use of drugs for humans and veterinary practices is increasing daily , and most consumers are left with some unused medicines at one time or the other . a study in ethiopia revealed that 89.1% of medicines purchased by consumers are never used . factors such as change of prescription by prescribers , adverse effects of the drug , unclear instruction , resolution of condition / clinical symptoms , and medicines reaching the expiry date contribute to nonusage and disposal of medicines by consumers . it is defined as  the science and activities associated with the detection , evaluation , understanding , and prevention of adverse effects of pharmaceuticals in the environment . human pharmaceuticals have been detected increasingly in environment in the recent years in surface water . some years ago , unintended exposure to diclofenac was reported to affect vultures , adversely producing a substantial decline in their numbers . bound and voulvoulis from the united kingdom have reiterated that entry of pharmaceuticals into environment through disposal in trash and sink / toilet requires a great attention . apart from the environmental and ecological effects , stocking expired or unused medicines or donating these to others can lead to accidental or inappropriate ingestion , increasing the risk of adverse effects . a recent review suggests that consumers use different methods for disposing unused medicines , most commonly throwing medicines in garbage , toilet , or sink . in a study conducted by swaroop et al . in india , most consumers stated that they dispose medicines in garbage and sink . in a study conducted by seehusen and edwards in the united states , more than half of the patients surveyed reported storing unused and expired medications at their homes , and more than half had flushed these down a toilet . despite being a large consumer of medicines , regulatory guidelines for safe disposal of medicines for consumers are lacking in india , and drug take - back programs are not functional / effective as in other countries . a study conducted by glassmeyer et al . in the united states suggested that providing the consumer with additional options for disposal by various community , city , and state collection events , ongoing programs such as opportunity to mail or bring unused medications to various collection points , such as pharmacies , may lead to their safe disposal . although the national formulary of india , 2011 , specifies guidelines for disposal of medicines , most people are not aware of and/or do not follow these guidelines . it is , thus , important to assess knowledge and practices employed by consumers in india with regard to medicine disposal . keeping in view these facts , this study was carried out to evaluate the knowledge , attitude , and practices of consumers regarding the disposal of unused medicines . this was a cross - sectional , questionnaire - based study , conducted at the outpatient department ( opd ) of a tertiary care teaching hospital in gujarat for 3 months . an interviewer - administered questionnaire consisting of 11 questions including two to assess knowledge , three to assess attitude , and six to assess practices of consumers regarding the disposal of unused medicines was prepared and prevalidated . the modified questionnaire was administered to a total of 200 consumers attending medicine , obstetrics and gynecology and surgery opds after obtaining written informed consent . consumers not willing to participate in the study or did not provide written informed consent were excluded from the study . a total of 200 consumers attending medicine , surgery , obstetrics , and gynecology opds were enrolled . out of the 200 consumers , 155 ( 77.5% ) were men and 45 ( 22.5% ) were women . consumers belonged to varied background and middle - to - lower socioeconomic strata of the society . sources of medicines for consumers included pharmacy stores with ( 121 , 60.5% ) or without ( 40 , 20% ) doctor 's prescription , and unused medicine at home ( 25 , 12.5% ) or friends and relatives ( 14 , 7% ) . a total of 78 ( 39% ) participants responded that they were aware of methods and sites of disposal of medicines . the method of disposal considered as best by participants included throwing in household trash ( 34 , 17% ) , flushing in toilet ( 20 , 10% ) , throwing in river or lake ( 4 , 2% ) , returning to pharmacist ( 16 , 8% ) or prescriber ( 2 , 1% ) , and donating the medicines to hospitals or voluntary organizations ( 2 , 1% ) . seven ( 3.5% ) participants were aware of institution or organizations which collect unused medicines . institutions suggested by these participants included pharmacy stores ( 3 , 1.5% ) , municipality hospitals ( 2 , 1% ) , neighboring health centers , and public health centers ( 2 , 1% ) . a total of 160 ( 80% ) participants opined that safe disposal of medicines is necessary . majority ( 152 , 76% ) of the consumers felt the need for a program to collect unused medicines from home . in addition , majority ( 154 , 77% ) of the participants opined that consumers should be made more aware about the hazards of unsafe disposal and methods of safe disposal . measures suggested by participants to improve consumers awareness included patient education by pharmacists , doctors , or nurses ( 57 , 28.5% ) , provision