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Practices related to sharps disposal among diabetic patients in Sri Lanka

Practices related to sharps disposal among diabetic patients in Sri Lanka Background: Patients with diabetes on insulin therapy use sharps (e.g., needles) on a regular basis and a consider- able proportion of them, within their home environments. These sharps and other bloodstained materials, if not disposed of appropriately has the potential to be a public health hazard. Objective: Our objective was to explore the practices related to sharps disposal among patients with diabetes from North Colombo Teaching Hospital (CNTH), Ragama, Sri Lanka. Methods: We conducted a cross-sectional study on 158 patients with diabetes from the CNTH. Patients had to use sharps for the daily management of their disease for inclusion into the study group. Data were collected on sharps disposal practices using an interviewer-administered questionnaire. Clinic records were also used as a secondary data source. Results: Most patients, 153/158 (96.8%) used syringes to inject insulin. Forty-three patients (27%) involved others (e.g., family) when disposing of sharps. Used sharps were commonly disposed to the household garbage bin by 66 participants (41.7%). Other methods used for sharps disposal were: sharps container, toilet pit, household garbage dump and indiscriminate measures. Importantly most patients, 147 (93%) had received no information on how to dispose of sharps after usage. Conclusion: Patients commonly used unsafe practices in home-based sharps disposal. These included disposing of in the household garbage bin, burning sharps in the household garbage dump and disposing of into the common garbage dump of the community. Being male and being > 60 years of age was associated with a higher dependence on family members for sharps disposal. Patient education and public resources for sharps handling can help improve this situation. Keywords: Diabetes mellitus, Insulin, Sharps disposal Introduction rapid rise in the number of patients living with diabetes Diabetes mellitus has grown into epidemic propor- in the country is most likely to have increased this num- tions across the world. Sri Lanka too is no exception to ber exponentially. this epidemic and has witnessed significant increases in For many patients living with Diabetes, day to day con- patient numbers throughout the country. At present, the trol and management requires daily blood sugar measure- total number of patients living with Diabetes in Sri Lanka ments and insulin injections. These procedures invariably is estimated to be around 2.8 million—approximately generate sharps within the household as most patients 13% of the population [1, 2]. Though the exact number inject insulin at home. Improper disposal of these sharps of patients using Insulin in Sri Lanka is not known, the has the potential to cause many public health problems [3–6]. These could include personal injury, blood-borne infections via needle stick injuries to others such as fam- ily members, neighbors and sometimes even the public. *Correspondence: sumuduwickramasinghe@gmail.com Centre for Online Health, School of Medicine, University of Queensland, Although the medical waste management and sharps Brisbane, Australia disposal systems are well managed within the hospital Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 2 of 7 settings in Sri Lanka, public health guidelines and public permitted us a month duration to enrol patients and health services for home-based sharp disposal are cur- we were time bound. Therefore we had to complete the rently unavailable. During preliminary scoping of public data collection at the end of the month with the num- health literature and review of published peer-reviewed ber we could collect only. Hence, we were only able to journal articles, we were unsuccessful in identifying pub- collect 158 patients during the collection time that was lished documents guiding proper sharps handling prac- permitted. We did not keep exact records of the number tices for patients in Sri Lanka. of patients who refused participation, but the number of patients refusing to be interviewed was not many (as Objective discussed at research group meetings with the data col- Our objective was to explore the practices related to lectors). At the time the study was designed the primary sharps disposal among diabetic patients from North research question was to identify how patients handled Colombo Teaching Hospital (CNTH), Sri Lanka. sharps and other Insulin-use related factors. Therefore, we have not delved into socio-economic considerations Methods of patients. We assumed that patients might not be able We conducted a cross-sectional study at the diabetes to spend adequate time with data collectors due to the clinic of the CNTH from 15th May 2015 to 15th June busy nature of the clinic and collection of detailed socio- 2015. The CNTH functions routine diabetes clinics and economic and educational data would have necessitated serves many patients daily. We were sampling from the us lengthening the questionnaire. main diabetic clinic. All diabetic patients on monthly Information sheets and consent forms were provided routine review from the hospital were represented at this for patients, and verbal consent was obtained before clinic. interviewing. Type of diabetes and duration of insulin We visited the clinic center at CNTH every working treatment was confirmed by reviewing the clinic records day of the week for one month to interview patients. The with the patient’s permission. An interviewer-admin- study population only included patients who were on istered questionnaire was used to collect information. routine review at the clinic. They were diagnosed of dia - The structured questionnaire was developed using pre- betes and were on routine clinic follow up. These patients identified questions from similar international journal were not acutely ill and were on monthly review to their articles [7, 8]. The issues explored insulin administration diabetic clinic. The patients who were on insulin would practices, equipment used, the frequency of needle use, come routinely every month to collect the free insulin. disposal of insulin syringes and pens, lancet disposal, We only included patients with Type 1 and Type 2 dia- sharing of needles and knowledge about disease spread betes mellitus. Patients with gestational diabetes were by sharing needles. excluded. All the patients had to be users of injectable The questionnaire was pre-tested among a group of insulin for at least a month’s duration. Both females and diabetic patients attending a family practice before the male adult patients of any age were included. study. During pretesting we understood that patients Each daily-clinic we visited served more than 50 have a “primary” method of disposal, i.e., how they ‘ini- patients each day. We selected every 3rd patient starting tially’ disposed of the sharps and a “secondary” mode of from number 1, from the clinic roster, using their ‘on the disposal—i.e., how they ‘ultimately’ got rid of it following day’ clinic number. the