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4. Literature review

4.1 Introduction
Literature review according to Degu and Yigzaw (2006) is an objective and critical summary of published research literature that is relevant to a topic that the researcher is interested in it. It then assist the researcher to identify what has been done and reported on the research problem and this section will then look at the available literature related to the proposed study.

4.2 Health care waste (HCW)
Health care commodities are all goods that are used during the provision of health care and these include medicines, sharps, bandages, gauze swaps etc. When these commodities are used or expired after the provision of such care they then form part of Health Care Waste (HCW) which is all waste that is produced due to rendering of patient care in clinics, hospitals, manufacturing plants for pharmaceuticals, home settings etc. (Hangulu and Akintola, 2017). HCW can be classified accordingly due to its nature as depicted in the table below.

Type of waste Description and examples
Infectious waste All waste that which contain pathogens which has been in contact with infected patients and excreta or body fluids and has the potential to cause infections for example, soiled bandages,wound dressing, swabs, gloves.
Pathological waste Human tissues or fluids, e.g. body parts; blood and other body fluids; fetuses; sharps waste, e.g. needles; infusion sets; scalpels; knives; blades; broken glass
Sharps waste This is waste that consists of used or unused sharps such as needles, auto disable syringes, insulin syringes with attached needles, infusion sets, scalpels, knives, blades and broken glass
Pharmaceutical waste Waste containing pharmaceuticals that are expired or no unwanted needed such as liquids, tablets ointments, vaccines
Cytotoxic waste Waste containing substances with genotoxic properties such as cytostatic drugs that are often used in cancer therapy
Chemical waste Waste containing chemical substance such as solvents and reagents used for laboratory preparations
Radioactive waste Waste which is radioactive in nature such as unused radiotherapy liquids and other radioactive diagnostic material
Table 1: The various types of healthcare waste (sourced from WHO, 2018)

World Health Organization (WHO) in 2018 reported that 85% of the total amount of waste produced during provision of healthcare service is general waste such as paper, plastics which thus it is generally non-hazardous and is comparable to household waste thus pose no risk of infections while the remaining 15% is considered hazardous and can cause serious health risk to the public and need to be disposed accordingly in a safe manner that would eliminate the potential risks or threats to the environment and public health..

