Household disposal of unused and expired medications in Bahir Dar City,Northwest Ethiopia: Knowledge,attitudes,practices,and factors associated with good disposal practices

Abstract

Introduction

Proper household management of unused and expired medications reduces environmental and public health risks. The aim of this study was to assess household knowledge, attitudes, and disposal practices of unused and expired medications, and identifies factors associated with good disposal practices among households in Bahir Dar City, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from October 1, 2025, to October 30, 2025. A total of 417 participants were selected using simple random sampling. Data were collected through face-to-face interviews using a pretested, structured questionnaire. Data were entered into Microsoft Excel and analyzed using SPSS version 26. Variables with p-values <0.05 in multivariable logistic regression analysis were considered statistically significant.

Results

Among 415 participants, 32.2% had good knowledge, 56.4% had a positive attitude, and 43.4% demonstrated good storage and disposal practices. The majority (89.4%) stored unused and expired medications at home, mainly due to improvement in medical condition (53.4%), intolerable side effects (17.5%), and medication change (14.3%). Analgesics (55.0%) and antibiotics (32.1%) were the most commonly stored medications. Although 75.7% reported disposing of unused and expired medications, poor practices were common. Unused medications were often kept until expiry (53.3%), discarded in household garbage (23.3%), or flushed into toilet or sink (15.4%). Expired medications were mainly discarded in household garbage (70.4%), whereas only 9.2% were returned to pharmacies or health facilities. Good disposal practices were significantly associated with age >35 years (AOR=7.14, 95% CI: 1.29-39.67), health insurance (AOR= 2.97, 95% CI: 1.03-8.55), college or higher education (AOR=2.14, 95% Cl: 1.02- 9.20), good knowledge (AOR = 3.41, 95% CI: 1.44-21.49), and positive attitude (AOR = 4.65, 95% CI: 1.29-16.76).

Conclusion

Households in Bahir Dar City had a positive attitude; however, their knowledge and disposal practices were poor. Strengthening public awareness and implementing medication take-back systems are recommended to promote good disposal practices and reduce public health and environmental risks.

Keywords

knowledge attitudes disposal practices unused medications expired medications Bahir Dar City

Introduction

When medicines are used rationally and stored under recommended conditions and within their expiry periods, they play a critical role in disease prevention, treatment, and health promotion.^1,2 However, when medications become expired, damaged, or remain unused, they may lose their therapeutic efficacy and degrade into harmful substances that pose potential health risks to the communities.^3,4

Globally, irrational prescribing, dispensing, and use of medicines, along with poor adherence, contribute to the accumulation of unused and expired medications at the household level.⁵ More than 50% of medicines are prescribed, dispensed, or sold improperly, while 50% of patients fail to adhere to treatment regimens, which causes unnecessary storage at home.^4–6 Although, the prevalence of unused and expired medications varies across regions and populations, their storage has emerged as a growing public health and environmental concern worldwide.^7,8

Unused and expired medications are classified as pharmaceutical waste, and their improper storage and disposal at the household level is a growing public health and environmental concern, particularly in low- and middle-income countries. Such practices pose significant risks to human health, safety, and the environment.^9–16 Inappropriate handling of these medications increases the risk of accidental poisoning, inappropriate self-medication, antimicrobial resistance, and contamination of water and soil systems.^{10–12,17–19} These concerns have led to the development of ecopharmacovigilance, which focuses on the detection, assessment, and prevention of adverse environmental effects caused by pharmaceuticals.^20,21

High-income countries have implemented structured pharmaceutical waste management systems, including medication take-back programs and regulatory guidance, whereas many low- and middle-income countries lack adequate disposal policies, infrastructure, and public awareness initiatives.^{2,7–10,14,18,22,23} Medication disposal practices are poorly integrated into routine healthcare services in Ethiopia, and community-level waste management systems and public awareness initiatives remain limited.^{20,21,24–26} Existing regulations mainly focus on institutional settings, with limited attention paid to household-level disposal practices.^{22,23,27–30}

Studies conducted in Ethiopia have reported a high burden of improper household medication storage and disposal, with 41.4%-89.1% of households storing unused or expired medications at home and 23.0%- 63.0% disposing of them in household garbage systems.^9,21–31 However, despite the growing public health and environmental implications of pharmaceutical waste, there is limited and updated community-based evidence assessing household knowledge, attitudes, and practices toward the disposal of unused and expired medications, as well as factors associated with good disposal practice in Bahir Dar City, Northwest Ethiopia.