first disposal, e.g. the ones who disposed of sharps in In the event, a patient corresponding to the clinic the sharps bin (primary) later dumped the sharps bin to number was not recruitable (not matching inclusion the garbage pits in their homes (secondary). The open- and exclusion criteria, patient in consultation with the ended items in the questionnaire and direct interviews medical officer, the patient with a member of the nursing allowed the respondents to describe their actual needle team or the patient refused participation) we moved on disposal practices including ‘primary’ and ‘secondary’ to the next 3rd number. Some of the patients (every 3rd disposal methods. The pre-trained research assistants selected) were on oral hypoglycemic medication only and (two pre-intern medical doctors) carried out the inter- were excluded from selection. views. They were asked to carry out data collection at We recruited, on average 6 to 8 patients daily. At the the pre-test of the questionnaire, and the data collec- end of 1  month period, we had collected data from 158 tion was found to be consistent and comparable among patients. The number of patients seen daily at the clinic the two data collectors. Also, they were trained to follow was not a constant. In the Sri Lankan context, some the same sequence of questions in collecting data. Patient patients may decide to seek a review in the private sec- response was recorded in written without alteration tor occasionally and for the next visit may come to the by the interviewer to minimise interviewer bias. Daily government clinic for care. The clinic authorities only patient records were collected and kept with a principal Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 3 of 7 investigator (RDN) securely. Hard copy data were saved members when injecting Insulin and 43 (27%) patients into an SPSS database. Descriptive statistics such as also included others in disposing of sharps. proportions, mean ± SD have been used to describe the Commonly generated sharps in the household were data. Analysis of data was done using Chi squared test needles from syringes and needles from Insulin pens. and Fisher’s Exact test at 95% confidence using Statisti - These were disposed of into a typical household garbage cal Package for the Social Sciences-SPSS version 18. Ethi- bin by 66 (41.7%) patients. The other methods used to cal clearance was obtained from the Faculty of Medicine, dispose of sharps were sharps container, toilet pit, com- University of Kelaniya (P/15/02/2014). mon public garbage dump and indiscriminate methods (Table  1). Interestingly 15 (9.5%) of the patients had col- Results lected sharps since the beginning in plastic bags and has At the completion of data collection, 158 patients not got rid of them. Surprisingly when inquired it was had been interviewed. Their ages ranged between found that they had not thought even about a plan of 21 and 90  years of age with a mean age of 59.3  years disposal. (SD ± 10.23). Out of the 158 patients, 121 (76.6%) were Eight patients (5.1%) disposed the sharps into a sharps female. Among the included patients, the mean dura- container inside the home environment but later emp- tion of living with diabetes was 7.4 years (SD ± 5.09), and tied it into the household garbage pit. One patient (0.6%) 155 (98.1%) of them were patients with type 2 diabetes. dumped the sharps container in the typical household Insulin administration practices showed that the aver- garbage bin that was taken by the municipal workers. age duration of insulin use was 3.16  years (SD ± 3.88). This must have been done without the knowledge of the Among these patients, 96 (60.7%) had used insulin for municipal workers as they would not collect garbage more than 1  year. Interestingly only very few patients; with sharps if it were notified to them. In Sri Lanka, the 5 (3.1%), used an Insulin pen as the majority were using municipality does not collect sharps. Importantly, none syringes for daily injections. Most patients 132 (83.5%) of the patients reported having used hospital facilities had required more than two doses of Insulin per day. Out for sharps disposal. Thirty two (20%) patients burnt the of the syringe users (153/158) many patients 150 (98%), sharps, while 8 (5.1%) dumped them in the latrine pits. had recapped and reused the same needle repeatedly. When age and gender were analyzed as essential vari- More than half of the syringe users 84/153 (54.9%) had ables in sharps disposal methods there was no statistical used the same syringe 6 or more times, and 95/153 (62%) significance (Table  2). When comparing sharp disposal had used the same needle for 3 or more days (mean 6.29 practices with the level of education, educational status times ± 4.8). Only 117/158 (74%) patients cleaned the was stratified as those who at least had ‘General cer - injection site before the injection. Just 10 (6.3%) of the tificate ordinary level qualification & above’ and those patients regularly checked blood sugar using needles. A who were educated below the ordinary level. Qualifying large number; 73 (46.2%), involved others such as family this examination is a prerequisite for upper secondary Table 1 Primary and secondary sharps disposal methods within households Primary disposal method Frequency (n = 158) Secondary disposal method Frequency Number Percent % Number Percent % Recap and dispose to the common household 66 41.7 Home garbage pit/fire 23 14.6 garbage bin Disposed into the Garbage lorry of the local 43 27.2 Municipal Council (MC) Sharps container 9 5.7 Home garbage pit/fire 8 5.1 Disposed in common garbage bin and then into 1 0.6 garbage lorry of the MC Toilet pit 8 5.1 N/A Paper bag 16 10.1 Common garbage dump of the area 14 8.9 Common garbage bin and into MC garbage lorry 2 1.2 Burn (fire) 32 20.2 N/A Indiscriminate (loosely or no specific place) 11 6.7 N/A Collected since beginning in plastic bags without 15 9.5 N/A disposal Old well 1 0.6 N/A Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 4 of 7 Table 2 Sharp disposal practices according to different characteristics of patients (n = 158) (N = 158) Practice of disposal of sharps Seeking assistance with injections Seeking help in disposal of sharps Safe Unsafe p value No value (%) Yes value (%) p value No value (%) Yes value (%) p value disposal disposal value value (%) (%) Age < 60 5 (3.2) 73 (46.2) 0.08 54 (34.2) 24 (15.2) 0.000* 64 (40.5) 14 (8.9) 0.01* 60 ≥ 12 (7.5) 68 (43.0) 31 (19.6) 49 (31.0) 51 (32.2) 29 (18.3) Gender Male 6 (3.8) 31 (19.6) 0.22 18 (11.4) 19 (12.0) 0.473 21 (13.3) 16 (10.1) 0.012* Female 11 (6.9) 110 (69.6) 67 (42.4) 54 (34.2) 94 (59.4) 27 (17.0) Level of education Primary 5 (3.2) 83 (52.5) 0.0403 * 38 (24.0) 50 (31.6) 0.004* 60 (37.9) 28 (17.7) 0.20 and lower secondary (< GCE O/L) Upper second- 12 (7.6) 58 (36.7) 47 (29.7) 23 (14.5) 55 (34.8) 15 (9.5) ary and ter- tiary (≥ GCE O/L) Duration of use, (years) a a < 1 8 (5.1) 19 (12.0) 0.004 * 12 (7.5) 15 (9.5) 0.517 18 (11.4) 9 (5.6) 0.014 1–5 7 (4.4) 99 (62.6) 60 (37.9) 46 (29.1) 84 (53.2) 22 (13.9) > 5 2 (1.3) 23 (14.6) 13 (8.2) 12 (7.5) 13 (8.2) 12 (7.5) Prior education