4.2.1 Pharmaceutical waste
Pharmaceutical waste occurs due to expired, damaged, recalled or unused medicinal products and patients may not use the medications issued to them for various reasons such as side effects, changes in dosages, medication being damaged due to improper storage or medication just expired. Therefore, it is common for patients to have unused or expired medicines in their possession (Seebusen and Edwards, 2006).
Contributing factors to pharmaceutical waste vary and include knowledge of the patients regarding proper use of their prescribed medication. Cultural behaviour scuh as the culture of not want to waste medicine thus people resolving insharing medication with others or keeping it for future use. Healthcare
Reducing medicine wastage and advocating for proper disposal practices is a global issue (Wheeler et al, 2017). In South Africa, generally medicines are allocated the second biggest budget allocation by the National Department of Health, therefore, expired and unused medicines may lead to wastage and fruitless expenditure and this might have dreadful impact on the type of healthcare patients may receive and might impact the entire healthcare system negatively. One of the recommended methods of disposing obsolete medicines in many countries is to return them to healthcare facilities for proper disposal (Tong et al, 2011) yet people still do dispose medicines improperly. A study conducted by Seebusen and Edwards in 2006 found that 50% of their study population stored unused and expired medicines in their homes while more than half flushed them down the toilet with only 22.9% returned them to healthcare facilities for safe disposal. In South African perspective, only 2.5% were returned to pharmacies while 62.5% were thrown in a bin with 6.5% and 17% flushed them sink and toilet respectively (Amod et al, 2008). These studies show consistencies globally that despite policies and laws being in place, there is still considerable amount of the population that do not dispose health commodities properly and it need further research to guide policymakers about challenges of the population when it comes to safe disposal of medicines. Furthermore, it has been found that household’s knowledge on disposal practices of unused pharmaceuticals was very weak and this was attributed as a result of poor or non-existence of public outreach and awareness campaigns, poor provision of disposal guidance to the patients by health professionals and unclear disposal instructions on patient leaflet forms as well as negligence by patients to read contents of their medication (Angi’enda S.A. and Bukachi S.A., 2016)
4.2.2 Insulin therapy waste
Medical waste includes sharps such as insulin syringes, gauze, swabs and soiled bandages (Makhura et al, 2016). The use of insulin syringes, lancets and test strips in home settings has increased globally due to an increase in insulin dependent type-2 diabetes and 90% of diabetics has type of diabetes thus rely on insulin injection to control their sugar levels and the estimated prevalence of insulin dependent diabetes is will be 5.4% by 2025 (Singh and Chapman, 2011). Therefore, insulin therapy is very essential in proper management of this form of diabetes and is mostly done in home settings and resulting in production of insulin therapy waste such as needles, syringes, lancets, cotton wool (da Cunha et al, 2017) and proper disposal of insulin waste is therefore crucial yet it is often neglected (Mekuria et al, 2016). Literature reveals that insulin therapy waste are frequently disposed improperly in the communities especially in developing countries such as India, Brazil, South Africa etc. Studies conducted in India by Singh and Chapman (2011) found that 84.1% of the respondents discarded their sharps in household bins. While 57.1% did the same in Brazil (da Cunha et al, 2017). In Ethopia 80.7% of participants had poor practice of disposing their used needles and they popular disposing trends were toilet (40%), garbage (36%), burried under ground (20.5%) and burned (3.5%) (Mekuria et al, 2016). In South Africa, even though studies are limited, Govender and Ross in 2012 found that a significant number of patients in their study population discarded their insulin syringes inappropriately. Other studies show that they used general household waste items like empty milk carton, envelopes, soap packets, jars to dispose used insulin syringes (Oluwokure et al, 2003). These studies show consistencies globaly that used insulin syringes are disposed improperly but the manner in which people dispose their used insulin syringes varies, therefore, improper disposal practices of insulin syringes is a global challenge that need to be researched and addressed constantly.

4.3 Impact of improper handling of obsoletes health care commodities
Health commodities have a very important role in disease prevention and treatment both in humans and animals but their waste might have unintended effects on humans and the environment hence proper handling and their management is very important (Boxall, 2004). Handling of HCW globally poses a threat to both public and environmental health when not handled accordingly and most literature is available for about the handling of HCW in healthcare facilities while very few literature for home settings even though home settings are not capacitated to handle HCW. It has been found that handling HCW is a challenge particularly in developing countries where there might not have enough resources, lack policies for handling of waste and lack of finances for latest technologies of handling HCW (Hangulu and Akintola, 2017). Improper disposed insulin syringes and needles can lead to needle prick injuries and this might lead to transmission of blood-borne diseases such HIV, hepatitis B (Govender and Ross, 2012) therefore, poor disposal of HCW can have a negative effect on healthcare workers, waste pickers, general public, patient caregivers, animals as well as the environment.
Pharmaceutical waste enters the environment in various routes (as shown in figure 1 below) and these include human and animal excretion (urination/defecation), washing off directly from skin in case of ointments and creams, improper disposal practices such as throwing pharmaceuticals down the drain, agricultural use where they are used for germination of seeds etc. (Boxall, 2004). Literature reveals that among the most popular ways of disposing pharmaceutical waste in home settings is through throwing them in garbage, flushing them down the toilet or sink, retuning them to healthcare facilities (Wheeler et al, 2017; Tong et al, 2011, Amod et al, 2008 and Seebusen and Edwards, 2006). Improper disposal of medicines through garbage or down the toilets end up in landfills and sewage system and the latter is not equipped to remove medication thus this might have negative environmental impact (Wheeler et al, 2017). Medicines or their metabolites have been traced in ground, surface and drinking water as the result of improper disposal and even though these has been detected in low levels but long-term exposure to them can affect the health of individuals (Seebusen and Edwards, 2006). Improper disposal has impact not just on human beings, for example, renal failure can be induced in vultures who ingest water or faeces contaminated with diclofenac, a commonly used pain and inflammation medication that is available without a prescription in South Africa (Tong et al, 2011) and this can reduce the life expectancy of the species. Furthermore, traces of antibiotics have also been detected in waters and soil and such exposure can result in formation of resistant microorganism thus posing a serious threat to human and animal health in the future (Boxall, 2004).
Figure 1: Route of pharmaceuticals entering the environment (source: Boxall A.B., 2004)
4.4 Knowledge, Attitudes and Practice (KAP) towards disposal of health commodities in home settings
Knowledge, attitudes and practice (KAP) of population plays a role in improving disposal of obsolete health commodities in home settings, therefore assessment of knowledge among communities should be made and gaps identified be addressed accordingly. In india for example, it was found that sociodemographic factors and diabetes management characteristics was associated significantly with high level of knowledge in household disposal practice of obsolete health commodities (Singh and Chapman, 2011). Also, a study in Brazil found that patients who have been educated about safe disposal were likely to dispose their waste properly than those who did not receive any disposal education (da Cunha et al, 2016). However, another study found that despite patients being provided with education about proper disposal of insulin needles, some patients might not perceive the severity of the adverse outcome in order to change their needle disposal behavior (Musselman et al, 2010). These studies contradict thus more studies maybe required to clarify such contradictions. Furthermore, literature reveals that barriers to safe disposal are lack of information about how and where to dispose, lack of proper advice from healthcare practitioners, wrong perception on disposal (Mekuria, 2016).

