My role: Conducted literature reviews, created qualitative and quantitative questionnaires, recruited research participants, facilitated a focus group discussion and in-depth interviews, analyzed qualitative and quantitative data, and brainstormed design solutions and recommendations.
Background
The wide availability and improper disposal of unused prescription medications have been implicated in negative health and environmental outcomes, including increased risk of medication abuse, accidental poisoning, and high levels of pharmaceutical traces in fresh and marine waters.
Figure 2: Medicine Bottles Clipart
The National Community Pharmacists Association found that up to 40% of prescription medications end up being unused and tend to be stored unsafely at homes. This has been linked to an increased risk of medication abuse and accidental poisoning incidents, especially among children and pets (Buffington et al., 2019; Wu & Juurlink, 2014; Schäfer et al., 2021). Improper disposal of medications can contribute to environmental pollution since medications disposed of in landfills can leach into the groundwater, and pharmaceutical traces can be resistant to water treatment plants, ultimately resulting in contaminated waterways (Ehrhart et al., 2020).
Take-back events and permanent disposal boxes have yielded minor effects, and the low adoption rates of current proper disposal methods point to the need for innovative solutions.
The Challenge
How might we make the proper medication disposal processes more accessible and user-friendly for the public?
Looking further into the factors that contribute to the low uptake of current proper medication disposal programs, the team hoped to find novel design interventions that can be incorporated to eliminate the barriers.
Objectives
• Understand the contributing factors for improper medication disposal
• Examine barriers to adopting current proper disposal methods
• Identify design implications for improving adoption rates to minimize the negative effects of improper medication disposal.
Research and Design tools
Figma | Adobe CC (InDesign, Photoshop, Premiere Rush) | Miro | Python | R | SPSS | Qualtrics | Zoom
Design Process
Understand the user
Methods
The study combined qualitative (focus groups and in-depth interviews) and quantitative (survey) research methods to get a holistic picture and deep understanding of the issue.
The survey allowed the research team to collect data from different demographic groups and gain a general understanding of the problem.
Focus group interviews were conducted to gain an understanding of the issue, as well as discover the roots of frustration that come with the process of safe medication disposal. It allowed the team to obtain underlying motives and explore possible solutions to making take-back programs more effective.
The interviews with pharmacists mostly focused on assessing their role in educating the general public on safe medication disposal, experiences related to disseminating safe medication disposal information, and the effectiveness of current medication take-back programs.
Figure 2: Research methods
Participants
Participants for the survey were residents of the United States, between the ages of 18 and 54.
For the team to understand if there is a difference in participant views on medication disposal practices based on the presence of children in the households, one focus group included members of the households with children, while the other one included participants without children.
Participants in the in-depth interviews included pharmacists who work at pharmaceutical retail stores. A subset of the pharmacists interviewed work in pharmacies that participate in medication take-back programs.
Procedure
A survey was launched to learn current practices of disposing of unused and expired prescription or over-the-counter medications and identify pain points. A small pilot study helped to test and fine-tune the survey before sharing it with the public. The survey was created in Qualtrics and included 26 sections with branching logic.
A total of 84 responses were received, 24 of which were discarded due to incomplete responses or not meeting eligibility requirements. The total time to complete the survey was 10-12 min.
Balancing between feasibility, practicality, and a representative sample, the study collected data using convenience sampling by collecting information from a population that is close to hand. However, to ensure that data also included responses from different age and gender groups, the team monitored responses as they came and supplemented convenience sampling with purposive cluster sampling by targeting specific clusters of respondents.
Focus group discussions and in-depth interviews took place virtually and were recorded via Zoom. Focus group discussions lasted about one hour, and the in-depth interviews lasted 20-30 minutes.
Data Analysis
Quantitative and qualitative analyses were conducted to comprehensively understand participants’ behavior.
R, Python, and SPSS statistical computing/programming languages and software were used to clean and analyze survey data.
After transcribing and reviewing data from the qualitative semi-structured interviews and focus groups, the team used the Miro collaboration tool to create affinity diagrams to identify central themes and categories.
Data collection and analysis video
The Discovery
Quantitative Results
Statistical analysis was conducted on the final sample of 60 respondents. The majority of respondents were between the ages of 25 and 34 (55%), identified as female (73%), and had at least a bachelor’s degree (88%). The participants were distributed almost evenly between single/never married and married/domestic partnership.
More than 80% of respondents reported having excess unused medication at home with 30% of them having over 6 medications currently stored.
Assessment of practice
discovery 01: The majority of respondents who endorsed storing excess/unused medications at home reported saving leftover medications because they believed they might need them in the future or because they took the medication until they felt better (Figure 3).
Figure 3: Reasons for unused medications
Methods of disposing of unused medications
discovery 02: The most commonly reported methods of disposing of the different types of medications (i.e., pills, liquids, creams, aerosols) were "keeping" or "throwing in the trash" for all types, with the exception of liquids which were most commonly flushed down the drain (Figure 4).