on safe disposal a a a Yes 6 (3.8) 5 (3.2) 0.0002 * 9 (5.6) 2 (1.2) 0.064 11 (6.9) 0 0.036 * No 11 (6.9) 136 (86.1) 76 (48.1) 71 (44.9) 104 (65.8) 43 (27.2) GCE O/L general certificate examination ordinary level * Statistically significant Fishers exact test education, and in Sri Lanka, this is considered the mini- involved family members more in disposing of sharps mum requirement for entry into vocational training, or (OR = 2.65 [95% CI 1.21–5.78], p = 0.012). Patients with employment. Level of education higher than an ordinary a lower level of education were seen to involve family level pass showed a unique use of safe primary disposal members more to inject insulin (OR = 2.68 [95% CI 1.39– methods than the group who had less than an ordinary 5.16], p = 0.004). level pass {(Odds ratio) OR = 3.43 [95% (Confidence interval) CI 1.15–10.27], p = 0.04} Needles were shared Discussion by only one patient. It was when a male patient shared This is the first study done on this topic in Sri Lanka. needles with his wife who herself was a diabetic—when We found that many of the interviewed patients han- checking blood sugar. Importantly, two patients reported dled household sharps poorly and disposed sharps either that other family members had experienced accidental loosely or into the household common garbage bin, needle-stick injuries. household garbage pit or a common garbage dump in Many patients 147 (93%) had never received any edu- the area. The findings are similar to other studies done cation regarding sharps disposal methods or the possibil- in this regard [9–15]. Such unsafe practices pose a major ity of a blood-borne infection upon a needle stick injury. threat to others through the possibility of needle stick Patients who were educated about sharp disposal were injuries [12, 14]. Similar to other studies, the results show likely to dispose of them “safely” (p < 0.001, OR 14.83, that most of the patients; 98% re-capped and re-used 95% CI 3.89–56.45). the same needle repeatedly [3, 15]. Furthermore > 50% Older patients (> 60 years of age) had a higher depend- of patients reported that they used the same needle over ency on family members for injecting insulin (p < 0.001 and over. This Re-capping and re-use of needles increase OR 3.55; 95% CI 1.84–6.87) and in disposal of sharps the risk of infection to the patient if proper procedures (OR = 2.59 [95% CI 1.24–5.42], p = 0.04) (Table 2). Males are not adhered to. The reuse of syringes has been Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 5 of 7 consistently identified as a major route of hepatitis B tend to attend clinic appointments alone. Similar behav- and C transmission in other countries [4–6, 10]. Patients ior is observed more in male patients. Even if advice who were > 60  years of age were involving family mem- on proper disposal of sharps had been provided during bers with injecting insulin and disposal of sharps. Male clinic time, the knowledge might not be transferred to patients tended to involve family members in the disposal family members at home. of sharps increasingly. This may be due to the traditional As expected, patients with a higher level of education family structure in Sri Lanka, where the female tends to than ordinary level, successfully used several “safe” meth- be responsible for activities in the kitchen which includes ods of primary disposal. This finding was in agreement garbage disposal. It would be usual to expect patients with some studies [6, 8, 14, 18] while others did not sup- with a higher level of education to be better able to cope port this [11]. However the higher educated are expected with injecting insulin and handling sharps. As expected, to have better ability to acquire information, so it is pos- lower level of education was associated with involving sible that they may have been better educated about their family members to inject insulin more. disease and to recognize the hazardous nature and need In the event injections are administered by fam- for safe disposal of their sharps. Even then, the sharps ily members, re-capping and re-use create potential for retainer that was used to collect sharps was dumped in needlestick injuries and the likelihood of spread of infec- garbage pits or disposed to the collection by the munici- tions. Though only a few family members reported nee - pality, due to the lack of better options provided by the dlestick injuries, the actual number of injuries involving authorities. If the municipality workers were to know members of the immediate family may be higher. whether sharps were in the garbage, they collected they When disposing of sharps, some patients tried to burn would refuse to collect it. This could be another reason sharps, but needles and lancets cannot be incinerated by why there were patients who had been using insulin for domestic fires; toxic fumes may be released in burning years but still had not disposed of their used sharps. plastic syringes. The primary methods of disposing of These patients may have thought that it was not correct sharps by the study group consisted of the sharps con- to put out sharps as it may harm others because in reality tainer and latrine pit. Although latter cannot be consid- there were no safe methods available to them. Although a ered an ideal safe option, use of these methods showed majority of patients 127 (80.4%) were aware of the spread that patients had some idea about keeping sharps away of blood-borne infections through needlestick injuries, it from others and could be described as generally ‘cau- had no bearing on safe, sharp disposal practices. tious or safe’ disposal methods. None of the secondary The study identifies two core issues that need urgent sharps disposal methods used by the study group could attention. Firstly, those patients who are conscious of the be described as safe. Patients who were educated about need for safe disposal of sharps were compelled to throw sharp disposal were likely to dispose of them “safely”. them into the general garbage collection eventually. This This finding is also supported by several other studies may be due to the unavailability of secure final disposal [3, 8, 9, 16, 17]. When all safe methods of sharps dis- options like incinerators or government sharps collec- posal are reviewed, there were no relationships between tion schemes. Secondly, the possible lack of knowledge age, gender or type of diabetes. Those who injected of available options for safe disposal of sharps among insulin for less than 1  year had better sharp disposal patients. practice than those who injected insulin for more than Designated sharps collection centers or coordinated 1  year. This finding was in agreement with another community-level government mechanisms are currently study done in Philippines where longer duration of unavailable in Sri Lanka. Disconcertingly, this deficiency diabetes mellitus and insulin use negatively influenced may be a proxy of the lack of importance placed on this disposal practices [18]. It may be because when one need by health authorities. Some countries practice dis- initially handles sharps they tend to be more cautious