Summary Obsolete health commodities such as expired or unused medicines

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 laws 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 and 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