setting where it is generated therefore can be threat to both the environmental and public health. There is a considerable amount of literature available on how HCW is handled in hospitals settings for example of which these are supposedly equipped to deal with such generated HCW yet very few literature on on how such waste is handled in the home settings eventhough the latter is not equipped to deal with such waste. Patients receive these health commodies on a monthly basis in our public hospitals yet it is not known how these are handled in home settings and where do these end up once they are used or when they are unwanted for various reasons including when they are expired or damaged. The proposed study therefore intend to add to this limited literature by determining the knowledge, attitude and practice of these patients regarding their handling of such obsolete health commodities as such information can be vital in assisting policy makers in curbing the improper handling of these obsolete health commodities in home environment as major focus has been on major sources of HCW such as hospitals.
1. Introduction
Health care commodities are all goods such as medicines, sharps, bandages, gauze swaps etc. that are utilized during the provision of health care service and when they are used or expired they then form part of Health Care Waste (HCW). All waste that is produced due to rendering of patient care in clinics, hospitals, manufacturing plants for pharmaceuticals, home settings etc. is known as HCW which can be classified accordingly due to its nature such as medical, pharmaceutical, cytotoxic, chemical, radioactive or general waste (Hangulu and Akintola, 2017).
Pharmacetical waste is occurs due to expired, damaged or recalled medicinal products whether liquids, tablets, ointments etc. Also, patients may not utilize all the medications issued to them for various reasons including side effects they cannot tolerate, changes in dosages, medication being damaged due to improper storage or medication just expired thus resulting in pharmaceutical waste. Furthermore, it is common for patients to have unused or expired medicines in their possession in their home settings (Seebusen and Edwards, 2006). Pharmaceuticals are allocated the second biggest budget by the National Department of Health and drug expenditure accounting 25% of total health expenditure in South Africa (Angi’enda and Bukachi, 2016). Therefore, expired and unused medicines may lead to wastage and fruitless expenditure and this in turn may decrease availability of the much needed healthcare commodity thus this might have dreadful impact on the type of healthcare patients may receive and this may negatively impact the entire healthcare system (Saul C, 2016). Medical waste on the other hand includes sharps such as insulin syringes, human tissue and carcasses, soiled bandages (Makhura et al, 2016).
All countries are obligated by the WHO to develop their own legislations and regulations in order to ensure that health care waste is managed accordingly. It also emphasises that the National Department of Health together with the Environmental affairs need to ensure that such developed legislation is implemented and enforced. Furthermore, there should be plans developed and guidelines on how to manage HCW from the point of generation until disposal of such waste (Hangulu and Akintola, 2017). In South Africa, there are guidelines developed as recommended by WHO and they clearly state how and by who must HCW be disposed. For example, it is recommended that HCW such as used insulin syringes at home should be packed in small puncture-proof containers and when these are full, they should then be returned to healthcare institutions for safe disposal. Thus, patients are supposed to be provided with such boxes. Also, expired or unwanted medication should also be returned for safe disposal (Hangulu and Akintola, 2017). Eventhough WHO has recommended legislation, HCW management still poses a threat globally to both the public and environmental health when not handled accordingly and most literature is available for handling of HCW in healthcare facilities while there is very minimal literature about handling of such waste in home settings. It has been found that handling HCW is a challenge particularly in developing countries including South Africa and countries where there are not enough resources. Therefore, there might be lack policies for handling of waste and lack of finances for latest technologies of handling HCW (Hangulu and Akintola, 2017).
Health commodities have a very important role in disease prevention and treatment both in humans and animals but their waste might have unintended effects on humans and the environment hence proper handling and their management is very important (Boxall, 2004). Pharmaceutical have been traced in the environment such as ground and drinking water and even though these has been detected in low levels but long-term exposure to them can affect the health of individuals (Seebusen and Edwards, 2006). Also, improper disposed insulin syringes and needles can lead to needle prick injuries and this might lead to transmission of blood-borne diseases such HIV, hepatitis B (Govender and Ross, 2012) therefore, poor disposal of HCW can have a negative effect on healthcare workers, waste pickers, general public, patient caregivers, animals as well as the environment.
The home-based use of insulin syringes, lancets, test strips has increased globally due to an increase in insulin dependent type 2 diabetes and proper management of the disease. For example, 90% of diabetics has Type 2 diabetes which require insulin injection and prevalence is estimated will be 5.4% by 2025 (Singh and Chapman, 2011). Therefore, insulin therapy is very essential in management of this form of diabetes and it is mostly done in home settings and resulting in production of insulin therapy waste such as needles, syringes, lancets, cotton wool (da Cunha et al, 2017). Literature reveals that insulin therapy waste are frequently disposed improperly in the communities especially in developing countries such as India, Brazil, South Africa etc. for example, a study conducted in India by Singh and Roberts (2011) found that 84.1% of the respondents discarded their sharps in household bins. While 57.1% did the same in Brazil (da Cunha et al, 2017). In South Africa, even though studies are limited, Govender and Ross found that 97% of patients in their study population discarded their insulin syringes inappropriately.
There is also a lack of knowledge globally on how to dispose expired, unwanted, and unused medications among population. Some international and national studies that have been conducted have showed that most patients in their home environment stored their medications improperly and that may lead to undesirable effects or unintentional risks like self-medication with damaged medications as the result of improper storage, accidental overdose, and prescription drug abuse. These patients tend to keep medications for a very long time because they do not want to waste them, they do not know how to read and check the expiry date, or they do not know how to dispose them in a proper and safe way (ALAzim et al, 2017).
The hospital where the study will be conducted is a District Hospital in Tshwane located in the central business district with an estimated population of more than 400 000 people. It was opened on the 7th of March with just 103 beds but today has over 200 beds and employs just over 500 personnel. It provides a 24hour emergency, martenal and radiology services while Out-Patient Department where the study will be conducted operates from 07h30 till 16h00. Other services offered are paediatrics, obstetrics and gynaecology comprehensive HIV ; AIDS, TB focal point and fully equipped eye clinic (REF).

