Public Awareness Regarding Household Drug Storage, Qassim Region, Saudi Arabia: A Cross-Sectional Study

Introduction

Treatment with medication represents the most used modality in the treatment of diseases. The level of access to medication is the main tool to classify medications as either prescribed or over-the-counter (OTC) medications. In this regard, safety, efficacy, and misuse are the most important and related factors in this classification.¹ The majority of drugs usually kept at home are not only OTC drugs but may also include prescribed drugs, which are either still in current use or are unused prescription drugs. Unused prescription drugs often accumulate in homes and may be misused for recreation, used inappropriately for self-medication due to future ailments, or accidentally ingested.² Antipyretics, pain medications, cough medications, decongestants, antibiotics, and vitamins are the most frequent household-stored medications. OTC medication remains the most commonly used type of medication in the central region of KSA, and the majority are not stored in the recommended conditions or in the original packaging.³ Drug stability is affected by environmental factors such as temperature, air, light, and humidity, which may lead to drug degradation process. The drug degradation has many negative effects on quality and safety of drug and may result in therapeutic activity reduction, which has serious consequences for the patients and organization. It is necessary to follow the storage instructions and guidance provided by manufacturers.^3,4

The availability of OTC drugs, combined with self-medication, potentiates the risk of adverse effects and drug interactions that are not commonly known to the general population.⁵ In Saudi Arabia, up to 81.4% of the general population has been reported to use drugs without a prescription.⁶ OTC drugs are the medicines most frequently used in self-medication. Moreover, all Saudi citizens are provided with free healthcare access and medication by the government, which contributes to the increasing number of unused and additional medications stored in Saudi houses.⁷ However, little information is available about the storage conditions of medicinal products after being dispensed in Saudi Arabia (SA). Moreover, unsafe drug storage under the particularly hot and humid climate of the country may lead to decline in essential performance levels and give rise to negative outcomes.⁸ Therefore, there is an urgent need to explore unused medication storage practices in Saudi Arabia. This cross-sectional study was designed to assess the awareness of household drug storage among the Qassim population.

Materials and Methods

Study Design, Location and Duration

A descriptive, quantitative, and cross-sectional study was conducted in the Qassim region, Saudi Arabia. The data collection was performed over a period of 3 months, from 27th October 2019 to 19th January 2020.

Study Tool

A well-structured self-administered questionnaire, accessible via an electronic link, was created on Google Drive™ using an online survey creator. The questionnaire Questions are designed with the help of reviewing previous literatures in the same discipline.^6,7,14 The questionnaire (as shown in the Appendix) was divided into four sections as follows: sociodemographic data (7 multiple-choice questions), household drug storage conditions (6 multiple-choice questions), storage behaviors (4 multiple-choice questions) and, finally, the last question regarding drug information sources. Since Arabic is the native language for most of the Qassim population, the questions were initially developed in English and then translated into simplified Arabic. The questionnaire were validated by five academicians in the pharmacy practice specialty.

Study Participants and Eligibility Criteria

This study targeted all adults in the Qassim region who were capable of using electronic links and storing drugs at home. Residents from outside the Qassim region, those under the age of 18, and those who did not keep drugs at home were excluded from this study. Prior participation and opening the questionnaire questions, the study participants were briefed with aims of study and about data protection guarantee for participants and asked direct question “Do you want to participate in the study?” so, all participants were voluntary participate in this study.

Sample Size and Data Collection

According to the population characteristics survey in 2017, the study targeted the total adult population of 1,074,007 in the Qassim region.⁹ The Cochran equation¹⁰ was applied to estimate the target sample size for representation of this study population, which was 385.

Where n is the sample size, Z is tabulated Z-value associated with the selected level of confidence, p is the population proportion, q = (1-p), and e is the error of estimation (precision). The level of confidence used in this study is 95%. The Z value associated with 95% of confidence is 1.96. The actual value of p is 50%; thus, q = (1–0.5) = 0.5. In this study, the error of estimation was 5%. Because the population of Qassim region more than one million, then we added 7% (≈27 persons) to the calculated sample extra to manage incomplete responses. Hence, the sample size for this study should not be less than 411 persons.

The data were collected using a well-structured and self-administered questionnaire via an electronic link distributed through social media applications such as WhatsApp, Telegram, Twitter, and Instagram using a simple random sampling method.

Data Analysis

Questionnaire responses were exported into an Excel spreadsheet for variable coding before being entered into the statistical package (SPSS 23.0). Storage behaviors were scored to differentiate between acceptable safe behavior (1 point) and non-acceptable unsafe behavior (0 point). Frequencies and percentages were used to present descriptive data. The statistical association between participants’ sociodemographic data and the presence of household drug storing behavior was tested using the Chi-square test. In addition, t-test, one-way ANOVA, and multiple comparison LSD test were used if necessary to investigate the significance of mean differences in various participant sociodemographic groups when p-value less than 0.05.

Ethical Approval

The ethical approval was obtained from Committee of Research Ethics at Qassim University, Saudi Arabia (reference number 19-03-03).

Results

Sociodemographic Characteristics of Participants

Of the 634 study participants, 604 (95%) stored drugs at home. The majority were Saudi (580 (95%)), female (510 (84%)), aged between 31 and 45 years (275 (45.5%)), highly educated (432 (71.6%)), and with 6–9 family members (317 (53%)). Most (415 (69%)) had a health practitioner/s in their family. Moreover, nearly half of them (285 (47%)) had 1–3 chronic illnesses in the household (Table 1). The number of drugs stored at home was heavily influenced by the number of family members in general and the number of members with medical issues in particular. The study found that no statistically significant associations between participants’ sociodemographic data and the household drug-storing behavior (p > 0.05; chi-squared test, as shown in Table S1).