of information in newspapers ( 39 , 19.5% ) , television ( 32 , 16% ) , or posters ( 18 , 9% ) , awareness programs by the government ( 3 , 1.5% ) , education by village health workers ( 3 , 1.5% ) , and written instructions on medicines ( 2 , 1% ) . responses of consumers ( n = 160 ) a total of 136 ( 68% ) consumers had unused medicines at home . the reasons for stocking unused medicines included frequent change of prescription by doctors ( 40 , 20% ) , prescription of more number of drugs than required ( 20 , 10% ) , purchase of more medicines by consumers for possible future use ( 15 , 7.5% ) , stoppage of treatment on symptomatic relief ( 58 , 29% ) , and noncompliance to therapy ( 3 , 1.5% ) . most common medicines stored by consumers included analgesics ( 53 , 26.5% ) , vitamins ( 35 , 17.5% ) , topical antimicrobials ( 25 , 12.5% ) , and oral antimicrobials ( 17 , 8.5% ) . other medicines stored by consumers included antacids ( 4 , 2% ) , antipyretic drugs ( 6 , 3% ) , and cough syrup ( 4 , 2% ) . analgesics ( 61 , 30.5% ) and vitamins ( 35 , 17.5% ) were the most common medicines disposed off by participants followed by oral ( 22 , 11% ) and topical antimicrobials ( 21 , 10.5% ) [ figure 2 ] . throwing in household trash was the method most commonly employed to dispose medicines , followed by flushing in sewer ( 24 , 12% ) , returning to seller or pharmaceutical company ( 16 , 8% ) , flushing in river ( 14 , 7.5% ) , and burning at home ( 4 , 2% ) . other methods used by consumers to dispose medicines were returning to hospitals ( 4 , 2% ) and donating to poor ( 3 , 1.5% ) [ figure 3 ] . advise regarding disposal of medicines was sought by 28 ( 14% ) participants from pharmacists ( 9 , 4.5% ) , friends ( 8 , 4% ) , doctors ( 5 , 2.5% ) , family members ( 3 , 1.5% ) , and nurses ( 3 , 1.5% ) . various advices given were to dispose unused medicines in trash , flush in sink ( wash basin ) , flush in toilet , return to pharmacy , store for future use , and throw in river . majority of the consumers ( 22 , 11% ) were satisfied with the advice [ table 1 ] . medicines commonly stored and disposed by consumers various means of disposal of medicines by consumers advice sought by consumers * ( n=28 ) regarding the methods of safe disposal of medicines a total of 78 ( 39% ) participants responded that they were aware of methods and sites of disposal of medicines . the method of disposal considered as best by participants included throwing in household trash ( 34 , 17% ) , flushing in toilet ( 20 , 10% ) , throwing in river or lake ( 4 , 2% ) , returning to pharmacist ( 16 , 8% ) or prescriber ( 2 , 1% ) , and donating the medicines to hospitals or voluntary organizations ( 2 , 1% ) . seven ( 3.5% ) participants were aware of institution or organizations which collect unused medicines . institutions suggested by these participants included pharmacy stores ( 3 , 1.5% ) , municipality hospitals ( 2 , 1% ) , neighboring health centers , and public health centers ( 2 , 1% ) . a total of 160 ( 80% ) participants opined that safe disposal of medicines is necessary . majority ( 152 , 76% ) of the consumers felt the need for a program to collect unused medicines from home . in addition , majority ( 154 , 77% ) of the participants opined that consumers should be made more aware about the hazards of unsafe disposal and methods of safe disposal . measures suggested by participants to improve consumers awareness included patient education by pharmacists , doctors , or nurses ( 57 , 28.5% ) , provision of information in newspapers ( 39 , 19.5% ) , television ( 32 , 16% ) , or posters ( 18 , 9% ) , awareness programs by the government ( 3 , 1.5% ) , education by village health workers ( 3 , 1.5% ) , and written instructions on medicines ( 2 , 1% ) . why is safe disposal of medicines necessary ?  - responses of consumers ( n = 160 ) a total of 136 ( 68% ) consumers had unused medicines at home . the reasons for stocking unused medicines included frequent change of prescription by doctors ( 40 , 20% ) , prescription of more number of drugs than required ( 20 , 10% ) , purchase of more medicines by consumers for possible future use ( 15 , 7.5% ) , stoppage of treatment on symptomatic relief ( 58 , 29% ) , and noncompliance to therapy ( 3 , 1.5% ) . most common medicines stored by consumers included analgesics ( 53 , 26.5% ) , vitamins ( 35 , 17.5% ) , topical antimicrobials ( 25 , 12.5% ) , and oral antimicrobials ( 17 , 8.5% ) . other medicines stored by consumers included antacids ( 4 , 2% ) , antipyretic drugs ( 6 , 3% ) , and cough syrup ( 4 , 2% ) . analgesics ( 61 , 30.5% ) and vitamins ( 35 , 17.5% ) were the most common medicines disposed off by participants followed by oral ( 22 , 11% ) and topical antimicrobials ( 21 , 10.5% ) [ figure 2 ] . throwing in household trash was the method most commonly employed to dispose medicines , followed by flushing in sewer ( 24 , 12% ) , returning to seller or pharmaceutical company ( 16 , 8% ) , flushing in river ( 14 , 7.5% ) , and burning at home ( 4 , 2% ) . other methods used by consumers to dispose medicines were returning to hospitals ( 4 , 2% ) and donating to poor ( 3 , 1.5% ) [ figure 3 ] . advise regarding disposal of medicines was sought by 28 ( 14% ) participants from pharmacists ( 9 , 4.5% ) , friends ( 8 , 4% ) , doctors ( 5 , 2.5% ) , family members ( 3 , 1.5% ) , and nurses ( 3 , 1.5% ) . various advices given were to dispose unused medicines in trash , flush in sink ( wash basin ) , flush in toilet , return to pharmacy , store for future use , and throw in river . majority of the consumers ( 22 , 11% ) were satisfied with the advice [ table 1 ] . medicines commonly stored and disposed by consumers various means of disposal of medicines by consumers advice sought by consumers * ( n=28 ) regarding the methods of safe disposal of medicines the current study was an observational , cross - sectional , questionnaire - based study conducted in 200 consumers of medicines attending the opd of a tertiary care hospital in gujarat . the knowledge , attitude , and practice of consumers regarding the disposal of unused medicines were evaluated using a prevalidated investigator - administered questionnaire . in the present study , majority ( 77.5% ) of the participants were men , and the mean age of participants was 32  6.2 years . this may be ascribed to the fact that participants were enrolled from opds of three departments , i.e. , medicine , surgery , obstetrics , and gynecology . young women attended opd of obstetrics and gynecology in larger numbers , contributing to relatively young cohort . sampling , however , was done on a convenient basis , and its influence on these characteristics can not be ruled out . furthermore , the younger male patients were more forthcoming in their providing consent to participate in the study . in the present study , majority ( 60.5% ) of the participants responded that they acquire medicines from pharmacy stores with the doctor 's prescription . however , a significant number of consumers had also bought medicines from pharmacy without doctor 's prescription ( 20% ) or from friends and relatives ( 7% ) . had reported that 16% of the consumers acquire medicines from pharmacy without doctor 's prescription . unsupervised use of medicines associated with an inherent risk of adverse effects can be harmful to consumers . further , it may lead to therapeutic failure and should be discouraged . in the current study , majority ( 68% ) of the participants stated that they store unused medicines at home . similar findings were reported by studies conducted in ireland , new zealand , and nigeria . major reasons suggested by participants in the present study for this practice included stoppage of therapy on symptomatic cure , frequent change of prescription by doctors , and prescription of more medicines than required . self - stoppage of treatment by consumers on achieving symptomatic cure has also been reported by braund et al . in new zealand and lagishetty et al . in south india . in a study conducted in the united states by law et al . disease / condition improved ( 42.4% ) , forgetfulness ( 5.8% ) , and side effects ( 6.5% ) were reasons cited for their nonuse . not just does this practice lead to unnecessary stocking of medicines , but also indicates a lack of awareness among consumers regarding the importance of completion of therapy . the findings of the present study also suggest that doctors should choose medicines judiciously during the first prescription itself , and minimize or avoid frequent changes in prescriptions to counter the problem of stocking of medicines by consumers . they should also counsel the patients regarding disposing or avoiding reuse of unused medicines or seek advice if the patient wishes to reuse these medications . some consumers bought more medicines for future use , which should be addressed by patient counseling . majority of the participants ( 61% ) in this study were not aware about the methods and sites of medicine disposal , implying a very poor awareness . of the remaining participants , majority perceived disposal in household trash ( 17% ) and flushing in toilet ( 10% ) as the best methods of disposal . only 8% of the participants in the current study perceived returning unused medicines to pharmacy as the best method of drug disposal . in addition , few ( 3.5% ) consumers were aware of organizations or institutions such as pharmacy , hospitals , or health centers that collect unused medicines , implying a poor level of knowledge . in similar studies conducted in malaysia and kuwait , majority of the respondents ( 32.1% and 54% , respectively ) stated that returning medicines to pharmacy was the best method of disposal of medicines . raising awareness through various educational interventions most participants ( 80% ) in the present study comprehended the importance of safe disposal and hazards associated with unsafe disposal of medicines such as illegal / unintended use of medicines , adverse reactions , and environmental pollution . the consumers sought education by pharmacist , nurses , and doctors , which could hint toward faith of consumers in these health professionals . similar recommendations were put forth by respondents in a study conducted by lagishetty et al . in south india . information about safe disposal of medicine in newspapers and television are yet another means of improving the awareness . a novel suggestion that emerged from the study was the establishment of a program / facility to collect unused medicines from homes . this study was conducted among parents of school - going children to