Journal of Pharmaceutical Health Services Research, 2023, XX, 1–6

https://doi.org/10.1093/jphsr/rmad043
Advance access publication 19 October 2023
Research Paper

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Awareness and beliefs of community pharmacists on
disposal of unused and expired household medications in
Indonesia: a cross-sectional study
Sofa D. Alfian1,2,*, , Qisty A. Khoiry1, Mochammad A. A. Pratama2, Wawan Wahyudin3,
Irma M. Puspitasari1,2, Ivan S. Pradipta1,2, , Rizky Abdulah1,2
1
Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Ir. Soekarno Km. 21 Jatinangor,
Indonesia
2
Drug Utilization and Pharmacoepidemiology Research Group, Centre of Excellence for Pharmaceutical Care Innovation, Universitas
Padjadjaran, Jl. Ir. Soekarno Km. 21 Jatinangor, Indonesia
3
Ciloto Health Training Centre, Ministry of Health, Republic of Indonesia, Jl. Raya Puncak Ciloto, Km. 90 Cianjur, Indonesia
*
Correspondence: Sofa D. Alfian; Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jl. Raya Jatinangor, KM
21 Jatinangor—Sumedang, Indonesia. E-mail: sofa.alfian@unpad.ac.id

Abstract
Objective: To assess the awareness and beliefs of community pharmacists regarding the disposal of expired and unused household medications
in Indonesia.
Methods: A cross-sectional survey was conducted through convenience sampling. All pharmacists participating in a virtual training event
were invited to take part in a self-administer voluntary online survey. A translated and validated questionnaire was used to assess awareness
about the harm caused by improper disposal and the beliefs of the best location for collecting expired and unused household medications.
Subsequently, demographic data such as age, gender, education level, and work experience of pharmacists were obtained through self-reported
data. The characteristics of pharmacists and the outcomes were summarized using descriptive analysis. Correlation analysis was carried out to
determine the association between sociodemographic variables and outcomes.
Key findings: A total of 202 pharmacists completed the survey (response rate: 96.2%). The majority were female (83.2%) and the mean work
experience was 4.7 years. Approximately 86% of pharmacists were aware of the environmental harm caused by improper disposing of expired
and unused household medications, and 98% acknowledged their role in preventing such risks. Approximately 70%–80% of the respondents
believed that community pharmacies were the best location for the collection of expired and unused household medications. No significant
associations were found among age, gender, education level, and years of experience and the outcomes.
Conclusion: Almost all pharmacists were aware of the risk of improper disposal of expired and unused household medications and acknowl-
edged their responsibilities to protect the environment. The strong inclination of pharmacists to select pharmacies as collection points for
expired and unused medications strongly advocates for the implementation of medication take-back programs in Indonesia.
Keywords: community pharmacists; awareness; beliefs; disposal of household medications; unused medications; expired medications; Indonesia

Introduction to their potential risks to human health and ecotoxicological

The concerns surrounding pharmaceutical waste are escalating
in recent years [1]. This is due to factors such as patient non-
adherence to treatment, improvement in medical condition,
treatment changes, adverse effect experiences, and oversupply
of medicines from multiple sources [2]. The high number of
expired and unused medications at home [3] may increase
pharmaceutical waste disposal [2]. In developing nations such
as Indonesia, the disposal of expired and unused medications
is often carried out through improper methods, including
flushing down the toilet or discarding in regular garbage [4, 5,
6, 7, 8]. This is possibly due to a lack of awareness regarding
the risk of improper disposal of expired and unused household
medications to both human health and the environment [9].
Inappropriate disposal practices of expired and unused
household medications can pose a threat to the ecosystem due
risks [10, 11]. A current study reported the presence of par-
acetamol residues in the waters of Muara Angke and Ancol
Bay, Indonesia [12]. Additionally, previous studies identified
the presence of antibiotics in drinking water, with certain bac-
teria displaying resistance to commonly found antibiotics in
these water sources [13, 14]. The detection of pharmaceutical
substances in drinking water at nanogram/liter concentrations
underscores the insufficiency of household water treatment
plants in removing them [15, 16].
Pharmacists are accessible healthcare professionals
and play an important role in influencing both the com-
munity and the environment by promoting proper disposal
practices for expired and unused household medications.
Although pharmacists possess satisfactory knowledge and
attitudes regarding medication disposal [17], most do not