Figure 4: Different methods of disposing of unused medications
Assessing the knowledge of available take-back programs
discovery 03: 63% of respondents had never heard of take-back programs before participating in this study and only 23 % participated in the programs before.
Those who were aware of them but never participated in the programs (13 %) preferred to keep medications at hand or had limited knowledge of the drop-off areas' location and timing.
Figure 5: Knowledge of available take-back programs
Information sources/outlets and preferred methods
discovery 04: By comparing what information sources and outlets are currently being used to inform the public vs. what respondents prefer, it was interesting to unveil a mismatch between supply and demand.
While information can be found on the internet and on medication packaging, respondents prefer getting information and reminders from the provider/doctor's office or having it delivered directly to their inboxes (Figure 6).
Figure 6: Participant reported current practices vs. preferences
Preferred ways to dispose of prescription (Rx) and over-the-counter (OTC) medications
discovery 05: 43% of respondents reported that Rx and OTC medications should be treated the same way, and the most frequently endorsed optimal methods for disposal were take-back programs and throwing medications in the trash.
However, more than half of respondents reported that Rx medications should always or sometimes be treated differently from OTC medications, and the most frequently endorsed optimal method was take-back programs.
Despite the similar tendency to recognize that returning OTC and Rx medications to a take-back program is the best method to dispose of them, fewer respondents claimed they would return OTC medications to a take-back program compared to Rx medications, as they perceive that OTC medications may be handled more freely and relaxed than Rx medications.
Figure 7: Reported preferred ways to dispose of prescription (Rx) and over-the-counter (OTC) medications
Qualitative Results
Most common medication disposal practices:
• Throwing away in the trash
• Pouring liquids down the sink or flushing in the toilet
• Not disposing/storing them at home
• Taking expired meds to the pharmacy to dispose of in the disposal boxes
• Giving medicine to close friends or family
• Throwing away in the trash
• Pouring liquids down the sink or flushing in the toilet
• Not disposing/storing them at home
• Taking expired meds to the pharmacy to dispose of in the disposal boxes
• Giving medicine to close friends or family
Pharmacies’ role in sharing information on proper medication disposal with customers:
• Pharmacists are currently the main source of information on proper medication disposal
• Provision of information depends on the type of pharmacy (mandatory for specialty and upon request for compounding and retail pharmacies)
• Directing customers to disposal locations (kiosks or the police department for controlled drugs)
Reasons for low participation in safe med. disposal programs:
• Lack of public awareness of:
a. the environmental impact of improper prescription disposal
b. take-back programs, participation procedures
c. locations of disposal kiosks
• Low availability of disposal kiosks
• Issue of convenience and disposal locations
• Lack of incentives
• The possibility of needing the medication in the future
a. the environmental impact of improper prescription disposal
b. take-back programs, participation procedures
c. locations of disposal kiosks
• Low availability of disposal kiosks
• Issue of convenience and disposal locations
• Lack of incentives
• The possibility of needing the medication in the future
Feelings and emotions around currently available disposal mechanisms:
• Inconvenience
• Confusion
• Repulsion (by the idea of going to police departments where disposal kiosks for controlled drugs are located)
As research findings confirm, the wide availability of excess and unused medications remains very high. Two significant gaps were identified that can be targeted for better uptake of existing proper medication disposal methods:
1. Gap between awareness and action. Respondents were unaware of the dangers of keeping excess medication at hand nor of the proper ways of disposing of them. Even when aware, participants reported limited knowledge of take-back program locations as well as the appropriate medications to take.
2. Gap between current information dissemination practices and participant-reported preferences. Research participants indicated that they do not necessarily want to seek information, but rather prefer accessing it at point-of-contact (e.g., annual visit checkup, pharmacy pick-up, etc.) and via targeted emails. Incorporating patient preferences when implementing outreach programs is likely to bridge the gaps in awareness and practice.
IdeatE
Proposed solutions to close the gaps combine strategies of different levels and problem areas, including education, policy changes, and motivation that can translate awareness into meaningful action.
• Education/awareness campaigns: Provide more information and raise awareness about the issue, its consequences, and potential solutions.
• Policy changes: Implement regulations and policies that encourage or require action on a societal level.
• Motivation: Leveraging the psychology of reward and value, strategically and meaningfully using reward systems, discounts, and other incentives to influence behavior effectively.
• Personal responsibility: Promoting the idea that individuals can make a difference through their everyday choices and actions.
• Personal responsibility: Promoting the idea that individuals can make a difference through their everyday choices and actions.
Suggestions for promoting safe medication disposal practices and changing public behavior
01: Availability of medication drop boxes
Expand the availability of drop boxes and place disposal kiosks in convenient locations with high-volume traffic.
02: Instructions on the medication bottles and boxes
Add a section on the labels and containers on proper disposal of medications.
03: Incentives/discounts/rewards
Offer financial rewards and coupons to be used at pharmacies.
04: Pickup programs
Offer a pick-up service to visit homes and neighborhoods to collect expired medications.
05: Medication disposal information
Providing information on proper medication disposal should become a requirement. Pharmacies, insurance companies, and doctor's offices should become more proactive in educating on proper medication disposal.