Although related studies have been conducted in other Ethiopian settings, including Harar, Gondar, and Adigrat, their findings may not be directly generalizable to Bahir Dar City because of contextual differences in healthcare service accessibility, medication-use patterns, urban structure, and pharmaceutical waste management systems.^{9,21,23,28,31} The absence of localized, up-to-date evidence limits the design of context-specific strategies, public health interventions, and policy frameworks to promote good disposal and management of unused and expired medications at the household level.

Understanding household knowledge, attitudes, and practices (KAP) toward the disposal of unused and expired medications is essential for designing effective and evidence-based interventions to promote safe pharmaceutical waste management. This study provides baseline evidence on household KAP toward unused and expired medication disposal and identifies factors associated with good disposal practices among households in Bahir Dar City, Northwest Ethiopia. The study will provide important insights into household medication management practices in the study area by identifying knowledge gaps, prevailing attitudes, practice patterns, and factors associated with good medication disposal practices. The findings will serve as valuable evidence for healthcare professionals, policymakers, and public health authorities to strengthen regulatory frameworks; enhance community awareness; and design targeted interventions, including medication take-back programs, to enhance safe pharmaceutical waste management and protect both public health and the environment.

Methods

Study setting and period

This study was conducted in Bahir Dar City from October 1, 2025, to October 30, 2025. Bahir Dar is the capital city of the Amhara Regional State and is located at 11036′N, 37023′E on the southern shore of Lake Tana, where the Blue Nile River starts, with an area coverage of approximately 76.5 km². Bahir Dar is one of the largest and most rapidly growing cities in Ethiopia, with commercial centers, small industries, and residences in all sectors of the city. According to the Central Statistics Agency (CSA), the city was home to 180,000 inhabitants in the 2007 census and currently has more than 400,000 people distributed across 6 sub-cities with a total of 26 kebeles, implying rapid population growth.³² The city was chosen because it is the largest and most rapidly growing city in the Amhara regional state and is along Lake Tana, being exposed to water contamination if there is improper disposal of medications.³³

Study design

A community-based descriptive cross-sectional study was conducted.

Source and study population

The source population was all households in Bahir Dar City, with the primary participants being adult household members (≥18 years) who were responsible for medication storage, use, or disposal within the home. The study population included all eligible households available during the study period.

Eligibility criteria

All households that had a medication history and were willing to participate in the study were included. Households less than 18 years old and mentally disabled persons were excluded from the study.

Independent variables

Sociodemographic characteristics (age, sex, religion, educational status, marital status, occupation, monthly income, and health insurance).

Dependent variables

Household KAP toward the disposal of unused and expired medications.

Sample size determination and sampling techniques

The required sample size was determined using a single population proportion formula, considering a 95% confidence level, a 5% margin of error, and an anticipated proportion of 55.9%, which was adopted from a previous comparable study conducted in a similar setting⁹:

n = \frac{{(Z α / 2)}^{2} p (1 - p))}{d^{2}} = \frac{{(1.96)}^{2} (0.559 (1 - 0.559))}{{0.05}^{2}} = \frac{0.94699}{0.0025} = 379

Where, n= required sample size, α = level of significant, Z=1.96 is standard normal distribution curve value for 95% confidence level, P =0.559 is the proportion estimate of previous study, and d= 0.05 is the margin of error. Adding 10% for non-response, the final sample size was 417.

Participants were selected using a simple random sampling technique. First, a complete list of households in Bahir Dar city was obtained from the respective kebele administrative offices and used as the sampling frame. The total sample size was proportionally allocated to the selected kebeles based on the number of households in each kebele. Each household in the sampling frame was assigned a unique identification number, and the required households were selected using a computer-generated random number method. In households with more than one eligible participant, one adult member (≥18 years) was selected by lottery method. If no eligible participant was available during the first visit, up to two repeat visits were made before considering the household a non-response.

Data collection tools and procedures

Data were collected through face-to-face interviews using a pretested, structured questionnaire adopted from previously published studies.^9,11,20–31 The questionnaire consisted of four sections: (I) sociodemographic characteristics; (II) 12 items assessing knowledge toward unused and expired medication disposal; (III) 13 Likert-scale items (5-point: strongly agree to strongly disagree) measuring attitudes; and (IV) 13 items evaluating household disposal practices of unused and expired medications (Supplementary File 1).

The original questionnaire was prepared in English and translated into Amharic, the local working language, by bilingual professionals experienced in health research translation to ensure clarity and cultural relevance for all participants. To ensure linguistic equivalence and consistency of meaning, the Amharic version was independently back-translated into English by another translator who was blinded to the original version. Discrepancies between the original and back-translated versions were reviewed and resolved through discussion among the research team and language experts, and the final Amharic version was pretested before the actual data collection.