tribution of hospital grade sharps collection bins to about it, but as they get used to it, it may be perceived patients to use at home and once filled are collected at as less threatening. However, in another study, insulin the hospital [12, 19]. Similar methods may be useful in use more than 5  years, being type 1 had better prac- the Sri Lankan context, and some patients may even wish tice [6]. These contradictory findings in different set - to purchase these if made available commercially. tings suggest that sharps disposal practises maybe more At present government hospitals in Sri Lanka provide intrinsically related to motivation and encouragement insulin products free of charge for patients. Sharps col- of patients irrespective of the duration of insulin use. lection boxes, similarly, could also be provided to the Being male gender, being > 60  years of age were associ- patients with their medications. Though, disposal of ated with including a family member in injecting insulin sharps in health care settings in Sri Lanka is well regu- and later in the disposal of sharps. Most adult patients lated no such regulation is available for residential Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 6 of 7 settings. In comparison, in some developed countries, may not be an issue as with government sector patients. strict guidelines on domestic sharps disposal practices Therefore future research should be multi-centered to are in a place where patient support schemes mandato- include all strata of the insulin-using patient population. rily provide domestic sharps boxes and later collect them The questionnaire was not validated and is identified as a at designated points. Severe penalty/fines are imposed limitation. on patients who do not corporate with the guidelines. Interviews were conducted by two interviewers so Options such as community drop off programs, syringe ‘Observer bias’ may have played a part in data diversity. exchange programmes, sharps mail-back programs, resi- Some respondents may have had difficulty in reporting dential waste special pick-up programs for sharps or at events that happened in the past (e.g., duration of insulin home needle destruction devices (needles are burnt therapy, diagnosis of diabetes, etc.), so the potential for or melt rendering it safe for disposal) are also reported recall bias must also be considered as a limitation. Also, from some developed countries [19–21]. In some coun- the Study could have been improved if answers to follow- tries, safe sharps website, smartphone-based applications ing questions were also sought. Whether they inject insu- have been created for the guidance of patients in finding lin only at home or even at work? How they dispose of the location of secure disposal services [22]. Though Sri when they are away from home? Among the patients who Lanka may lack the financial resources for such enhanced were said to be educated about sharp disposal—who pro- systems, simple solutions such as using a “hard plastic” vided education? Also, the reasons for the current prac- bottle to collect sharps at home could be implementa- tice could have been asked. Still, the results available will ble widely [23]. These could be later collected at hospi - be useful in providing information for further study. tal clinics or designated counters. Commercial providers could also be encouraged to provide safe sharps disposal Conclusion options in public places (e.g., bus stops) as a longer-term The study shows that a majority of the patients inter - solution. viewed, disposed of sharps using indiscriminate and The study shows that only a few of the recruited potentially hazardous means. A feasible method that patients had been educated regarding methods of correct could be proposed for immediate implementation in disposal of sharps. This can be considered an opportunity Sri Lanka is to encourage the patients to handover their lost as the majority who received information on dis- sharps retainer to the hospital during their monthly posal found to have disposed of sharps cautiously. Educa- clinic visits, just before obtaining the free consignment tion of patients has the potential to minimise hazards to of insulin. Public willingness to pay for sharps disposal patients themselves and also to family members. Meth- services or desire to pay extra for insulin products where ods to educate Sri Lankan patients can include the use of the pharmaceutical provider will bear the responsibility informational videos, supplemental reading material and of collecting and properly disposing of sharps can also teaching sessions during clinic time. The clinicians need be explored. Education of patients living with diabetes to encourage their patients to use and dispose of sharps regarding acceptable methods of disposal of sharps via safely, and these clinical interactions can be a good point patient education programs and even via development of contact for education as it can encompass full cover- of national guidelines is hence, essential and urgent. Fol- age of all types of patients with Diabetes. Patients, their lowing implementation of national guidelines, a penalty family members, and local healthcare workers need to be system could also be introduced where inappropriate educated on the importance of proper disposal of sharps. disposal will be fined or penalized. Developing publicly Local healthcare workers, especially of the public health placed resources for the disposal of sharps too needs service can be requested to propagate the message to urgent consideration by authorities. families. Locally available resources such as a local hospi- tal can be asked to open-up the sharps handling program Authors’ contributions SW and KW developed the research idea. The development of the study tool, to the general public of the area. Identifying cost-effec - data collection, and compilation of the data set was carried out by all the tive methods in disposing of sharps is also needed for the authors, collectively. The analysis of data and manuscript preparation was longer term. done by SW, KW, and KA. RS reviewed the findings and final manuscript for submission. All authors read and approved the final manuscript. The limitations of this study include having only a lim - ited number of patients, poor collection of data on eth- Author details nicity, religion and socio-demographic data and being Department of Physiology, Faculty of Medical Sciences, University of Sri Jayewardenapura, Nugegoda, Sri Lanka. Centre for Online Health, School a single center study. Furthermore, very few patients of Medicine, University of Queensland, Brisbane, Australia. General Practi- had used insulin pens. In the private health sector in Sri tioner, Colombo, Sri Lanka. Senior Registrar in Ophthalmology, National Eye Lanka, most patients use insulin pens as affordability Hospital, Colombo, Sri Lanka. Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 7 of 7 Acknowledgements 6. Mekuria A, et al. Knowledge and self-reported practice of insulin The authors would like to thank the North Colombo Teaching Hospital (NCTH), injection device disposal among diabetes patients in Gondar Town, Ragama, Sri Lanka for approving for the study to be carried out at its outpa- Ethiopia: a cross-sectional study. J Diabetes Res. 2016. https ://doi. tient clinics. Also, authors would like to thank all the patients who participated org/10.1155/2016/18975 17. and to the data collectors of the study. 7. Crawshaw G, Irwin DJ, Button J. Disposal of syringes, needles, and lancets The Initial findings of this study have been published in the Ceylon Medi- used by diabetic patients in North East Essex. Commun Dis Public Health. cal Journal as a letter to the editor. We kindly request the applicable fees to be 2002;5(2):134–7. waived. 8. Ishtiaq O, Qadri AM, Mehar S, Gondal GM, Iqbal T, Ali S, et al. Disposal of syringes, needles, and lancets used by diabetic patients in Pakistan. J Infect Public Health. 2012;5(2):182–8. Competing interests 9. Musselman K. Patients’ knowledge of and practices relating to the dis- The authors declare that they have no competing interests. posal of used insulin needles. Innovat Pharm. 2010;1:2. 10. Bouhanick B, et al. What do the needles syringes lancets and reagent stris Availability of data and supporting materials of diabetic patients become in the absence of common attitude? Diab Please contact the author for data requests. Metab (paris). 2000;26:288–93. 11. Govender D, Ross A. Sharps disposal practices among diabetic patients Consent for publication using insulin. S Afr Med J. 2012;102:3. Not applicable. 12. Majumdar A, Sahoo J, Roy G, Kamalanathan S. Improper sharp disposal practices among diabetes patients in home care settings: need for con- Ethics approval and consent to participate cern? Indian J Endocrinol Metab. 2015;19(3):420–5. Ethical clearance was approved by the ethical clearance board of the Faculty 13. Udofia, et al. Solid medical waste: a cross sectional study of household of Medicine, University of Kelaniya, Sri Lanka (P/15/02/2014). disposal practices and reported harm in Southern Ghana. BMC Public Health. 2017;17:464. https ://doi.org/10.1186/s1288 9-017-4366-9. Funding 14. Olowokure B, et al. The disposal of used sharps by diabetic patients living None. at home. Int J Environ Health Res. 2003;13:117–23. 15. Markkanen P, et al. Understanding sharps injuries in home health care: the safe home care qualitative methods study to identify pathways Publisher’s Note for injury prevention. BMC Public Health. 2015;15:359. https ://doi. Springer Nature remains neutral with regard to jurisdictional claims in pub- org/10.1186/s1288 9-015-1673-x. lished maps and institutional affiliations. 16. Cunha G, et al. Insulin therapy waste produced in the households of people with diabetes monitored in primary care. Rev Bras Enferm. Received: 7 April 2016 Accepted: 3 December 2018 2017;70(3):618–25. https ://doi.org/10.1590/0034-7167-2016-0406. 17. Costello J, et al. The sticking point: diabetic sharps disposal practices in the community. J Gen Intern Med. 2013;28(7):868–9. https ://doi. org/10.1007/s1160 6-013-2350-3. 18. Quiwa L, Jimeno C. Knowledge attitudes and practices on the disposal of References sharps in patients of the up-philippine general hospital diabetes clinic. J 1. Jayawardena R, Ranasinghe P, Byrne NM, Soares MJ, Katulanda P, Hills AP. ASEAN Fed Endocrine Soc. 2014;29:2. Prevalence and trends of the diabetes epidemic in South Asia: a system- 19. Environmental Protection Authority. Medical Waste. 2016. https ://www. atic review and meta-analysis. BMC Public Health. 2012;12:380. epa.gov/rcra/medic al-waste . Accessed 10 Jan 2017. 2. Katulanda P, Sheriff MH, Matthews DR. The diabetes epidemic in Sri 20. Gold K, et al. 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Malays J Med diabetes on insulin therapy. Ceylon Med J. 2016;61(2):91. Sci. 2016;23(1):44–55. Ready to submit your research ? Choose BMC and benefit from: fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Practices related to sharps disposal among diabetic patients in Sri Lanka

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/s12930-018-0049-7
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Abstract

Background: Patients with diabetes on insulin therapy use sharps (e.g., needles) on a regular basis and a consider- able proportion of them, within their home environments. These sharps and other bloodstained materials, if not disposed of appropriately has the potential to be a public health hazard. Objective: Our objective was to explore the practices related to sharps disposal among patients with diabetes from North Colombo Teaching Hospital (CNTH), Ragama, Sri Lanka. Methods: We conducted a cross-sectional study on 158 patients with diabetes from the CNTH. Patients had to use sharps for the daily management of their disease for inclusion into the study group. Data were collected on sharps disposal practices using an interviewer-administered questionnaire. Clinic records were also used as a secondary data source. Results: Most patients, 153/158 (96.8%) used syringes to inject insulin. Forty-three patients (27%) involved others (e.g., family) when disposing of sharps. Used sharps were commonly disposed to the household garbage bin by 66 participants (41.7%). Other methods used for sharps disposal were: sharps container, toilet pit, household garbage dump and indiscriminate measures. Importantly most patients, 147 (93%) had received no information on how to dispose of sharps after usage. Conclusion: Patients commonly used unsafe practices in home-based sharps disposal. These included disposing of in the household garbage bin, burning sharps in the household garbage dump and disposing of into the common garbage dump of the community. Being male and being > 60 years of age was associated with a higher dependence on family members for sharps disposal. Patient education and public resources for sharps handling can help improve this situation. Keywords: Diabetes mellitus, Insulin, Sharps disposal Introduction rapid rise in the number of patients living with diabetes Diabetes mellitus has grown into epidemic propor- in the country is most likely to have increased this num- tions across the world. Sri Lanka too is no exception to ber exponentially. this epidemic and has witnessed significant increases in For many patients living with Diabetes, day to day con- patient numbers throughout the country. At present, the trol and management requires daily blood sugar measure- total number of patients living with Diabetes in Sri Lanka ments and insulin injections. These procedures invariably is estimated to be around 2.8 million—approximately generate sharps within the household as most patients 13% of the population [1, 2]. Though the exact number inject insulin at home. Improper disposal of these sharps of patients using Insulin in Sri Lanka is not known, the has the potential to cause many public health problems [3–6]. These could include personal injury, blood-borne infections via needle stick injuries to others such as fam- ily members, neighbors and sometimes even the public. *Correspondence: sumuduwickramasinghe@gmail.com Centre for Online Health, School of Medicine, University of Queensland, Although the medical waste