06: Education on proper medication disposal
Educate the public about the dangerous consequences of improper disposal. Integrate education on proper medication disposal into school programs.
07: Medication take-back events
Promote community/public events for medication take-back programs. Post flyers on proper medication disposal mechanisms and through media inform and persuade.
08: Mobile application to guide
Through the mobile application, the users will receive information on proper medication disposal and notifications on the medication expiration dates, easily access the list of nearby medication drop boxes, locate them on the map, etc.
Evaluate
A number of design recommendations and solutions were extracted from this research to inform outreach programs and increase awareness and participation. The design solutions were further discussed with the pharmacist to gather stakeholder perspectives and feedback on each of the solutions. Further research is required to evaluate the feasibility and effectiveness of each approach.
recommendation 01: Expand the quantity and types of sites that offer take-back boxes to make it more convenient for patients to dispose of unused medications. This includes grocery stores and urgent care clinics.
feedback: This approach can be very effective, especially if it includes language and signage that makes it easy to understand and addresses language barriers.
recommendation 02: Add instructions and information on medication disposal on the medication bottles and boxes.
feedback: This might not be very feasible as space is very limited and is usually primed for law-mandated information.
recommendation 03: Offer financial incentives, discounts, and rewards that patients can redeem at pharmacies to act as a motivator for changing the public's behavior.
feedback: This has the potential to be a good starting point for increasing awareness of take-back programs among the general public. However, it cannot serve as a long-term solution, in the same way the practice of offering coupons, for example, for flu shots works, as coupons usually have short expiration dates.
recommendation 04: Expand pickup programs and offer a pick-up service to collect expired prescriptions.
feedback: This can serve as a good option for the public and especially for patients with disabilities and home-bound patients. Individuals involved in the pick-up process should be thoroughly trained to abide by HIPAA rules and regulations. However, this will require considerable financial and logistical input.
recommendations 05 & 06: Providing information on proper medication disposal should become a requirement and be included in the school programs.
feedback: Ensuring that pharmacists and provider's offices are well-versed in proper medication disposal methods is key. Pharmacists can also be invited to schools to educate and spread awareness on this topic.
recommendation 07: Promote community/public events for medication take-back programs. Increasing educational opportunities via advertisements is one of the most powerful strategies to increase awareness of drug disposal safety.
feedback: Using banners and signs that provide information on proper medication disposal methods in pharmacies, hospitals, and doctors' offices, as well as widely advertise National Prescription Drug Take Back Day to provide a safe, convenient, and responsible way to dispose of medications can be a very effective method and will likely increase turnout numbers. This will require resources and organization.
recommendation 08: Design an app for reminders and guidance on proper medication disposal steps.
feedback: A digital tool, such as a mobile application to notify users when the purchased medication expires, offer a list of nearby disposal locations, and provide a disposal guidance chart about the proper disposal methods, has the potential to succeed, especially if the application is integrated with the patient’s pharmacy system for more accurate information on the expiration date. This may be a preferred option for younger patients.
Conclusion
The purpose of this study was to understand factors that contribute to improper medication disposal and identify design solutions that can improve proper medication disposal processes and make it more accessible and user-friendly for the public. Based on the analysis results, it was conceived that improper medication disposal is mainly due to the lack of awareness of the take-back programs that some pharmacies provide. It was also concluded that the take-back programs are not widely available and are in inconvenient locations. A range of user-centered design recommendations were presented from incorporating incentives to increasing the availability of take-back boxes, from creating a mobile application to widely promoting and educating the public.
Future research should thoroughly assess the feasibility and effectiveness of each design recommendation in a well-represented sample. It is important to continue furthering our understanding of improper medication disposal practices to create effective solutions and improve the state of people's health and the environment.
Lessons Learned
Conducting pilot testing of questionnaires to identify and eliminate ambiguities was very important in checking potential inaccuracies and finalizing the surveys. However, during analysis when thinking about potential relationships between different data points, limitations surfaced regarding the range of analyses feasible due to the data types. As a result, our conclusions and results from the quantitative data were not as rich as they could have been. This reminded us of the importance of planning for the required data types and desired analyses during the questionnaire drafting phase.
References
[1] Buffington, D. E., Lozicki, A., Alfieri, T., & Bond, T. C. (2019). Understanding factors that contribute to the disposal of unused opioid medication. Journal of Pain Research, 12, 725–732.
[2] Ehrhart, A. L., Granek, E. F., Nielsen-Pincus, M., & Horn, D. A. (2020). Leftover drug disposal: Customer behavior, pharmacist recommendations, and obstacles to drug take-back box implementation. Waste Management, 118, 416–425.
[3] Schäfer, W. L. A., Johnson, J. K., Wafford, Q. E., Plummer, S. G., & Stulberg, J. J. (2021). Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions. The American Journal of Drug and Alcohol Abuse, 47(5), 548–558.
[4] Wu, P. E., & Juurlink, D. N. (2014). Unused prescription drugs should not be treated like leftovers. CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 186(11), 815–816.