Finally, data were collected by four trained pharmacy professionals after receiving training on the study objectives, interviewing techniques, ethical considerations, and data collection procedures.

Data quality control

To maintain data quality, an appropriate and valid data extraction tool was used. The data collection tool was pretested for consistency and completeness of data items on 5% of the sample size. Before the actual data collection, the data collectors and supervisor were trained, and both the supervisor and investigators checked the data for completeness at each stage. The Cronbach’s alpha test values were 0.76 for knowledge, 0.82 for attitude, and 0.84 for practice, which were near or above 0.78, which confirms the reliability and internal consistency of the items.³⁴

Data processing and analysis

Data were collected, coded, entered into Microsoft Excel, and analyzed using SPSS version 26. Descriptive statistics were used to summarize participants’ sociodemographic characteristics and KAP outcomes. Variables with a p-value < 0.25 in univariable logistic regression analysis were further analyzed in multivariable analysis. Variables with a p-value < 0.05 at a 95% confidence interval in the multivariable analysis were considered statistically significant. The multivariable model was significant (Model χ² = 46.78, P < 0.001) and demonstrated a good fit (Hosmer–Lemeshow test χ² = 6.2, P = 0.62). Multicollinearity was assessed using variance inflation factors (VIF: 1.33–1.69) and tolerance (T: 0.59–0.75), indicating no significant multicollinearity.

Operational definitions

Knowledge

Participants who scored greater than or equal to the mean score on these knowledge questions were considered to have “good knowledge,” and those who scored less than the mean score were considered to have “poor knowledge”.^{2,9,11,13,20,21,23,31,35}

Attitude

Participants who scored greater than or equal to the mean score were considered to have a “positive attitude,” and those who scored less than the mean score were considered to have a “negative attitude”.^{2,9,11,13,20,21,23,31,35}

Practice

Participants who scored greater than or equal to the mean score were considered to have “good practice,” whereas those who scored less than the mean score were considered to have “poor practice” toward disposal of expired and unused medications.^{2,9,11,13,20,21,23,31,35}

Unused medications

Medications that are no longer being used for treatment but are still within their expiry date, often due to changes in prescription, recovery, or side effects.^9,13,35

Expired medications

Medications that have passed their manufacturer-stated expiry date and are considered potentially unsafe or ineffective.^9,13,35,36

Proper disposal

Disposal of medication using recommended, safe methods (e.g., returning to health facilities, incineration, and authorized take-back systems) to minimize environmental or health risks.^9,13,35,36

Good storage practice

Storing unused and expired medications in a locked cabinet or on a shelf out of reach of children, and regularly checking expiry dates.^9,13,35,36

Results

Sociodemographic characteristics of the participants

A total of 415 participants were included in the study, with a response rate of 99.5%. Around half of the participants, 211 (50.8%), were females, 190 (45.8%) were older than 35 years, and 232 (55.9%) were married. Less than half, 163 (39.3%), had attained college or higher-level education, and 164 (39.5%) were self-employed, followed by governmental employees, 87 (21.0%). One hundred twenty-five (30.1%) had a 5000-10,000 ETB monthly income, and 222 (53.5%) had health insurance (Table 1).

Table 1.

Sociodemographic characteristics of participants in Bahir Dar City, Northwest Ethiopia, 2025 (N=415).

Variables	Category	Frequency (n)	Percentage (%)
Age (year)	18-24	123	29.6
	25-35	102	24.6
	>35	190	45.8
Sex	Male	204	49.2
Sex	Female	211	50.8
Religion	Orthodox	241	58.1
	Muslim	122	29.4
	Protestant	51	12.3
	Others	1	0.2
Educational Status	Illiterate	41	9.9
	Primary	65	15.7
	Secondary	146	35.2
	College and above	163	39.3
Marital status	Single	157	37.8
	Married	232	55.9
	Divorced	22	5.3
	Widowed	4	1.0
Occupations	Self employed	164	39.5
	Governmental employee	87	21.0
	Student	66	15.9
	Housewife	76	18.3
	Others	22	5.3
Monthly income (ETB)	<1,500	118	28.4
	1500- 5000	92	22.2
	5000 -10,000	125	30.1
	>10,000	80	19.3
Health insurance	Yes	222	53.5
Health insurance	No	193	46.5

ETB= Ethiopian Birr.

Knowledge of participants toward unused and expired medication disposal

Less than half of the participants, 134 (32.3%), had good knowledge toward unused and expired medication disposal. More than three-fourths, 319 (76.9%), were unaware of medication disposal instructions; 359 (86.5%) did not know local laws or guidelines; 258 (62.2%) were unaware of the harm of flushing medication into the toilet/sink; and 224 (54.0%) did not know that throwing medication in household trash could contaminate the soil (Table 2).