management and sharps Brisbane, Australia disposal systems are well managed within the hospital Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 2 of 7 settings in Sri Lanka, public health guidelines and public permitted us a month duration to enrol patients and health services for home-based sharp disposal are cur- we were time bound. Therefore we had to complete the rently unavailable. During preliminary scoping of public data collection at the end of the month with the num- health literature and review of published peer-reviewed ber we could collect only. Hence, we were only able to journal articles, we were unsuccessful in identifying pub- collect 158 patients during the collection time that was lished documents guiding proper sharps handling prac- permitted. We did not keep exact records of the number tices for patients in Sri Lanka. of patients who refused participation, but the number of patients refusing to be interviewed was not many (as Objective discussed at research group meetings with the data col- Our objective was to explore the practices related to lectors). At the time the study was designed the primary sharps disposal among diabetic patients from North research question was to identify how patients handled Colombo Teaching Hospital (CNTH), Sri Lanka. sharps and other Insulin-use related factors. Therefore, we have not delved into socio-economic considerations Methods of patients. We assumed that patients might not be able We conducted a cross-sectional study at the diabetes to spend adequate time with data collectors due to the clinic of the CNTH from 15th May 2015 to 15th June busy nature of the clinic and collection of detailed socio- 2015. The CNTH functions routine diabetes clinics and economic and educational data would have necessitated serves many patients daily. We were sampling from the us lengthening the questionnaire. main diabetic clinic. All diabetic patients on monthly Information sheets and consent forms were provided routine review from the hospital were represented at this for patients, and verbal consent was obtained before clinic. interviewing. Type of diabetes and duration of insulin We visited the clinic center at CNTH every working treatment was confirmed by reviewing the clinic records day of the week for one month to interview patients. The with the patient’s permission. An interviewer-admin- study population only included patients who were on istered questionnaire was used to collect information. routine review at the clinic. They were diagnosed of dia - The structured questionnaire was developed using pre- betes and were on routine clinic follow up. These patients identified questions from similar international journal were not acutely ill and were on monthly review to their articles [7, 8]. The issues explored insulin administration diabetic clinic. The patients who were on insulin would practices, equipment used, the frequency of needle use, come routinely every month to collect the free insulin. disposal of insulin syringes and pens, lancet disposal, We only included patients with Type 1 and Type 2 dia- sharing of needles and knowledge about disease spread betes mellitus. Patients with gestational diabetes were by sharing needles. excluded. All the patients had to be users of injectable The questionnaire was pre-tested among a group of insulin for at least a month’s duration. Both females and diabetic patients attending a family practice before the male adult patients of any age were included. study. During pretesting we understood that patients Each daily-clinic we visited served more than 50 have a “primary” method of disposal, i.e., how they ‘ini- patients each day. We selected every 3rd patient starting tially’ disposed of the sharps and a “secondary” mode of from number 1, from the clinic roster, using their ‘on the disposal—i.e., how they ‘ultimately’ got rid of it following day’ clinic number. the first disposal, e.g. the ones who disposed of sharps in In the event, a patient corresponding to the clinic the sharps bin (primary) later dumped the sharps bin to number was not recruitable (not matching inclusion the garbage pits in their homes (secondary). The open- and exclusion criteria, patient in consultation with the ended items in the questionnaire and direct interviews medical officer, the patient with a member of the nursing allowed the respondents to describe their actual needle team or the patient refused participation) we moved on disposal practices including ‘primary’ and ‘secondary’ to the next 3rd number. Some of the patients (every 3rd disposal methods. The pre-trained research assistants selected) were on oral hypoglycemic medication only and (two pre-intern medical doctors) carried out the inter- were excluded from selection. views. They were asked to carry out data collection at We recruited, on average 6 to 8 patients daily. At the the pre-test of the questionnaire, and the data collec- end of 1  month period, we had collected data from 158 tion was found to be consistent and comparable among patients. The number of patients seen daily at the clinic the two data collectors. Also, they were trained to follow was not a constant. In the Sri Lankan context, some the same sequence of questions in collecting data. Patient patients may decide to seek a review in the private sec- response was recorded in written without alteration tor occasionally and for the next visit may come to the by the interviewer to minimise interviewer bias. Daily government clinic for care. The clinic authorities only patient records were collected and kept with a principal Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 3 of 7 investigator (RDN) securely. Hard copy data were saved members when injecting Insulin and 43 (27%) patients into an SPSS database. Descriptive statistics such as also included others in disposing of sharps. proportions, mean ± SD have been used to describe the Commonly generated sharps in the household were data. Analysis of data was done using Chi squared test needles from syringes and needles from Insulin pens. and Fisher’s Exact test at 95% confidence using Statisti - These were disposed of into a typical household garbage cal Package for the Social Sciences-SPSS version 18. Ethi- bin by 66 (41.7%) patients. The other methods used to cal clearance was obtained from the Faculty of Medicine, dispose of sharps were sharps container, toilet pit, com- University of Kelaniya (P/15/02/2014). mon public garbage dump and indiscriminate methods (Table  1). Interestingly 15 (9.5%) of the patients had col- Results lected sharps since the beginning in plastic bags and has At the completion of data collection, 158 patients not got rid of them. Surprisingly when inquired it was had been interviewed. Their ages ranged between found that they had not thought even about a plan of 21 and 90  years of age with a mean age of 59.3  years disposal. (SD ± 10.23). Out of the 158 patients, 121 (76.6%) were Eight patients (5.1%) disposed the sharps into a sharps female. Among the included patients, the mean dura- container inside the home environment but later emp- tion of living with diabetes was 7.4 years (SD ± 