Abstract
Background:
Diabetes treatment requires the use of medical sharps for glycemic control. Improper sharps collection and disposal poses substantial threats to people with diabetes (PWD), health care professionals, the environment, and public health.
Objectives:
To identify the prevalence and predictors of improper sharps collection practices among PWD in Saudi Arabia.
Methods:
We surveyed 288 PWD at King Saud University Diabetes Center in Riyadh, Saudi Arabia, from September to October 2021. We asked questions about demographics, diabetes history, sharps collection practices, and prior education on proper sharps collection practices. We defined “proper sharps collection” as: using a designated sharps disposal container or homemade sealed container to collect sharps.
Results:
Of the PWD surveyed, 60% were women, 54% were ≥35 years old, and 53% had type 1 diabetes. Most respondents (80% and 72%) reported improper collection of needles and lancets, respectively. Approximately, 56% of needle users and 61% of lancet users reported that they had never received instructions on safe sharps disposal. Receiving education on safe sharps disposal practices was associated with a 66% reduction in the risk of improper sharps collection practices (odds ratio (OR) [95% confidence interval (CI)]: 0.34 [0.16-0.68]) after adjusting for age, gender, type and duration of diabetes, income, education, and nationality of the study participants. Among those who improperly dispose their needles, 67% thought their sharps collection practices were appropriate.
Conclusions:
Our findings highlight the high prevalence of unsafe sharps collection practices among PWD in Saudi Arabia, and how prior education on safe sharps collection practices can help address this environmental and public health threat. Policies to reduce diabetes-related waste, unify the approach to proper sharps collection and disposal, and promote safe disposal education are needed to achieve a sustainable and safe waste management system.
Introduction
Diabetes prevalence is on the rise globally, with the highest prevalence reported in the Middle East and North Africa (MENA) region. 1 In many cases, diabetes is managed with life-long injectable therapies which require the use of sharps on a regular basis. All people with type 1 diabetes (T1D) and up to 40% of those with type 2 diabetes (T2D) are recommended to use insulin injections or pumps. In addition, most people with diabetes (PWD), irrespective of the type of diabetes, are recommended to regularly monitor their glucose levels. All these activities involve the use of sharp objects outside the health care facilities. The World Health Organization (WHO) classifies the following sharps as medical waste: lancets, continuous glucose monitoring (CGM) sensors, insulin injection needles, syringes, auto injectors, and insulin pump insertion needles and infusion tubes. 2 Recently, many of these sharps have become disposable (ie, single-use materials) to optimize the user’s experience and minimize biological hazards (eg, single-use insulin pen needles, single-use blood glucose monitoring lancets, etc). However, the use of disposable sharps has created an additional large amount of waste and threats to the health care personnel, public, and environment. 3
When disposed improperly, diabetes sharps carry the risk of infection and injury to health care personnel, as well as to the public, through needle stick injuries and potential exposure to bloodborne pathogens (eg, hepatitis B virus, hepatitis C virus, HIV, etc). 4 Such risk extends beyond PWD to include household members, waste collection workers, Materials Recovery Facility workers, and others who may be exposed to needlestick injuries and their complications. 5 Therefore, the United States Food and Drug Administration (FDA) recommends placing used needles and other sharps into a formal sharps, or sealable, container to reduce the risk of needlestick injuries. 6 Very few countries, including the United States, Australia, and the United Kingdom, have implemented policies and guidance to promote the safe disposal of medical sharps from home-based care activity.7 -9 The safe disposal practices include the use of community drop-boxes where diabetes waste and sharps could be deposited and sent for safe biohazard disposal at community sites, hospitals, and pharmacies.
In contrast, many countries, including those in the MENA region, have no policies to regulate the collection and disposal of household medical sharps. Data about sharp collection and disposal practices and the level of awareness about this topic among PWD in the MENA region remain scarce. Such disparity in data availability is concerning considering the staggering burden of diabetes and the high utilization of diabetes sharps in this part of the world. Global efforts to address the negative health and environmental impact of diabetes waste will remain insufficient unless the international community works together and data about sharps collection and disposal practices become available from parts of the world where diabetes is highly prevalent.
In this study, we examine the current sharps collection practices and predictors of improper sharps collection practices among PWD in Saudi Arabia, where diabetes prevalence is among the highest across the MENA region and worldwide.
Material and Methods
Study Design and Participants
A face-to-face survey of PWD was conducted by trained health care personnel between September 1 and October 31, 2021. The survey was conducted during the patients’ routine clinic visits at the Diabetes Center at King Saud University Medical City in Riyadh, Saudi Arabia. We surveyed adolescents and adults (≥12 years old) with any type of diabetes who use diabetes sharps (eg, insulin needles, insulin pumps, lancets, CGM, or other diabetes-related sharps). The survey consisted of 25 multiple choice questions including questions about the participants’ sociodemographics, type and duration of diabetes, level of income and education, prior education on proper disposal of sharps, and current sharps collection practices. The study was approved by the Institutional Review Board at King Saud University and informed consent was obtained from all participants.