Received: 24 May 2023 Accepted: 27 September 2023

© The Author(s) 2023. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/
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2 Alfian et al.
proactively counsel patients about medication disposal
practices [18, 17]. In some developed countries, medication
take-back programs are well-established, with pharmacists
and pharmacies playing important roles in encouraging ap-
propriate medication disposal practices and acting as collec-
tion points [19, 20, 8]. This type of program allow patients
and the general population to return expired and unused
medications to pharmacies for appropriate disposal. This
program has been reported effectively because a higher pro-
portion of respondents in Sweden (43%) have returned their
medications to pharmacies [21].
Some pharmacies in Indonesia may offer medication
take-back programs at their own cost and time as part of
their community’s social responsibility. However, official
guidelines for community pharmacies to accept expired
and unused medications from the general population are
lacking. The provisions mostly concern expired and unused
medications from healthcare facilities and pharmacies but
not from household settings. In 2019, a campaign under the
slogan “Let’s Dispose of Medication Properly” was launched
where 1000 pharmacies in Indonesia collaborated to dissem-
inate information to return expired and unused household
medications to pharmacies [22]. However, the effectiveness
and sustainability of such a program are unknown because
very few Indonesian populations return their expired and
unused medications to pharmacies [5]. Therefore, a system
should be developed to collect expired and unused household
medications.
For a new system or service to be successfully and effec-
tively implemented, acceptance plays a crucial role [23].
Therefore, an early assessment of pharmacists’ aware-
ness and beliefs is important to measure their acceptance
of such a service. This information is important for devel-
oping and implementing such a service. However, to date,
no study assessed the level of awareness and beliefs among
pharmacists regarding the disposal practices of expired and
unused household medications in any form within Indonesia.
Therefore, this study aimed to assess the awareness and
beliefs of community pharmacists concerning the disposal of
expired and unused household medications in Indonesia to
better understand the development of effective interventions
to address the issue.
Methods
Study design, setting, and participants
A cross-sectional survey was performed using conven-
ience sampling. All registered pharmacists working in the
Community Health Centers who participated in the virtual
training event in September 2022 were invited to a self-
administered voluntary online survey. The virtual training
event was organized by the Ciloto Health Training Center of
the Ministry of Health, Indonesia, and was attended by 210
representatives of pharmacists from 29 provinces in Indonesia.
The virtual training event was free, and the schedule included
lectures and workshops regarding pharmaceutical care for
patients. The topic of medication disposal was not included
in this virtual training event.
The Health Research Ethics Committee of Universitas
Padjadjaran, Indonesia, approved this study (No. 671/UN6.
KEP/EC/2022). Consent was obtained from all participating
pharmacists through an online checkbox in the survey,
ensuring their privacy and anonymity during data collec-
tion and analysis. This study adhered to Strengthening
the Reporting of Observational Studies in Epidemiology
(STROBE) guidelines for cross-sectional studies [24]
(Supplementary Table S1).
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Data collection
The self-administered online survey was distributed after
the virtual training event to assess pharmacists’ awareness
and beliefs regarding the disposal of expired and unused
household medications. The questionnaire was developed
based on previous studies [25, 26, 8]. Two independent
translators from professional language services translated
the questionnaire into Indonesian and then back to English.
The translated questionnaire was reviewed by two experts
from the pharmacoepidemiology and clinical pharmacy
fields. Subsequently, the opinion of these experts regarding
the clarity of each item was considered before finalizing
the questionnaire. A pilot study including 30 pharmacists
assessed content and face validity. The questionnaire was
shown to be valid and reliable based on the content va-
lidity index and Cronbach’s alpha coefficient of 0.8 and 0.7,
respectively.
The validated questionnaire comprised four sections. The
first section consisted of questions about the demographic
information of pharmacists, including age upon completing
the questionnaire, sex (male and female), highest educa-
tional level (registered pharmacists, master’s, Ph.D.), and
experience in clinical practice (in years). The second section
consisted of four questions designed to assess the awareness
of pharmacists toward environmental damage (e.g. “How
much damage will affect the environment if you, as an indi-
vidual, had thrown away unused medications in the trash?”)
using a 3-point Likert scale (e.g. no damage (0 points), uncer-
tain (1 point), or damage (2 points)). A total score of <50%
was classified as unaware, while a total score of ≥50% was
classified as aware.
The third section included three questions aimed at
assessing the beliefs of pharmacists regarding the appro-
priate place for collecting expired and unused household
medications (e.g. “secure containers inside pharmacies within
community pharmacies”) using a 3-point Likert scale (e.g. not
a good idea (0 points), uncertain (1 point), or a good idea (2
points)). A total score of <50% was classified as poor beliefs,
while a total score of ≥50% was classified as good beliefs.
Sample size calculation
The minimum sample size was calculated for the cross-sec-
tional survey by considering an expected proportion of
participants at 50%, an absolute error at 5%, and a conven-
tional normal variate of type 1 error at 5%. This indicates
that at least 192 participants are needed.
Data analysis
Data analysis was carried out using descriptive statistics to
show the characteristics of pharmacists. The Spearman’s
rank correlation coefficient was performed to assess the as-
sociation between the characteristics of pharmacists and their
awareness and beliefs on the disposal practices of expired
and unused household medications. Correlation coefficients
of <0.49, <0.69, and ≥0.70 indicated weak, moderate, and
strong correlations, respectively (27). A P-value of <0.05 was
deemed statistically significant. All statistical analyses were
Awareness and beliefs of community pharmacists 3