2. Problem statement
Obsolete health commodities such as expired or unused medicines, used sharps and soiled bandages are part of the Health care waste (HCW) which is generated in facilities like hospitals, clinics or homes where patient care is taking place. HCW if not handled properly, can be threat to both the environmental and public health and exposure can become a health risk due to death causing diseases such as HIV, hepatitis B, cholera for a variety of people including community members, health care workers, caregivers, waste pickers and animals (Hangulu and Akintola, 2017). Furthermore, traces of improperly disposed medications have been found in drinking and ground water (Seebusen and Edwards, 2006) and can have general impact on health. For example, renal failure can be induced in vultures who ingest water or faeces contaminated with diclofenac, a commonly used pain and inflammation medication that is available without a prescription in South Africa (Tong et al, 2011) thus reducing the life expectancy of the species.
Considerable amount of literature regarding the handling of HCW in healthcare facilities settings globally and in South Africa is available, yet very few studies have been done about how patients handle HCW in their home settings (Olowokure B et al, 2003) even though these home settings are not capacitated to deal with HCW like hospitals do (Hangulu and Akintola, 2017). Ideally, HCW is supposed to be returned to healthcare facilities for safe disposal but this is not happening due to various challenges and despite the South African government through both the National Department of Health (NDOH) and National Environmental Affairs (NDEA) having regulations and policies that encourage citizens to bring their used or expired health commodities to healthcare facilities for safe disposal, there are still people who do not dispose these accordingly. For example, a study conducted by Govender and Ross (2012), found that 97% of their study population discarded their used sharps inappropriately and Amod et al (2008) found that 62.5% of household medicines were disposed by being thrown away thus ending up in sewerage or municipality dumping site. For years, the hospital in Tshwane has been providing their outpatients with medicines, insulin syringes and bandages yet it is not known exactly where and how they dispose their expired or unused medicines, used insulin syringes and soiled bandages. Therefore, there is a need to explore attitudes and perceptions of patients about the manner in which they handle HCW in their home settings.
3. Rationale of the study
The study will explore the knowledge, attitude and practices of disposal of obsolete health commodities by patients attending a Tshwane Hospital. In South Africa and globally, there are policies, laws, regulations and awareness campaigns regarding disposal of health care commodities yet literature reveals that these are not disposed appropriately. The study will be significant in adding to the limited literature as well as assisting policy makers to evaluate their health commodities programmes adapt them based on attitudes of the population.
3.1 Aim of the study
The aim of the study is to explore the knowledge, attitude and practices of patients attending a Tshwane hospital about the manner in which they dispose their obsolete health commodities such as expired, damaged and unusable medicines, syringes and bandages in their home settings.
3.2 Research questions
The research questions for the proposed study are:
? How do patients attending Out-Patient Department Pharmacy in a Tshwane Hospital determine that a medicine, syringe or bandage is expired or unusable?
? Which safe disposal methods do they know of?
? What is their attitude towards expired and damaged medicines, syringes and bandages? Do they feel that they can still use them, give them away or sell them?
? How and where do they dispose the expired, damaged and unusable medicines, syringes and bandages?