evaluate the knowledge , attitude , and practice of unused medicine disposal . pharmacy ( 9.6% ) , physicians ( 15.1% ) , newspapers ( 35.2% ) , and media ( 40.1% ) were suggested as a source of information in this study . most medicines stored by consumers were those that were required for common ailments such as pain , fever , cough , epigastric distress , and  generalized weakness . while this practice may not be entirely irrational , it is important for the consumers to be aware of safe use and disposal of unused medicines and optimize storage requirements for these medicines . pain relievers , vitamins , and topical and systemic antimicrobials ( both prescription and over - the - counter ) were the most often stored medicines as stated by consumers in the present study . common use of analgesics in pain , a common symptom , may explain this observation . interestingly , stocking of topical and systemic antimicrobials implied that many of these medicines were stopped prematurely by consumers or stored for future use . such unsupervised medicine use , however , can increase the chance of drug resistance and should be discouraged . , perhaps owing to the fact that it is easy and least time - consuming practice . however , the method increases the risk of misuse and/or accidental exposure to drugs . storage of medicines for future use or lending these to friends or relatives ( recycling ) was also stated by some consumers . most consumers did not seek any advice regarding drug disposal , which implies that these practices were perceived as adequate or correct by the consumers . the minority of the participants who sought advice consulted pharmacists , doctors , friends , or family members and nurses . methods recommended by these personnel , such as disposal in household trash , flush in sink ( wash basin ) or toilet , are however not ideal and implied a lack of awareness even among health professionals . in the study conducted by swaroop et al . in south india among medical professionals , however , 65% of the respondents agreed that they dispose unused medication in the garbage and 9% of the respondents dispose in the toilet or sink ( wash basin ) . in a study conducted among pharmacists by abahussain et al . , the respondents stated that they disposed medicines in trash ( 73% ) , sink ( 32% ) and toilet ( 9% ) , and/or passed it to someone ( 20% ) . a study conducted by tai et al . in california among pharmacists showed favorable attitude toward providing education regarding disposal of medicines . however , their knowledge in this area may be lacking and they are not consistently providing this information to their patients . this problem needs to be tackled , since consumers are likely to seek advice regarding the disposal of medicines from pharmacists . consumers perceive that safe disposal of medicines is necessary . however , the requisite knowledge and practice of safe methods of disposal are currently inadequate . educational interventions to improve awareness and regulatory interventions in this regard are recommended . this study has been carried out in a small sample comprising a segment of population visiting a public health facility . there is a scope for future studies in varied samples with different literacy and socioeconomic background . this study has been carried out in a small sample comprising a segment of population visiting a public health facility . there is a scope for future studies in varied samples with different literacy and socioeconomic background .
objectives : to evaluate the knowledge , attitude and practice of consumers in india about disposal of unused medicines.materials and methods : a questionnaire comprising 11 questions evaluating the knowledge ( 2 ) , attitude ( 3 ) and practice ( 6 ) of unused medicines was prepared and pre validated before administering to 200 consumers of medicines attending the outpatient department of civil hospital ahmedabad , a tertiary care teaching hospital in western india . 
 requisite permissions from institutional ethics committee and informed consent were obtained prior to recruiting them for the study . 
 responses were recorded , in microsoft excel spreadsheet and evaluated for percentage response.results:majority of the respondents ( 136 , 68% ) stored unused medicines at home . 
 analgesics ( 26.5% ) were the most common unused medicine stored . 
 safe disposal of medicine was considered necessary by majority respondents ( 160 , 80% ) for different reasons like prevention of illegal / unintended use ( 84 , 42% ) , prevention of environmental pollution ( 32 , 16% ) or possible adr caused by old drugs ( 54 , 27% ) . only 78 ( 39% ) respondents were aware of appropriate methods of disposal . 
 disposal in household trash ( 61 , 30.5% ) was the most common method used . 
 majority of respondents felt the need for a facility or programme to collect unused medicines ( 152 , 76% ) and an increased awareness among consumers regarding hazards and methods of disposal of unused medicines ( 154 , 77%).conclusion : majority of consumers are aware about the need for safe disposal of unused medicines . 
 but the right attitude for and practice of safe disposal of medicines is lacking . a need for increased awareness regarding safe disposal of medicines 
 is acknowledged by majority of consumers .