Table 2.

Knowledge of participants toward unused and expired medication disposal in Bahir Dar City, Northwest Ethiopia, 2025 (N = 415).

S.No	Variables	Category	Frequency (n)	Percentage (%)
1.	Know the difference between unused and expired medications	Yes	302	72.8
1.	Know the difference between unused and expired medications	No	113	27.2
2.	Know about medication waste	Yes	267	64.3
2.	Know about medication waste	No	148	35.7
3.	Types of medication waste (n = 267)	Expired medications	102	38.2
		Leftover medications due to some reasons	68	25.5
		Damaged medications that cannot be used	57	21.3
		Opened medications beyond their use date	40	15.0
4.	Know medication disposal instructions.	Yes	96	23.1
4.	Know medication disposal instructions.	No	319	76.9
5.	Possible harm of inappropriate disposal	Environment contamination	90	21.7
		Killing wildlife	27	6.5
		Accidental swallowing by children	298	71.8
6.	Hazards effect of unused and expired medications minimized or controlled by	Providing proper guidance to the consumer	225	54.2
		Prescribe the correct quantity/duration	139	33.5
		Reduce the number of prescribed medicines	42	10.1
		Donating or sharing unused medicines	9	2.2
7.	Responsible bodies to create awareness on the proper disposal of unused and expired medications	Mass media	141	34.0
		Physician	81	19.5
		Pharmacy	173	41.7
		Pharmaceutical industry	20	4.8
8.	Receiving any education or information on proper disposal of medication	Yes	65	15.7
8.		No	350	84.3
9.	Hospitals or pharmacies accept unused or expired medications for disposal	Yes	37	8.9
9.		No	378	91.1
10.	Flushing medications harms the water system	Yes	157	37.8
10.	Flushing medications harms the water system	No	258	62.2
11.	Throwing medications in household trash can contaminate the soil	Yes	191	46.0
11.		No	224	54.0
12.	Awareness of any local laws or guidelines regarding the disposal of medication in Ethiopia	Yes	56	13.5
12.		No	359	86.5

Attitudes of participants toward unused and expired medication disposal

More than half of the participants, 234 (56.4%), had a positive attitude toward the disposal of unused and expired medications. Around two-thirds, 259 (62.4%), agreed that keeping unused or expired medication at home poses potential risks, and 229 (55.2%) strongly agreed that children are more vulnerable to these risks. In addition, 231 (55.7%) agreed that there is insufficient information on proper disposal, and 189 (45.5%) believed that a take-back system of unused and expired medications should be mandatory (Table 3).

Table 3.

Attitude of participants toward unused and expired medication disposal in Bahir Dar City, Northwest Ethiopia, 2025 (N=415).

S.No.	Variables	SD, n (%)	D, n (%)	N, n (%)	A, n (%)	SA, n (%)
1.	Unused medicines present potential risks at home	6 (1.4)	4 (1.0)	19 (4.6)	259 (62.4)	127 (30.6)
2.	There is a lack of adequate information on the safe disposal of unused medications	1 (0.2)	6 (1.4)	18(4.3)	231 (55.7)	159 (38.3)
3.	Children are more vulnerable to the risks associated with unused and expired medications	2 (0.5)	1 (0.2)	15 (3.6)	168 (40.5)	229 (55.5)
4.	Health professionals provide advice on the safe disposal of medicines	166 (40.0)	177 (42.7)	40 (9.6)	23 (5.5)	9 (2.2)
5.	Take-back system should be mandatory	10 (2.4)	66 (15.9)	37 (8.9)	189 (45.5)	113 (27.2)
6.	Improper medication disposal should carry legal consequences	13 (3.1)	69 (16.6)	46 (11.1)	164 (39.5)	123 (29.6)
7.	Willingness to participate in disposal programs	3 (0.7)	5 (1.2)	47 (11.3)	250 (60.2)	110 (26.5)
8.	Health institutions are doing enough to promote proper medication disposal	148 (35.7)	174(41.9)	48 (11.6)	34 (8.2)	11 (2.7)
9.	Do you feel comfortable asking pharmacists about how to dispose of medication	69 (11.8)	84 (20.2)	81(19.5)	166 (40.0)	35 (8.4)
10.	It’s not a waste of resources to worry about how medications are disposed	13 (3.1)	25 (6)	22 (5.3)	166 (40)	189 (45.5)
11.	Concern about the environmental impact of improper disposal	3 (0.7)	7 (1.7)	45 (10.8)	251 (60.5)	109 (26.3)
12.	Government should provide better disposal facilities	1 (0.2)	4 (1.0)	19 (4.6)	242 (58.3)	149 (35.9)
13.	The government should open channels for reporting ADRs	1(0.2)	5 (1.2)	52 (12.5)	213 (51.3)	144 (34.7)

ADR=adverse drug reaction, SD=strongly disagree, D=disagree, N=neutral, A=agree, and SA=strongly agree.