Outcomes and Covariates
We collected self-reported data on sociodemographics, type and duration of diabetes, level of income and education, whether the participant had received prior education on proper sharps disposal, and the participants’ current sharps collection practices. In addition, PWD were asked about how they dispose their injection needles, syringes, auto injectors, lancets, CGM sensors, and insulin pump infusion sets and other parts of the pump, when applicable. Proper sharps collection was defined as disposing medical sharps in a sealed container (eg, cartoon, plastic jug, and water bottle) or a formal sharps container (disposal box) that is designed for sharp disposal and is obtained from the clinic, pharmacy, or other stores. Additional questions were also asked to assess the participants’ level of knowledge about the risk of disease transmission via needlestick injuries. Those who reported improper sharps collection practices were asked about why they use that particular method of collection. Participants were allowed to choose more than one answer for some of the questions.
Statistical Analysis
All significance testing was two-tailed with α of .05, and data were analyzed using Stata Statistical Software (release 15). Categorical variables were examined using contingency table arrays and the χ2 statistic. Logistic regression analysis was used to identify potential predictors of improper sharps collection practices, and the associations between the predictors and outcomes are presented as odds ratios (ORs) and 95% confidence intervals (CIs). We present the ORs before and after adjusting for potential confounders including age, sex, education level, income, duration of diabetes, residence status (nationals vs expats), and whether the respondent had received prior education on how to properly dispose sharps.
Results
Population Characteristics and Prevalence of Improper Sharps Collection Practices
Of the 288 respondents, majority were either 15 to 34 years old (34.4%) or ≥55 years old (34.4%); and two-thirds were women (60.4%). More than half of the participants had T1D (52.8%), 32.6% had T2D, 1.4% had other types of diabetes, and 13.2% did not know the type of diabetes. More than half of the participants had diabetes for >10 years. Most respondents (83%) reported improper sharps collection practices (eg, throwing sharps in the garbage or toilet, bending the needles, burning the sharps, etc). Although all our study participants were using medical sharps, only 40% of them reported that they had received education on safe sharps collection practices. However, among the 17% of respondents who practice proper sharps collection in our study, the majority (58%) had received a form of education on safe sharps disposal practices. Whereas, among the 83% of respondents who practice improper sharps collection, only 36% reported that they had received prior education on safe sharps disposal. Table 1 highlights the other characteristics of our study participants and how they differed by sharps collection practices.
Characteristics of the Study Participants (n = 288).
Abbreviations: T1D, type 1 diabetes; T2D, type 2 diabetes.
The overall prevalence of improper lancets collection practices was (72.8%) (Table 2). The prevalence of improper lancets collection practices was significantly lower among PWD who received education on safe sharps disposal compared with those who did not (58.3 vs 82.1%, P < .01). Likewise, the overall prevalence of improper needles collection practices was 79.5%. The prevalence of improper needles collection practices was significantly lower among those who received education on safe sharps disposal compared with those who did not (70.4 vs 86.5%, P < .01). Among insulin pump users, 59.1% of those who received education on proper sharp disposal reported improper sharps collection practices compared with 82.1% of those who did not receive education (P = .07) (Table 2).
Sharps Collection Practices Among Those Who Received Educational Sessions on How to Properly Dispose Sharps Versus Those Who Did Not.
Univariate and Multivariable Logistic Regression Analyses
The results of multivariable logistic regression analyses examining the relationship between improper sharp collection practices and various predictors are shown in Table 3. The odds of improper sharps collection practices were significantly higher in PWD who had not received education on safe sharps disposal practices compared with those who had received education (OR [95% CIs]: 2.49 [1.34, 4.63]). After adjusting for age, sex, type and duration of diabetes, income, education, and nationality of the study participants; the odds of improper sharps collection practices remained significantly higher in PWD who had not received education on safe sharps disposal compared with those who had received education (OR [95% CIs]: 2.77 [1.24, 6.17]) (Table 3).
Logistic Regression of the Relationship Between Improper Sharps Collection Practices and Potential Predictors.
Knowledge About the Risk of Disease Transmission Via Needlestick Injuries
Only 41 and 36% of PWD in our study knew that hepatitis B and hepatitis C infections, respectively, can be transmitted via needlestick injury (NSI). Approximately, 15%, 18%, and 11% of PWD thought that tuberculosis, COVID-19, and influenza, respectively, can be transmitted via NSI. No major differences were noted in the level of knowledge about disease transmission via NSI between those who reported proper sharps collection practices versus those who reported improper sharps collection practices (Figure 1).
Level of knowledge about the risks of disease transmission via needlestick injuries.
Barriers to Proper Sharps Collection Practices as Reported by PWD Who Improperly Collect Sharps
The majority of those who improperly collect and dispose sharps thought that their method of sharps disposal was appropriate (63%), and 17% reported not knowing what the appropriate sharps collection method is. In addition, 12% of PWD reported having no time to properly dispose sharps, 8% reported inability to buy a formal sharps disposal container, and 18% did not know that formal or sealable sharps disposal containers exist (Figure 2).
Barriers to proper sharps collection practices as reported by PWD who improperly dispose sharps.