5.09), and tied it into the household garbage pit. One patient (0.6%) 155 (98.1%) of them were patients with type 2 diabetes. dumped the sharps container in the typical household Insulin administration practices showed that the aver- garbage bin that was taken by the municipal workers. age duration of insulin use was 3.16  years (SD ± 3.88). This must have been done without the knowledge of the Among these patients, 96 (60.7%) had used insulin for municipal workers as they would not collect garbage more than 1  year. Interestingly only very few patients; with sharps if it were notified to them. In Sri Lanka, the 5 (3.1%), used an Insulin pen as the majority were using municipality does not collect sharps. Importantly, none syringes for daily injections. Most patients 132 (83.5%) of the patients reported having used hospital facilities had required more than two doses of Insulin per day. Out for sharps disposal. Thirty two (20%) patients burnt the of the syringe users (153/158) many patients 150 (98%), sharps, while 8 (5.1%) dumped them in the latrine pits. had recapped and reused the same needle repeatedly. When age and gender were analyzed as essential vari- More than half of the syringe users 84/153 (54.9%) had ables in sharps disposal methods there was no statistical used the same syringe 6 or more times, and 95/153 (62%) significance (Table  2). When comparing sharp disposal had used the same needle for 3 or more days (mean 6.29 practices with the level of education, educational status times ± 4.8). Only 117/158 (74%) patients cleaned the was stratified as those who at least had ‘General cer - injection site before the injection. Just 10 (6.3%) of the tificate ordinary level qualification & above’ and those patients regularly checked blood sugar using needles. A who were educated below the ordinary level. Qualifying large number; 73 (46.2%), involved others such as family this examination is a prerequisite for upper secondary Table 1 Primary and secondary sharps disposal methods within households Primary disposal method Frequency (n = 158) Secondary disposal method Frequency Number Percent % Number Percent % Recap and dispose to the common household 66 41.7 Home garbage pit/fire 23 14.6 garbage bin Disposed into the Garbage lorry of the local 43 27.2 Municipal Council (MC) Sharps container 9 5.7 Home garbage pit/fire 8 5.1 Disposed in common garbage bin and then into 1 0.6 garbage lorry of the MC Toilet pit 8 5.1 N/A Paper bag 16 10.1 Common garbage dump of the area 14 8.9 Common garbage bin and into MC garbage lorry 2 1.2 Burn (fire) 32 20.2 N/A Indiscriminate (loosely or no specific place) 11 6.7 N/A Collected since beginning in plastic bags without 15 9.5 N/A disposal Old well 1 0.6 N/A Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 4 of 7 Table 2 Sharp disposal practices according to different characteristics of patients (n = 158) (N = 158) Practice of disposal of sharps Seeking assistance with injections Seeking help in disposal of sharps Safe Unsafe p value No value (%) Yes value (%) p value No value (%) Yes value (%) p value disposal disposal value value (%) (%) Age < 60 5 (3.2) 73 (46.2) 0.08 54 (34.2) 24 (15.2) 0.000* 64 (40.5) 14 (8.9) 0.01* 60 ≥ 12 (7.5) 68 (43.0) 31 (19.6) 49 (31.0) 51 (32.2) 29 (18.3) Gender Male 6 (3.8) 31 (19.6) 0.22 18 (11.4) 19 (12.0) 0.473 21 (13.3) 16 (10.1) 0.012* Female 11 (6.9) 110 (69.6) 67 (42.4) 54 (34.2) 94 (59.4) 27 (17.0) Level of education Primary 5 (3.2) 83 (52.5) 0.0403 * 38 (24.0) 50 (31.6) 0.004* 60 (37.9) 28 (17.7) 0.20 and lower secondary (< GCE O/L) Upper second- 12 (7.6) 58 (36.7) 47 (29.7) 23 (14.5) 55 (34.8) 15 (9.5) ary and ter- tiary (≥ GCE O/L) Duration of use, (years) a a < 1 8 (5.1) 19 (12.0) 0.004 * 12 (7.5) 15 (9.5) 0.517 18 (11.4) 9 (5.6) 0.014 1–5 7 (4.4) 99 (62.6) 60 (37.9) 46 (29.1) 84 (53.2) 22 (13.9) > 5 2 (1.3) 23 (14.6) 13 (8.2) 12 (7.5) 13 (8.2) 12 (7.5) Prior education on safe disposal a a a Yes 6 (3.8) 5 (3.2) 0.0002 * 9 (5.6) 2 (1.2) 0.064 11 (6.9) 0 0.036 * No 11 (6.9) 136 (86.1) 76 (48.1) 71 (44.9) 104 (65.8) 43 (27.2) GCE O/L general certificate examination ordinary level * Statistically significant Fishers exact test education, and in Sri Lanka, this is considered the mini- involved family members more in disposing of sharps mum requirement for entry into vocational training, or (OR = 2.65 [95% CI 1.21–5.78], p = 0.012). Patients with employment. Level of education higher than an ordinary a lower level of education were seen to involve family level pass showed a unique use of safe primary disposal members more to inject insulin (OR = 2.68 [95% CI 1.39– methods than the group who had less than an ordinary 5.16], p = 0.004). level pass {(Odds ratio) OR = 3.43 [95% (Confidence interval) CI 1.15–10.27], p = 0.04} Needles were shared Discussion by only one patient. It was when a male patient shared This is the first study done on this topic in Sri Lanka. needles with his wife who herself was a diabetic—when We found that many of the interviewed patients han- checking blood sugar. Importantly, two patients reported dled household sharps poorly and disposed sharps either that other family members had experienced accidental loosely or into the household common garbage bin, needle-stick injuries. household garbage pit or a common garbage dump in Many patients 147 (93%) had never received any edu- the area. The findings are similar to other studies done cation regarding sharps disposal methods or the possibil- in this regard [9–15]. Such unsafe practices pose a major ity of a blood-borne infection upon a needle stick injury. threat to others through the possibility of needle stick Patients who were educated about sharp disposal were injuries [12, 14]. Similar to other studies, the results show likely to dispose of them “safely” (p < 0.001, OR 14.83, that most of the patients; 98% re-capped and re-used 95% CI 3.89–56.45). the same needle repeatedly [3, 15]. Furthermore > 50% Older patients (> 60 years of age) had a higher depend- of patients reported that they used the same needle over ency on family members for injecting insulin (p < 0.001 and over. This Re-capping and re-use of needles increase OR 3.55; 95% CI 1.84–6.87) and in disposal of sharps the risk of infection to the patient if proper procedures (OR = 2.59 [95% CI 1.24–5.42], p = 0.04) (Table 2). Males are not adhered to. The reuse of syringes has been Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 5 of 7 consistently identified as a major route of hepatitis B tend to attend clinic appointments alone. Similar behav- and C transmission in other countries [4–6, 10]. Patients ior is observed more in male patients. Even if advice who were > 60  years of age were involving family mem- on proper disposal of sharps had been provided during bers with injecting insulin and disposal of sharps. Male clinic time, the knowledge might not be transferred to patients tended to involve family members in the disposal family members at home. of sharps increasingly. This may be due to the traditional As expected, patients with a higher level of education family structure in Sri Lanka, where the female tends to than ordinary level, successfully