Participant disposal practices toward unused and expired medications

Only 180 (43.4%) participants demonstrated good disposal practices toward unused and expired medications. The majority, 371 (89.4%), stored unused medications at home, mainly analgesics, 204 (55.0%), and antibiotics, 119 (32.1%). The main reason for having unused medication at home was improvement in medical condition, 198 (53.4%), followed by intolerable side effects, 65 (17.5%) (Table 4). Of 314 (75.7%) who disposed of unused and expired medications, 167 (53.3%) kept unused medications until expiry and 221 (70.4%) discarded expired medications in household garbage. In contrast, only 9.2% of participants returned expired medications to pharmacies or health facilities (Figure 1).

Table 4.

Participants disposal practices toward unused and expired medications in Bahir Dar City, Northwest Ethiopia, 2025 (N=415).

S.No.	Variables	Category	Frequency (n)	Percentage (%)
1.	Check the expiry date of your medications	Yes	230	55.4
		No	73	17.6
		Sometimes	112	27.0
2.	Presence of unused medications at home	Yes	371	89.4
2.	Presence of unused medications at home	No	44	10.6
3.	Reasons for having unused medications (n = 371)	Improvement in medical condition	198	53.4
		Intolerable side effect	65	17.5
		Change of medication by a prescriber	53	14.3
		Keeping for future use	30	7.2
		Passed expiry date	19	5.1
		Prescribed more than needed	6	1.6
4.	Types of unused medications at home (n = 371)	Analgesic	204	55.0
		Antibiotics	119	32.1
		Chronic drugs	41	11.1
		Others*	7	1.9
5.	Storage condition of medications at home	Unlocked Shelf	228	54.9
5.	Storage condition of medications at home	Locked Shelf	187	45.1
6.	If not locked, stored on an unlocked shelf out of reach of children (n=228)	Yes	112	49.1
6.		No	116	50.9
7.	Ever disposed of unused and expired medications	Yes	314	75.7
7.	Ever disposed of unused and expired medications	No	101	24.3
8.	Read disposal instructions (n = 314)	Yes	76	24.2
8.	Read disposal instructions (n = 314)	No	238	75.8
9.	Separate medications before disposal	Yes	48	15.3
9.	Separate medications before disposal	No	266	84.7
10.	Educated others on medication disposal	Yes	77	24.7
10.	Educated others on medication disposal	No	237	75.3
11.	Received guidance from a health professional	Yes	77	24.7
11.	Received guidance from a health professional	No	237	75.3

Figure 1.

Participants’ unused and expired medications disposal methods at Bahir Dar City, Northwest Ethiopia, 2025 (N=415).

Factors associated with good disposal practices toward unused and expired medications

Multivariable logistic regression analysis identified age, educational status, health insurance, knowledge, and attitude as independent factors associated with good disposal practices for unused and expired medications. Participants who were more than 35 years old (AOR=7.14, 95% CI: 1.29-39.67) were more likely to have good disposal practices. Similarly, those who had a college and above educational level (AOR=2.14, 95%Cl: 1.02- 9.20), health insurance (AOR = 2.97, 95% CI: 1.03-8.55), good knowledge (AOR = 3.41, 95% CI: 1.44-21.49), and a positive attitude (AOR = 4.65, 95% CI: 1.29-16.76) were more likely to practice good disposal of unused and expired medications (Table 5).

Table 5.

Univariable and multivariable logistic regression analysis of factors associated with good disposal practice among participants in Bahir Dar City, Northwest Ethiopia, 2025 (N=415).