3.3 Research objectives
The objectives for the proposed study are
? To describe how do patients attending Out-Patient Department Pharmacy in a Tshwane Hospital determine that a medicine, syringe or bandage is expired or unusable
? To determine their level of knowledge about safe disposal methods of obsolete health commodities
? To describe their attitude towards expired and damaged medicines, syringes and bandages
? To describe their practices of disposing the expired, damaged and unusable medicines, syringes and bandages

4. Literature review

4.1 Introduction
Literature review according to Degu and Yigzaw (2006) is an objective and critical summary of published research literature that is relevant to a topic that the researcher is interested in it. It then assist the researcher to identify what has been done and reported on the research problem and this section will then look at the available literature related to the proposed study.

4.2 Health care waste (HCW)
Health care commodities are all goods that are used during the provision of health care and these include medicines, sharps, bandages, gauze swaps etc. When these commodities are used or expired after the provision of such care they then form part of Health Care Waste (HCW) which is all waste that is produced due to rendering of patient care in clinics, hospitals, manufacturing plants for pharmaceuticals, home settings etc. (Hangulu and Akintola, 2017). HCW can be classified accordingly due to its nature as depicted in the table below.

Type of waste Description and examples
Infectious waste All waste that which contain pathogens which has been in contact with infected patients and excreta or body fluids and has the potential to cause infections for example, soiled bandages,wound dressing, swabs, gloves.
Pathological waste Human tissues or fluids, e.g. body parts; blood and other body fluids; fetuses; sharps waste, e.g. needles; infusion sets; scalpels; knives; blades; broken glass
Sharps waste This is waste that consists of used or unused sharps such as needles, auto disable syringes, insulin syringes with attached needles, infusion sets, scalpels, knives, blades and broken glass
Pharmaceutical waste Waste containing pharmaceuticals that are expired or no unwanted needed such as liquids, tablets ointments, vaccines
Cytotoxic waste Waste containing substances with genotoxic properties such as cytostatic drugs that are often used in cancer therapy
Chemical waste Waste containing chemical substance such as solvents and reagents used for laboratory preparations
Radioactive waste Waste which is radioactive in nature such as unused radiotherapy liquids and other radioactive diagnostic material
Table 1: The various types of healthcare waste (sourced from WHO, 2018)

World Health Organization (WHO) in 2018 reported that 85% of the total amount of waste produced during provision of healthcare service is general waste such as paper, plastics which thus it is generally non-hazardous and is comparable to household waste thus pose no risk of infections while the remaining 15% is considered hazardous and can cause serious health risk to the public and need to be disposed accordingly in a safe manner that would eliminate the potential risks or threats to the environment and public health..