performed using Statistical Package for the Social Sciences are the most appropriate locations for collecting expired and
(version 27.0; IBM, Armonk, NY, USA). unused household medications (Table 3).

Correlations of sociodemographic factors to the

Results respective knowledge and beliefs

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Characteristics of participants
The self-administered online survey was delivered to 210
pharmacists attending the event, and 202 pharmacists (re-
sponse rate: 96.2%) completed the survey. The majority were
female (83.2%), the average age was 29.9 years and were
relatively new as pharmacists (mean work experience of 4.7
years) (Table 1).
No significant associations were found among the age,
gender, educational level, and years of experience of
pharmacists and their awareness of the risk of improper
disposal of expired and unused household medications in
the environment or the beliefs about the appropriate place
to collect expired and unused household medications (P >
0.05) (Tables 4 and 5).

Awareness and beliefs on the appropriate place Discussion

for disposal of expired and unused household The majority of pharmacists were aware that improperly
medications disposed of expired and unused household medications may
Half of pharmacists were aware of the environmental hazards harm the environment, and they agreed on their responsibility
of unused and expired household medication disposal to prevent such risks. A high number of pharmacists believe
(58.4%) (Table 1). A very high number of pharmacists (98%) that community pharmacies as the appropriate place for the
agreed that one of their responsibilities is to protect the envi- collection of expired and unused household medications.
ronment (Table 2). Subsequently, no significant associations were observed be-
Regarding beliefs on appropriate disposal locations, about tween pharmacists’ age, gender, education level, and years
67.3% of pharmacists held strong beliefs in suitable collection of experience with the awareness of the risk of improper
sites for expired and unused household medications (Table disposal of expired and unused household medications on
1). The majority of pharmacists believed that community the environment or the beliefs about the appropriate place
pharmacies and pharmacies of private and public hospitals to collect expired and unused household medications.
In comparison to pharmacists in Saudi Arabia [26] and
Kuwait [25] using a similar instrument, pharmacists in this
Table 1. Characteristics of pharmacists (N = 202). study showed higher awareness levels regarding improper
medication disposal risks on the environment. Furthermore,
Characteristics N (%) the majority of pharmacists agreed that the environment
Age in years, mean (SD) 29.9 (4.6)
can be harmed when expired and unused medications are
disposed of in either the sink or the trash. Subsequently,
Gender Male 34 16.8
expired and unused medications disposal, either through
Female 168 83.2 household waste, the toilet, or the sink, may be an important
Educational level Registered 198 98.0 route that enables pharmaceutical waste to get into the en-
pharmacists
vironment ([28]). The Food and Drug Administration in the
Master 4 2.0 United States recommends disposing of medication in house-
Work experience in years, mean (SD) 4.7 (3.3) hold garbage for certain medications (29), but this method is
Awareness Aware 118 58.4 suggested only in the settings when a medication take-back
Unaware 84 41.6 program is not established. These guidelines suggested mixing
Beliefs Good 136 67.3 the medication with unpalatable materials and placing it in a
Poor 66 32.7
sealed plastic container. However, a small amount of this mix-
ture may escape this confinement eventually and contaminate

Table 2. Awareness among community pharmacists of environmental hazards of unused and expired household medication disposal (N = 202).

Items Responses

No damage, Damage, N Uncertain,

N (%) (%) N (%)