Variable	Category	COR (95% CI)	p-value	AOR (95% CI)	p-value
Sex	Male	1		1
Sex	Female	2.72 (1.00, 7.41)	0.05*	2.97 (0.87, 10.07)	0.08
Age	18-24	1		1
	25-35	2.05 (0.68, 6.14)	0.20	3.31 (0.77, 14.11)	0.11
	> 35	4.29 (0.93, 19.71)	0.06	7.14 (1.29, 39.67)	0.02*
Occupation status	Employed	1		1
Occupation status	Unemployed	3.18 (1.19, 8.53)	0.02*	2.47 (0.65, 9.43)	0.19
Educational Status	Illiterate	1		1
	Primary	0.44 (0.07, 2.77)	0.38	0.23 (0.02, 3.32)	0.29
	Secondary	3.14 (0.46, 21.57)	0.25	2.28 (0.11, 46.78)	0.24
	College and above	2.30 (0.17, 30.60)	0.24	2.14 (1.02, 9.20)	0.04*
Marital status	Married	1		1
	Divorced	0.54 (0.23, 1.27)	0.16	0.30 (0.09, 1.99)	0.21
	Widowed	0.31 (0.09, 1.11)	0.07	0.33 (0.07, 1.55)	0.16
Monthly income	1500-5000	1		1
	5000-10,000	2.29 (0.95, 5.52)	0.07	1.12 (0.13, 9.67)	0.92
	> 10,000	1.79 (0.74, 4.31)	0.19	1.35 (0.36, 5.02)	0.65
Health Insurance	No	1		1
Health Insurance	Yes	2.54 (1.23, 5.25)	0.02*	2.97 (1.03, 8.55)	0.04*
Knowledge	Poor	1		1
Knowledge	Good	5.54(1.02, 30.02)	0.04*	3.41 (1.44, 21.49)	0.01*
Attitude	Poor	1		1
Attitude	Good	5.22 (1.76, 15.53)	0.03*	4.65 (1.29, 16.76)	0.01*

AOR = adjusted odds ratio, COR = crude odds ratio, 1= reference category, *p < 0.05 = statistically significant.

Discussion

This study assessed household knowledge, attitudes, and practices toward the disposal of unused and expired medications, and identified factors associated with good disposal practices in Bahir Dar City, Northwest Ethiopia. The findings revealed substantial gaps in participants’ knowledge and disposal practices, despite more than half of the participants demonstrating a positive attitude.

Around two-thirds of participants (64.3%) were aware of medication waste. However, awareness of proper disposal instructions was low (23.1%), and only 8.9% and 13.5% were aware of hospital or pharmacy-based disposal systems and local laws and guidelines in Ethiopia, respectively. Overall, only 32.2% had good knowledge toward the disposal of unused and expired medications. This finding is lower than findings reported from Gondar (42.6%) and Adigrat (50.14%).^21,23 This discrepancy may reflect variations in healthcare infrastructure, public awareness initiatives, and implementation of local disposal policies across different settings.

Although 84.3% of participants had never received education on proper medication disposal, 71.8% knew that inappropriate disposal could result in accidental swallowing by children, followed by environmental contamination (21.7%) and harm to wildlife (6.5%). This finding is consistent with a finding reported from Gondar (69.1%).⁹ However, it is lower than findings from other Ethiopian settings, such as Mekele (91.4%)³⁷ and Hawassa (90.0%)³⁸ but is higher than reports from Indonesia (53.1%)¹⁴ and Debre Tabor (50.0%).²⁵ These differences may indicate variations in public awareness, educational exposure, and access to information on medication disposal across different settings.

Less than half of the participants were aware of the environmental effects of improper medication disposal, such as soil (46.0%) and water contamination (37.8%). In addition, only 54.2% of participants correctly knew that proper guidance could reduce or control the hazardous effects of unused and expired medications on the community. This finding is lower than a finding reported from Adigrat (72.4%).²³ This difference may be due to variations in the study period, differences in exposure to medication-related health education, and variability in the local health system capacity to provide consistent public awareness interventions.

Participants identified pharmacists (41.7%) as the predominant source for creating community awareness toward proper storage and disposal of unused and expired medications, followed by mass media (34.0%), and physicians (19.5%). This indicates that pharmacists play a central role in providing medication counseling and promoting safe storage and disposal practices. These findings are consistent with findings reported from Qatar, Gondar, Adigrat, and Mekele.^11,21,23,37 In contrast, a study conducted in Harar identified electronic media (49.6%) as the main source, followed by physicians (24.50%) and pharmacists (8.5%).³¹ This discrepancy may be due to variations in study settings, access to healthcare professionals, and exposure to communication channels.

More than half of the participants (56.4%) had an overall positive attitude toward the safe disposal of unused and expired medications, which is higher than findings reported from Kenya (31.8%),¹³ and Gondar (42.9%)²¹ but lower than from Adigrat (82.2%).²³ The majority (93.0%) agreed that unused medications pose potential risks at home, children are particularly vulnerable (96.0%), and improper disposal can negatively affect the environment (86.8%). Most participants (72.7%) also supported take-back systems, improved government disposal facilities (94.2%), and opened channels for reporting adverse drug reactions (86.0%). These findings indicate a generally positive attitude toward good medication disposal.