4.2.1 Pharmaceutical waste
Pharmaceutical waste occurs due to expired, damaged, recalled or unused medicinal products and patients may not use the medications issued to them for various reasons such as side effects, changes in dosages, medication being damaged due to improper storage or medication just expired. Therefore, it is common for patients to have unused or expired medicines in their possession (Seebusen and Edwards, 2006).
Contributing factors to pharmaceutical waste vary and include knowledge of the patients regarding proper use of their prescribed medication. Cultural behaviour such as the culture of not want to waste medicine thus people resolving in sharing medication with others or keeping it for future use. Healthcare
Reducing medicine wastage and advocating for proper disposal practices is a global issue (Wheeler et al, 2017). In South Africa, generally medicines are allocated the second biggest budget allocation by the National Department of Health, therefore, expired and unused medicines may lead to wastage and fruitless expenditure and this might have dreadful impact on the type of healthcare patients may receive and might impact the entire healthcare system negatively. One of the recommended methods of disposing obsolete medicines in many countries is to return them to healthcare facilities for proper disposal (Tong et al, 2011) yet people still do dispose medicines improperly. A study conducted by Seebusen and Edwards in 2006 found that 50% of their study population stored unused and expired medicines in their homes while more than half flushed them down the toilet with only 22.9% returned them to healthcare facilities for safe disposal. In South African perspective, only 2.5% were returned to pharmacies while 62.5% were thrown in a bin with 6.5% and 17% flushed them sink and toilet respectively (Amod et al, 2008). These studies show consistencies globally that despite policies and laws being in place, there is still considerable amount of the population that do not dispose health commodities properly and it need further research to guide policymakers about challenges of the population when it comes to safe disposal of medicines. Furthermore, it has been found that household’s knowledge on disposal practices of unused pharmaceuticals was very weak and this was attributed to poor or non-existence of public outreach and awareness campaigns, poor provision of disposal guidance to the patients by health professionals and unclear disposal instructions on patient leaflet forms as well as negligence by patients to read contents of their medication (Angi’enda S.A. and Bukachi S.A., 2016)
4.2.2 Insulin therapy waste
Medical waste includes sharps such as insulin syringes, gauze, swabs and soiled bandages (Makhura et al, 2016). The use of insulin syringes, lancets and test strips in home settings has increased globally due to an increase in insulin dependent type-2 diabetes and 90% of diabetics has type of diabetes thus rely on insulin injection to control their sugar levels and the estimated prevalence of insulin dependent diabetes is will be 5.4% by 2025 (Singh and Chapman, 2011). Therefore, insulin therapy is very essential in proper management of this form of diabetes and is mostly done in home settings and resulting in production of insulin therapy waste such as needles, syringes, lancets, cotton wool (da Cunha et al, 2017) and proper disposal of insulin waste is therefore crucial despite being neglected often (Mekuria et al, 2016). Literature reveals that insulin therapy waste are frequently disposed improperly in the communities especially in developing countries such as India, Brazil, South Africa etc. Studies conducted in India by Singh and Chapman (2011) found that 84.1% of the respondents discarded their sharps in household bins. While 57.1% did the same in Brazil (da Cunha et al, 2017). In Ethopia 80.7% of participants had poor practice of disposing their used needles and they popular disposing trends were toilet (40%), garbage (36%), burried under ground (20.5%) and burned (3.5%) (Mekuria et al, 2016). In South Africa, even though studies are limited, Govender and Ross in 2012 found that a significant number of patients in their study population discarded their insulin syringes inappropriately. Other studies show that they used general household waste items like empty milk carton, envelopes, soap packets, jars to dispose used insulin syringes (Oluwokure et al, 2003). These studies show consistencies globaly that used insulin syringes are disposed improperly but the manner in which people dispose their used insulin syringes varies, therefore, improper disposal practices of insulin syringes is a global challenge that need to be researched and addressed constantly.

4.3 Impact of improper handling of obsoletes health care commodities
Health commodities have a very important role in disease prevention and treatment both in humans and animals, but their waste might have unintended effects on humans and the environment hence proper handling and their management is very important (Boxall, 2004). Handling of HCW globally poses a threat to both public and environmental health when not handled accordingly and most literature is available for about the handling of HCW in healthcare facilities while very few literature for home settings even though home settings are not capacitated to handle HCW. It has been found that handling HCW is a challenge particularly in developing countries where there might not have enough resources, lack policies for handling of waste and lack of finances for latest technologies of handling HCW (Hangulu and Akintola, 2017). Improper disposed insulin syringes and needles can lead to needle prick injuries and this might lead to transmission of blood-borne diseases such HIV, hepatitis B (Govender and Ross, 2012) therefore, poor disposal of HCW can have a negative effect on healthcare workers, waste pickers, general public, patient caregivers, animals as well as the environment.
Pharmaceutical waste enters the environment in various routes (as shown in figure 1 below) and these include human and animal excretion (urination/defecation), washing off directly from skin in case of ointments and creams, improper disposal practices such as throwing pharmaceuticals down the drain, agricultural use where they are used for germination of seeds etc. (Boxall, 2004). Literature reveals that among the most popular ways of disposing pharmaceutical waste in home settings is through throwing them in garbage, flushing them down the toilet or sink, retuning them to healthcare facilities (Wheeler et al, 2017; Tong et al, 2011, Amod et al, 2008 and Seebusen and Edwards, 2006). Improper disposal of medicines through garbage or down the toilets end up in landfills and sewage system and the latter is not equipped to remove medication thus this might have negative environmental impact (Wheeler et al, 2017). Medicines or their metabolites have been traced in ground, surface and drinking water as the result of improper disposal and even though these has been detected in low levels but long-term exposure to them can affect the health of individuals (Seebusen and Edwards, 2006). Improper disposal has impact not just on human beings, for example, renal failure can be induced in vultures who ingest water or faeces contaminated with diclofenac, a commonly used pain and inflammation medication that is available without a prescription in South Africa (Tong et al, 2011) and this can reduce the life expectancy of the species. Furthermore, traces of antibiotics have also been detected in waters and soil and such exposure can result in formation of resistant microorganism thus posing a serious threat to human and animal health in the future (Boxall, 2004).
Figure 1: Route of pharmaceuticals entering the environment (source: Boxall A.B., 2004)
4.4 Knowledge, Attitudes and Practice (KAP) towards disposal of health commodities in home settings
Knowledge, attitudes and practice (KAP) of population plays a role in improving disposal of obsolete health commodities in home settings, therefore assessment of knowledge among communities should be made and gaps identified be addressed accordingly. In india for example, it was found that sociodemographic factors and diabetes management characteristics was associated significantly with high level of knowledge in household disposal practice of obsolete health commodities (Singh and Chapman, 2011). Also, a study in Brazil found that patients who have been educated about safe disposal were likely to dispose their waste properly than those who did not receive any disposal education (da Cunha et al, 2016). However, another study found that despite patients being provided with education about proper disposal of insulin needles, some patients might not perceive the severity of the adverse outcome to change their needle disposal conduct (Musselman et al, 2010). These studies contradict thus more studies maybe required to clarify such contradictions. Furthermore, literature reveals that barriers to safe disposal are lack of information about how and where to dispose, lack of proper advice from healthcare practitioners, wrong perception on disposal (Mekuria, 2016).