Discussion
Few studies have explored the prevalence and predictors of improper sharps collection practices among PWD outside the United States. Our study is the first to explore the prevalence and predictors of improper sharps collection practices among PWD at a tertiary diabetes center in the MENA region. We identified barriers to proper sharps collection practices and examined the association between prior provider-patient education on safe sharps disposal and the prevalence of improper sharps collection practices among PWD in Saudi Arabia. We have shown that four out of five PWD in Saudi Arabia (83%) practice unsafe collection and disposal of their diabetes-related sharps, a percentage that is among the highest worldwide. 10 Among PWD in the United States, for instance, the prevalence of unsafe disposal of lancets and insulin needles is estimated to be around 40% and 33%, respectively. 11 Moreover, only 40% of PWD in our study reported that they had received prior education on proper sharps disposal, which is among the lowest percentages worldwide. 11
Our findings highlight the importance of providing PWD with formal training on proper sharps disposal and collection practices. Unfortunately, there is no mandated training on proper sharps collection and disposal for PWD in the MENA region, nor is there any policy to regulate proper sharps disposal in the community in most countries in the region. This has likely contributed to the high prevalence of improper sharps collection and disposal practices and underappreciation of this emerging global crisis. The lack of counseling and formal training on proper sharps disposal was associated with an increased risk of unsafe sharps disposal practices by almost three times among PWD in our study (OR [95% CI]: 2.77 [1.24, 6.17]) after adjusting for potential confounders. Moreover, the majority of PWD who practice unsafe sharps collection in our study thought that their method of sharps collection was appropriate and safe. These findings call for standardized training programs on proper sharps disposal to be incorporated into the diabetes education sessions that many PWD attend during their routine clinic visits.
The environmental and public health threats associated with improper sharps disposal cannot be overemphasized. It is estimated that eight billion injections are administered outside of health care facilities annually. 12 Many PWD use other medical sharps, in addition to injections, to self-manage their disease (eg, lancets, CGM sensors, pump infusion needles, etc). 12 As the global burden of diabetes continues to rise, concerns regarding medical sharp waste will likely to grow further and become a global environmental and public health crisis over the next years. 13 While several organizations in the US and Europe have published guidelines and policies on proper sharps disposal, majority of PWD live in parts of the world where such policies and guidelines do not exist.6,14 -17 Therefore, addressing this potential global environmental crisis requires an international collaboration across all involved stakeholders (eg, national and international policymakers, relevant governmental and non-governmental organizations, professional societies, industry, health care professionals, and the community). Recently, the Diabetes Technology Society has launched the Green Diabetes Initiative to reduce diabetes-related waste. 3 Strategies to address this issue need to be tailored according to the available resources within each country, the current practices and behaviors of PWD living in those countries, and the major barriers to proper sharps disposal as reported by those individuals.
Our study provides a valuable insight regarding the current sharps collection practices, knowledge and behaviors of PWD, and barriers to proper sharps collection practices in Saudi Arabia. However, our study has several limitations including the potential risk of underreporting of improper sharps collection practices as these data were self-reported by PWD. Moreover, we surveyed PWD who visited an academic tertiary diabetes center in Riyadh, the capital city of Saudi Arabia, which may have underestimated the national prevalence of improper sharps disposal practices. It is likely that PWD who live in remote areas and receive care at non-specialized clinics may have less access to proper sharps collection training, potentially leading to unsafe sharps collection practices. Moreover, diabetes treatment modalities continue to evolve, and future studies are needed to explore how newer treatment options may impact the home collection and disposal of diabetes-related sharps.
Conclusions
Our findings present the first comprehensive data on sharps collection practices among PWD in their homes in Saudi Arabia. Future studies should examine the subsequent steps of sharps disposal, including the handling of full containers and their impact on health, safety, and the environment. There is an urgent need to address the growing diabetes-related waste and its associated public safety threats and potential global environmental and public health crises. To achieve a sustainable and safe diabetes-related waste management, global initiatives are needed to (1) minimize diabetes-related waste through the production of environmentally-friendly diabetes supplies; (2) standardize the global requirements for safe sharps disposal methods; (3) engage local communities, governments, producers of diabetes supplies, health care facilities and organizations, and waste management institutions to create a unified approach to sharps disposal that takes into account the specific regulatory, cultural, and logistic factors within each country; (4) educate PWD on safe sharps disposal practices through public awareness campaigns; and (5) develop global policies that regulate sharps disposal and ensure easy accessibility to sharps disposal containers and collection points at the local level.
Footnotes
Abbreviations
PWD, People With Diabetes; MENA, Middle East and North Africa; WHO, World Health Organization; CGM, Continuous Glucose Monitoring; HIV, Human Immunodeficiency Virus; US, United States; FDA, Food and Drug Administration; OR, Odds ratio; CI, Confidence Interval; T1D, Type 1 Diabetes; T2D, Type 2 Diabetes; NSI, Needlestick Injury.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MA has served on an advisory panel for Medtronic, Insulet, Abbott, VitalAire, Sanofi, and Dexcom and has received honoraria for speaking from Abbott, Insulet, Dexcom, Eli Lilly, Medtronic, Novo Nordisk, Sanofi, and VitalAire.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