Many participants (86.7%) were willing to participate in disposal programs, indicating strong public readiness for future interventions. However, 94.0% agreed that there was a lack of adequate information on the safe disposal of unused medications. This finding is higher than that reported from a study conducted in Zambia (51.7%).¹⁰ It indicates limited public awareness campaigns, counseling services, and institutional commitment. In addition, 42.7% agreed that healthcare professionals should provide disposal advice, which is consistent with a study conducted in Gondar (40.6%),⁹ but lower than in Adigrat (57.7%).²³ These consistencies and variations may be due to similarities or differences in health system capacity, including the extent of public health education, availability of counseling services, and strength of community outreach programs.

Less than half of the participants (43.4%) demonstrated good disposal practices toward unused and expired medications, indicating generally inadequate household medication management practices. Although 55.4% reported regularly checking expiry dates, 27.0% did so only sometimes, and 17.6% never checked expiry dates at all, highlighting inconsistent medication safety behavior at the household level. This may contribute to the accumulation of expired and unused medications and increase the risk of inappropriate use, accidental poisoning, and improper disposal.

The majority of participants (89.4%) stored unused and expired medications at home, mainly due to improvement in medical condition (53.4%), intolerable side effects (17.5%), and changes in therapy by prescribers (14.3%), indicating treatment discontinuation, adverse drug reactions, and possible overprescribing. This finding is consistent with findings reported from Saudi Arabia (89.3%),¹⁵ Gondar (89.1%),²⁸ China (86.0%),³⁹ and Malaysia (84.0%)⁴⁰ but slightly lower than from Indonesia (95.0%).¹⁴ However, it is higher than findings from Uganda (68.0%),⁴¹ Tanzania (70.2%),⁴² and various Ethiopian settings, including Gondar (55.0%),²⁸ Arba Minch (49.4%),²² Adigrat (52.4%),²³ Debre Tabor (47.5%),²⁵ Dessie (62.4%),²⁶ Addis Ababa (61.0%),²⁹ Harar (66.0%),³¹ and Mekele (41.4%).³⁷ It is also higher than the pooled prevalence reported in a systematic review from Ethiopia (44.34%).³⁰ These differences may be due to variations in healthcare systems, prescribing and dispensing practices, awareness of disposal methods, and availability of medication take-back systems.

Analgesics (55.0%) and antibiotics (32.1%) were the most commonly unused class of medications at home. This pattern is consistent with studies conducted in Adigrat (41.5% and 36.7%)²³ and Harar (62.7% and 24.0%)³¹ but inconsistent with studies conducted in Arba Minch (21.0% and 64.0%),²² Gondar (17.6% and 37.0%),²⁸ and Addis Ababa (30.0% and 29.0%),²⁹ respectively. These findings indicate that medications used for pain management and infectious conditions constitute the largest proportion of unused medication stored at the household level and suggest widespread practices of self-medication, overprescribing, and incomplete treatment courses, raising concerns about antimicrobial resistance.

Most participants (75.7%) reported disposing of unused and expired medications. This finding is consistent with studies conducted in Addis Ababa (69.2%)²⁹ and Mekele (77.3%).³⁷ However, it is lower than from Indonesia (82.1%)¹⁴ but higher than from different settings in Ethiopia, including Gondar (60.4%),²¹ Arba Minch (60.0%),²² Adigrat (63.0%),²³ and Harar (53.2%).³¹ The disposal practices varied by medication status (unused or expired). Of these participants, 53.3% stored unused medications at home until expiry, 23.3% discarded them in household garbage, and 15.4% flushed them down the toilet or sink. Regarding expired medications, 70.4% discarded them through household garbage, and 13.1% flushed them down the toilet or sink. It is higher than findings from Harar (50.0%)³¹ and Saudi Arabia (48.1%).⁴³ This variation may be due to limited public awareness, inadequate counseling, and the absence of structured medication take-back systems.

Only, 9.2% of participants returned expired medications to pharmacies or healthcare facilities, indicating weak implementation of drug take-back programs and gaps in public health education. This proportion is significantly lower than reports from Malaysia (27.0%),⁴⁰ Sweden (43.0%),⁴⁴ and Bangladesh (21.0%).⁴⁵ This discrepancy is likely due to the variation in infrastructure and public systems. Despite regulatory recommendations advocating take-back systems, returning to a nearby pharmacies, and appropriate household disposal methods, such practices remain uncommon in Bahir Dar City and in other studies in Indonesia,⁴⁶ Tanzania,⁴² and Kuwait.⁴⁷ Improper disposal may increase medication wastage and compromise quality of care, particularly in resource-limited settings.⁴⁸