4.5 Legislation and guidelines on disposal of health care commodities
Disposal of HCW is regulated globally yet studies still show that obsolete health commodities are still not disposed properly. In New York for example, fines are imposed for individuals who do not dispose HCW correctly, yet people still dispose commodities improperly as the imposed fines and enforcement is relatively low (Musselman et al, 2010). In South Africa, the Constitution protects it citizens against improper disposal of obsolete health commodities and states clearly that everyone’s has the right to an environment that is not harmful to their health and well-being (du Toit and Bodenstein, 2013). Furthermore, there is the National Environmental Management Act of 1998 that protect the environment from harm including the improper disposal of obsolete health commodities where it states that the polluter must take measures to prevent pollution through proper disposal of such obsolete health commodities. Then, there is the National Health Act of 61 of 2003 which compels the Health Minster to come up with regulations regarding medical waste including handling in home settings. As the result, there are guidelines that are developed by the NDOH to give guidance regarding disposal of HCW. Departmental programmes and campaigns are part of those guidelines that encourage patients to bring back obsolete health commodities to health care institutions for safe and proper disposal (Hangulu and Akintola, 2017). The knowledge, attitudes and practice of the population towards HCW disposal still need studied and new measures developed that would minimize improper waste disposal practices. Despite, guidelines being in place for example, hospitals have policy and health education material in place for patients to return their obsolete commodities to health care facilities, yet these commodities are still handled improperly. Therefore, the reasons for continued improper disposal practice need to be continually investigated to determine challenges and this will assist policy makers to review existing guidelines and policies so that this assist the handling of HCW.

4.6 Conclusion
The practice of disposing HCW is a global phenomenon and impact environmental and public health. In South Africa, the Constitution states that everyone has the right to an environment that is not harmful to their health and well-being, but the illegal dumping of hazardous obsolete health commodities poses a danger to public health and the environment when pollutants migrate into water sources and ultimately cause widespread infection and toxicity (du Toit and Bodenstein, 2013). Therefore, public health practioners still need to research why this practice is not eradicated as its impact has been widely studied and if this practice is not address, its environmental and public health risks will be increased and will have dire health and consequently financial implications. Research has been conducted around globe about disposal of medicines in house holds and throwing them down the drain and throwing them in garbage have been popular (Wheeler et al, 2017). The National Department of health and the Environmental department have programmes and policies encouraging the ordinary South Africans about safe disposal of HCW even encougares the public to bring their medical waste to healthcare facilities, yet this is still not happening. Therefore, there is still the need to study the knowledge, attitudes and practice of improper disposal of HCW in households so that interventions can be devised to curb such practice.