Disregarding what others are doing, how much damage will affect the environment if you, as 2 (1.0) 199 (98.5) 1 (0.5)
an individual, had thrown away unused medications in the trash?
Disregarding what others are doing, what extent of damage on the environment if you, as 24 (11.9) 175 (86.6) 3 (1.5)
an individual, dispose of unused medications by throwing them away in the sink or toilet
(sewage)?
Disagree, Agree, Uncertain,
N (%) N (%) N (%)
It is my responsibility to protect the environment even if others are unconcerned or irrespon- 1 (0.5) 200 (99.0) 1 (0.5)
sible.
It is my responsibility to ensure the safety of other living species on earth. 1 (0.5) 199 (98.6) 2 (1.0)
4 Alfian et al.
Table 3. Beliefs of community pharmacists about the appropriate location for collecting unused and expired household medications (N = 202).
Item
Secure containers inside pharmacies within community pharmacies
Secure containers inside pharmacies within government hospitals
Secure containers inside pharmacies within private hospitals
Table 4. Correlation of sociodemographic factors with awareness of
disposal of unused and expired medications (N = 202).
Characteristics Awareness
rhoa
Age 0.025
Gender −0.031
Education level 0.048
Work experience 0.025
a
Spearman rank correlation coefficient.
Table 5. Correlations of sociodemographic factors with beliefs of
disposal of unused and expired medications (N = 202).
Characteristics Beliefs
rhoa
Age 0.075
Gender 0.110
Education level −0.053
Work experience 0.064
a
Spearman rank correlation coefficient.
the environment. Additionally, the majority of pharmacists
indicated their responsibility to protect the environment
from such risks. This is an encouraging finding in which
pharmacists indicate high awareness and good responsibility
to protect the environment from improper disposal of expired
and unused household medications.
Most of pharmacists in this study believed that community
pharmacies were an appropriate place for the collection of
expired and unused household medications from the public
and they are willing to designate their pharmacies as a col-
lection site for expired and unused household medications.
However, the percentage of these beliefs was lower compared
to beliefs among pharmacists in Saudi Arabia [26] and Kuwait
[25] using a similar instrument. This willingness reflects
their awareness and sense of responsibility in reducing the
risk of improper disposal of expired and unused household
medications. This inclination also mirrors patient preferences
in Indonesia, where returning medications through gov-
ernment health centers was the favored method ([2] [5]).
Therefore, there is a need to develop a policy that would
allow pharmacists to accept returned expired and unused
medications from the general population and subsequently
guide pharmacists on the appropriate disposal practices to re-
place their voluntary efforts.
Response
Good idea, N (%) Not a good idea, N (%) Uncertain, N (%)
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163 (80.7) 17 (8.4) 22 (10.9)
163 (80.7) 16 (7.9) 23 (11.4)
143 (70.8) 15 (7.4) 44 (21.8)
There were no significant associations observed among the
age, gender, education level, and experience of pharmacists
and their awareness of the environmental risks related to
improper medication disposal or their beliefs about appro-
priate collection locations. This is similar to conflicting results
P value about the sociodemographics of pharmacists in previous
studies [25, 26, 17]. In general, it seems that pharmacists’
0.729 awareness and beliefs regarding the disposal of expired and
0.666 unused household medications are not influenced by their
0.499 sociodemographic factors.
0.723 These results strongly support the initiation of medica-