In the multivariable logistic regression analysis, age, educational status, health insurance coverage, knowledge, and attitude were significantly associated with good disposal practices of unused and expired medications. Participants aged 35 years and above were around seven times (AOR = 7.14, 95% CI: 1.29-39.67, p = 0.02) more likely to practice good medication disposal than those aged 18-34 years. Those who had attained college-level education or higher were around two times (AOR = 2.14, 95% CI: 1.02-9.20, p = 0.04) more likely to have good disposal practices than those who were illiterate. Similarly, participants with health insurance coverage were nearly three times (AOR = 2.97, 95% CI: 1.03-8.55, p = 0.04) more likely to demonstrate good disposal practices than uninsured participants, consistent with findings from Gondar.²⁸ These results indicate that the influence of sociodemographic and health system factors on good medication disposal practices.

Knowledge and attitude toward unused and expired medication disposal demonstrated strong associations with good disposal practices. Participants with good knowledge were 3.4 times (AOR = 3.41, 95% CI: 1.44-21.49, p = 0.01) more likely to exhibit good disposal practices than those with poor knowledge. Similarly, participants with a positive attitude toward medication disposal were around five times (AOR = 4.65, 95% CI: 1.29-16.76, p = 0.01) more likely to engage in good disposal practices than those with a negative attitude. This indicates that adequate knowledge and a positive attitude play a crucial role in improving good medication disposal practices.

Strengths and limitations

This study has several strengths, including a large sample size and a community-based design that evaluated factors influencing the disposal of unused and expired medications among the general population of Bahir Dar City, thereby enhancing generalizability and providing contextual insight into household knowledge, attitudes, and practices. However, the study has limitations: the cross-sectional design limits temporal and causal inference, potential recall bias may have led to an underestimation, and the findings may not be generalizable to rural populations.

Future research directions

To enhance cause inference and generalizability, community-based studies that include rural populations are recommended, as disposal practice and access to disposal systems may differ from urban settings. In addition, mixed-methods research is needed to evaluate public awareness interventions, medication take-back programs, and context-specific health-system and policy factors influencing good medication disposal.

Conclusions

This study revealed that households in Bahir Dar City had a positive attitude; however, their knowledge and actual disposal practices were poor. Many households stored unused and expired medications at home. Analgesics and antibiotics were the most commonly unused medications at home. Inappropriate storage and disposal methods, such as keeping medications until they expired, throwing them in household garbage, and flushing them, were common. Older age, college or higher level of education, health insurance coverage, good knowledge, and positive attitudes were significantly associated with good disposal practices.

Recommendations

Strengthened public awareness campaigns via mass media and community approaches, the creation of accessible medication take-back systems, and the development and implementation of clear national guidelines and community-based interventions are recommended to improve good disposal practices.

Supplemental material

Supplemental material - Household disposal of unused and expired medications in Bahir Dar City, Northwest Ethiopia: Knowledge, attitudes, practices, and factors associated with good disposal practices

Supplemental material for Household disposal of unused and expired medications in Bahir Dar City, Northwest Ethiopia: Knowledge, attitudes, practices, and factors associated with good disposal practices by Biset Asrade Mekonnen, Tefera Minwagaw Biadigilign, Gizachew Motbaynor Alene and Dagninet Derebe Abie in Sage Open Medicine.

Footnotes

Acknowledgments

The authors extend their deepest gratitude to the data collectors, supervisors, and study participants.

ORCID iDs

Biset Asrade Mekonnen

Tefera Minwagaw Biadigilign

Gizachew Motbaynor Alene

Ethics considerations

This study was approved by the Ethical Review Board of Bahir Dar University, Pharmacy Education and Service Directorate (approval No. SoP4/92/25) and conducted in accordance with the national ethical regulations, institutional policies, and the tenets of the Helsinki Declaration.

Consent to participate

Oral informed consent was obtained from all participants after they were fully informed about the study objectives, procedures, potential benefits, and their right to refuse or withdraw at any time. The use of verbal informed consent was approved by the Institutional Review Board, considering the minimal-risk and community-based nature of the study. For participants with no formal education, the consent information was clearly explained in the local language (Amharic), and the consent statement was read aloud to ensure adequate understanding before verbal informed consent was obtained. Confidentiality was maintained throughout the study.

Author contributions

B.A.M: conceptualization, data curation, formal analysis, preparation of the original draft, revision, review, editing, and approval of its submission. T.M.B: conceptualizations, data curation and formal analysis. G.M.A: data curation, formal analysis, and validation. D.D.A: validation, review, and editing. All authors have agreed on the journal to which the article will be submitted and have given their final approval for publication.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All the data generated or analyzed during this study are included in this article and supplementary files.*

Supplemental material

Supplemental material for this article is available online.

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