Table 1 Sociodemographic Characteristics of Participants (N = 604)

The number of family members significantly affects the number of stored drugs at home (p = 0.003; ANOVA test, as shown in Table S2).

Saudi participants had statistically significantly higher storage behavioral scores than non-Saudi participants (p = 0.002; t-test). Moreover, female participants had statistically significantly higher storage behavioral scores than male participants (p < 0.001; t-test). A highly significant difference was observed between participants’ educational levels regarding storage behavior scores (p = 0.001; ANOVA test), particularly for participants with a bachelor’s degree, who had the most significant mean difference compared to the non-educated participants (p < 0.05; Multiple Comparison LSD). Furthermore, the number of family members with chronic diseases significantly affects the storage behavioral score (p < 0.001; ANOVA test). The participants without chronic diseases behaved more appropriately than participants with more than 3 chronic diseases (p < 0.001; Multiple Comparison LSD). Unexpectedly, the presence of a health practitioner in the family was not found to affect the household storage behaviors (p > 0.05; t-test).

Household Drug Storage Conditions

Approximately half of the participants (45.7%) kept 1–5 drugs at home, mostly for personal use (45%). Analgesics and antipyretics were the most commonly stored drugs (71.9%), followed by antidiabetics (11.6%). The most commonly stored dosage forms are tablets and capsules (72.3%). The refrigerator was the most popular location for storing household drugs (54.6%) followed by bedrooms (17.7%) and home pharmacies (15.5%). Unfortunately, only 10% of participants kept their medications in secure locations.

Public Behaviors Regarding Household Drug Storage

Almost half of the participants (45%) always checked the expiry dates of stored drugs on a regular basis, always based on the storage instructions written in leaflets for 40% of them. Almost all (90%) immediately discarded the drug if it had expired or if its color or appearance had changed (93%). The majority of participants (68%) always followed drug usage instructions written in leaflets or prescriptions, and nearly half (49%) occasionally shared drugs with family members or relatives (Table 2).

Table 2 Participants’ Behaviors Concerning Household Drugs (N = 604)

Public Drug Information Sources

Doctor counseling (52.1%) followed by pharmacist counseling (18.4%) were the most reliable sources of information for the participants.

Discussion

In this study, the overall prevalence of household drug storage was 95%. Our finding was echoed by many previous studies, including those conducted in Punjab (100%),¹¹ Cebu City (97.03%),¹² Sudan (97.7%),¹³ and Western India (93.75%).⁵ However, the result is in contrast to a study conducted in Saudi Arabia, in which a lower prevalence (77.66%) was reported.¹⁴ In some studies, conducted in the UAE¹⁵ and Cebu City,¹² self-administration was found to be the preferred method.

The location of drug storage at home is crucial, as storing drugs in inappropriate places at home can lead to accelerated degradation, health risks to children resulting from accessibility, and resource waste. In this study, the refrigerator was the primary location for the storage of household drugs. Similar results have been well established by previous studies in the area of drug storage.^7,13 However, other studies reported that other locations for drug storage, such as home cabinets, were the most preferred.³

The reasonable number of drugs being stored in Saudi Arabia may be that governmental regulations restrict the dispensing of drugs to governmental hospitals and a limited number of pharmacies due to the recently approved “Wasfaty program”.¹⁶ In our study, almost half of the participants (45%) always checked drug expiry dates before their use, the majority (90%) immediately discarded expired drugs, and nearly all (93%) immediately discarded drugs if the color or appearance had changed, indicating a high level of public awareness about safe storage behaviors for household drugs in the Qassim region. Comparable results have been reported in several studies regarding the checking of drug expiry dates^{13–15,17,18} and the disposal of expired drugs.¹⁵

Notably, medications are prescribed for specific individuals and conditions. Therefore, the sharing of household drugs may be considered risky behavior. Although diseases can cause similar symptoms, a medication that works for one person may not work for another with similar symptoms, due to many variables, including patient weight and age, the presence of allergies and pre-existing diseases, and potential interactions with other medications.¹⁹

In the present study, doctor counseling (52.1%) was the most reliable source of drug information, followed by pharmacist counseling (18.4%), reflecting the growing rate of public trust and the dependability of health-care providers, a nearby finding that has been previously reported in a Sudanese study.¹³

This study has several limitations as it is a cross-sectional and the results represent only specific time. Also, the study was conducted among population in Qassim region with relatively acceptable sample size and the results were comparable to the results of other studies; however, the sample was unrepresentative of the entire population of the country. Depending on online responses has largely affected the responses from several important categories, such as non-Saudi residents, low-grade or non–educated population and the male gender population as well.

Conclusions

In conclusion, the results revealed that the majority of participants kept drugs in the refrigerator or other easily accessible places, which could lead to toxicity or health risks, particularly for children. Awareness public campaigns should be initiated concerning the safety measures of keeping drugs at home. Therefore, health practitioners should play a positive role in their families and communities, spreading awareness about the impact of drug storage conditions on their stability and efficacy as well as raising public awareness about drug safety. In addition, further care for chronically ill populations is required to protect them from health hazards. Addressing “HOW” the household drugs were discarded is recommended for coming studies.