Journal of health research in community

Introduction
Introduction: Due to their impacts on household health, the storage of surplus medicines in homes requires special attention and should be optimized based on demographic and cultural factors.  The presence of surplus medicines in homes is a major worldwide problem that can lead to children poisoning, an increase in expired pharmaceutical wastes, and environmental pollution. Several challenges, including non-adherence to treatment, irrational or excessive prescribing, changes in treatment processes, patients’ early recovery, transfer to a hospital, or death are the main causes of excess household medications.  These medications ultimately contribute to the production of pharmaceutical waste in the health sector. Identifying these problems and implementing appropriate solutions can improve public health, reduce associated environmental risks, and decrease pharmaceutical waste. The aim of this study was to classify and economically evaluate surplus medicines stored in homes in Tehran in 2023. 

Methods
This descriptive-analytic, cross-sectional study included households living in selected areas of Tehran, which were selected purposively.  Data were collected using a validated researcher-made questionnaire whose questions were based on the relevant literature. The validity of the tool was determined using the content validity ratio (CVR) and content validity index (CVI). To determine the CVR using the Lawshe method, the questionnaire was sent to 15 experts in pharmacy, environmental health engineering, biostatistics, and epidemiology. The reliability of the collected data was assessed using Cronbach’s alpha coefficient. Based on Cochran›s method, the sample size was calculated as 384 households; however, 437 households were included in the study. To account for possible dropouts during the study and questionnaire completion, the sample size was increased by approximately 30%.
 The questionnaire, which contained the desired questions, was completed by the project implementer with the assistance of 510 heads of households selected for this study. Seventy-three questionnaires were incomplete or contained problems and were excluded from the study, leaving 437 heads of households for evaluation, with a response rate of 86% percent. In some cases, citizens were accessed in coordination and cooperation with the municipality, after obtaining permits and holding briefing sessions; in other cases, coordination was conducted with the officials of the boards of directors of residential complexes. 
In many cases, with the consent of the head of the household, surplus medicines in citizens’ homes, including medicines with and without an expiration date, were collected in a mixed form and then examined to determine their quantity, classification, and economic value. 
First, all drugs were divided into two categories: valid and expired. Then, the collected drugs with expiration dates were classified according to the ATC guidelines into different groups, including respiratory, cardiovascular, dermatological, neuropsychiatric, and digestive drugs; antibiotics; and various vitamins and nutritional supplements. The value of each drug in each group was then determined using the Shaygan Safeware (Pharmacy) software, based on the government rates subject to drug subsidies in 2023. 
Data were analyzed using Excel and SPSS software, version 26. Descriptive statistical methods were used to describe the data. 

Results
Among the studied households, 94.1% had surplus medicines at home, and approximately 48.7% of households kept medicines until their expiration dates. Of the surplus medicines, 67.2% were valid and intact, whereas 32.8% were expired and defective. The average value of these medicines per household was estimated at approximately 4.5 million IR of Iranian currency (Rials).
The largest quantities surplus medicines were respiratory, digestive, cardiovascular, and neurological drugs, respectively. According to these results, each family in Tehran kept an average of 361 g of surplus medicines at home. Of these medicines, 67.2 percent had not expired and were intact, whereas 32.8 percent were expired and defective. 
The highest economic values among the surplus medicines were associated with digestive, respiratory, cardiovascular, nutritional and vitamin, and nervous systems drugs (Table 1). 



Conclusion
The supply chain is one of the most important and vital resources, playing significant roles in the economy and national security and in maintaining, providing, and improving societal health. 
Pharmaceutical waste is classified as special and hazardous chemical waste and must be collected, managed, and ultimately disposed of in accordance with specific regulations and guidelines. 
Keeping surplus medicines at home, especially after recovery, was a common behavior in more than 95% of the households under study. These medicines eventually become outdated and contribute to the production of pharmaceutical waste. This issue is influenced by various factors, including the patient’s individual characteristics, the functioning of the healthcare system, and the inappropriate management of the medication cycle. 
Understanding these factors and implementing appropriate strategies can help improve societal health, reduce the risks associated with surplus medicines in homes, decrease citizens’ treatment costs, and reduce healthcare system costs in the country. 
According to the results of this study, it is necessary to improve public awareness and educate people using all modern tools and technologies through an approach based on information and encouragement.  Stakeholders should also revise the guidelines for the procurement, storage, distribution, and use of medicines. These measures can protect environmental resources from threats arising from the improper disposal of medicines and safeguard public health by ensuring compliance with health requirements related to the optimal management of surplus medicines. 
Educational and cultural interventions to promote the proper management of medication use at the household level, as well as reviews of drug-prescribing and sales systems to reduce the amount of surplus medication, should be considered. 

Ethical Considerations
Compliance with ethical guidelines
The study protocol was approved by the Ethics Committee of Baqiyatallah University of Medical Sciences (Code: IR.BMSU.REC.1402.032).

Funding
This article was extracted from a master’s thesis in environmental health, funded by Baqiyatallah University of Medical Sciences.

Authors contributions
All authors contributed equally to study design, data collection, data analysis, and manuscript drafting and approved the final version.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors gratefully acknowledge the cooperation of the Department of Environmental Health, the Vice-Chancellor for Research and Technology, and the Student Research Committee of Baqiyatallah University of Medical Sciences for their cooperation and support.

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