4.5 Legislation and guidelines on disposal of health care commodities
Disposal of HCW is regulated globally yet studies still show that obsolete health commodities are still not disposed properly. In New York for example, fines are imposed for individuals who do not dispose HCW correctly yet people still dispose commodities improperly as the imposed fines and enforcement is relatively low (Musselman et al, 2010). In South Africa, the Constitution protects it citizens against improper disposal of obsolete health commodities and states clearly that everyone’s has the right to an environment that is not harmful to their health and well-being (du Toit and Bodenstein, 2013). Furthermore, there is the National Environmental Management Act of 1998 that protect the environment from harm including the improper disposal of obsolete health commodities where it states that the polluter must take measures to prevent pollution through proper disposal of such obsolete health commodities. Then, there is the National Health Act of 61 of 2003 which compels the Health Minster to come up with regulations regarding medical waste including handling in home settings. As the result, there are guidelines that are developed by the NDOH to give guidance regarding disposal of HCW. Departmental programmes and campaigns are part of those guidelines that encourage patients to bring back obsolete health commodities to health care institutions for safe and proper disposal (Hangulu and Akintola, 2017). The knowledge, attitudes and practice of the population towards HCW disposal still need studied and new measures developed that would minimize improper waste disposal practices. Despite, guidelines being in place for example, hospitals have policy and health education material in place for patients to return their obsolete commodities to health care facilities, yet these commodities are still handled improperly. Therefore, the reasons for continued improper disposal practice need to be continually investigated to determine challenges and this will assist policy makers to review existing guidelines and policies so that this assist the handlinging of HCW.

4.6 Conclusion
The practice of disposing HCW is a global phenomenon and impact environmental and public health. In South Africa, the Constitution states that everyone has the right to an environment that is not harmful to their health and well-being but the illegal dumping of hazardous obsolete health commodities poses a danger to public health and the environment when pollutants migrate into water sources and ultimately cause widespread infection and toxicity (du Toit and Bodenstein, 2013). Therefore, public health practioners still need to research why this practice is not eradicated as its impact has been widely studied and if this practice is not address, its environmental and public health risks will be increased and will have dire health and consequently financial implications. Research has been conducted around globe about disposal of medicines in house holds and throwing them down the drain and throwing them in garbage have been popular (Wheeler et al, 2017). The National Department of health and the Environmental department have programmes and policies encouraging the ordinary South Africans about safe disposal of HCW even encougares the public to bring their medical waste to healthcare facilities, yet this is still not happening. Therefore, there is still the need to study the knowledge, attitudes and practice of improper disposal of HCW in households so that interventions can be devised to curb such practice.