tion take-back programs within community pharmacies in
Indonesia. The appropriate collection and disposal of expired
and unused household medications through a well-established
collection program and disposal system are paramount to
guarantee the safety of human health and the natural environ-
ment. Subsequently, policies should be developed to govern
the collection of returned medications through pharmacies,
using pharmacists’ positive environmental awareness and
P value willingness to participate. An official policy for the disposal
of expired and unused household medications has a positive
0.289 effect on how the general population dispose of them [30].
0.120 Therefore, close collaboration between governmental sectors
0.458 and national awareness of public and health care providers is
0.362 necessary to develop and initiate an effective medication take-
back program at the national level.
This study is likely the first to assess the awareness and
beliefs of Indonesian pharmacists regarding the disposal
practices of expired and unused household medications.
However, several limitations should be acknowledged. Similar
to any self-reported survey, the potential effects of social de-
sirability bias in the responses remain a threat to internal
validity. Additionally, response bias might be present since
pharmacists who chose to complete the survey could differ in
their responses from non-participants, a common occurrence
in voluntary surveys. Pharmacists were recruited by conven-
ience sampling that may reduce the cost and time needed
but with limited generalizability. Particularly, pharmacists
attending the virtual training event might not represent non-
attendees, and, therefore, these results cannot be generalized
to a greater population. Future studies, particularly using a
mixed-methods study design, are needed to further explore
the perception, willingness, and barriers toward medication
disposal programs among pharmacists on a national level in
Indonesia.
Conclusions
Almost all pharmacists were aware of the risk of improper dis-
posal of expired and unused household medications and ac-
knowledged their responsibilities to protect the environment.
The beliefs among pharmacists in designating pharmacies
for collecting expired and unused household medications
Awareness and beliefs of community pharmacists
strongly supported the initiation of medication take-back
programs in Indonesia.
Supplementary Material
Supplementary data are available at Journal of Pharmaceutical
Health Services Research online.
Acknowledgment
We thank all respondents for their effort and contributions.
Author contributions
S.D.A., Q.A.K., I.M.P., and I.S.P. were involved in protocol
development; S.D.A. and Q.A.K. were involved in gaining
ethical approval; S.D.A., Q.A.K., M.A.A.P., W.Y., I.M.P.,
I.S.P., and R.A. were involved in patient recruitment and data
analysis. S.D.A. wrote the first draft of the manuscript. All
authors reviewed and edited the manuscript and approved the
final version of the manuscript.
Conflict of interest
The author(s) declare that there are no conflicts of interest.
Funding
This study was supported by a grant-in-aid from Universitas
Padjadjaran, Indonesia (No. 2203/UN6.3.1/PT.00/2022).
This funding body did not have any role in designing the
study, writing this article, and deciding to submit it for pub-
lication.
Data availability
The data that support the findings of this study are available
from the corresponding author upon reasonable request.
Ethics approval
The study was approved by the Health Research Ethics
Committee of Universitas Padjadjaran, Indonesia (No. 671/
UN6.KEP/EC/2022). All participants provided their con-
sent to participate by selecting a checkbox in the online
survey.
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