used several “safe” meth- be responsible for activities in the kitchen which includes ods of primary disposal. This finding was in agreement garbage disposal. It would be usual to expect patients with some studies [6, 8, 14, 18] while others did not sup- with a higher level of education to be better able to cope port this [11]. However the higher educated are expected with injecting insulin and handling sharps. As expected, to have better ability to acquire information, so it is pos- lower level of education was associated with involving sible that they may have been better educated about their family members to inject insulin more. disease and to recognize the hazardous nature and need In the event injections are administered by fam- for safe disposal of their sharps. Even then, the sharps ily members, re-capping and re-use create potential for retainer that was used to collect sharps was dumped in needlestick injuries and the likelihood of spread of infec- garbage pits or disposed to the collection by the munici- tions. Though only a few family members reported nee - pality, due to the lack of better options provided by the dlestick injuries, the actual number of injuries involving authorities. If the municipality workers were to know members of the immediate family may be higher. whether sharps were in the garbage, they collected they When disposing of sharps, some patients tried to burn would refuse to collect it. This could be another reason sharps, but needles and lancets cannot be incinerated by why there were patients who had been using insulin for domestic fires; toxic fumes may be released in burning years but still had not disposed of their used sharps. plastic syringes. The primary methods of disposing of These patients may have thought that it was not correct sharps by the study group consisted of the sharps con- to put out sharps as it may harm others because in reality tainer and latrine pit. Although latter cannot be consid- there were no safe methods available to them. Although a ered an ideal safe option, use of these methods showed majority of patients 127 (80.4%) were aware of the spread that patients had some idea about keeping sharps away of blood-borne infections through needlestick injuries, it from others and could be described as generally ‘cau- had no bearing on safe, sharp disposal practices. tious or safe’ disposal methods. None of the secondary The study identifies two core issues that need urgent sharps disposal methods used by the study group could attention. Firstly, those patients who are conscious of the be described as safe. Patients who were educated about need for safe disposal of sharps were compelled to throw sharp disposal were likely to dispose of them “safely”. them into the general garbage collection eventually. This This finding is also supported by several other studies may be due to the unavailability of secure final disposal [3, 8, 9, 16, 17]. When all safe methods of sharps dis- options like incinerators or government sharps collec- posal are reviewed, there were no relationships between tion schemes. Secondly, the possible lack of knowledge age, gender or type of diabetes. Those who injected of available options for safe disposal of sharps among insulin for less than 1  year had better sharp disposal patients. practice than those who injected insulin for more than Designated sharps collection centers or coordinated 1  year. This finding was in agreement with another community-level government mechanisms are currently study done in Philippines where longer duration of unavailable in Sri Lanka. Disconcertingly, this deficiency diabetes mellitus and insulin use negatively influenced may be a proxy of the lack of importance placed on this disposal practices [18]. It may be because when one need by health authorities. Some countries practice dis- initially handles sharps they tend to be more cautious tribution of hospital grade sharps collection bins to about it, but as they get used to it, it may be perceived patients to use at home and once filled are collected at as less threatening. However, in another study, insulin the hospital [12, 19]. Similar methods may be useful in use more than 5  years, being type 1 had better prac- the Sri Lankan context, and some patients may even wish tice [6]. These contradictory findings in different set - to purchase these if made available commercially. tings suggest that sharps disposal practises maybe more At present government hospitals in Sri Lanka provide intrinsically related to motivation and encouragement insulin products free of charge for patients. Sharps col- of patients irrespective of the duration of insulin use. lection boxes, similarly, could also be provided to the Being male gender, being > 60  years of age were associ- patients with their medications. Though, disposal of ated with including a family member in injecting insulin sharps in health care settings in Sri Lanka is well regu- and later in the disposal of sharps. Most adult patients lated no such regulation is available for residential Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 6 of 7 settings. In comparison, in some developed countries, may not be an issue as with government sector patients. strict guidelines on domestic sharps disposal practices Therefore future research should be multi-centered to are in a place where patient support schemes mandato- include all strata of the insulin-using patient population. rily provide domestic sharps boxes and later collect them The questionnaire was not validated and is identified as a at designated points. Severe penalty/fines are imposed limitation. on patients who do not corporate with the guidelines. Interviews were conducted by two interviewers so Options such as community drop off programs, syringe ‘Observer bias’ may have played a part in data diversity. exchange programmes, sharps mail-back programs, resi- Some respondents may have had difficulty in reporting dential waste special pick-up programs for sharps or at events that happened in the past (e.g., duration of insulin home needle destruction devices (needles are burnt therapy, diagnosis of diabetes, etc.), so the potential for or melt rendering it safe for disposal) are also reported recall bias must also be considered as a limitation. Also, from some developed countries [19–21]. In some coun- the Study could have been improved if answers to follow- tries, safe sharps website, smartphone-based applications ing questions were also sought. Whether they inject insu- have been created for the guidance of patients in finding lin only at home or even at work? How they dispose of the location of secure disposal services [22]. Though Sri when they are away from home? Among the patients who Lanka may lack the financial resources for such enhanced were said to be educated about sharp disposal—who pro- systems, simple solutions such as using a “hard plastic” vided education? Also, the reasons for the current prac- bottle to collect sharps at home could be implementa- tice could have been asked. Still, the results available will ble widely [23]. These could be later collected at hospi - be useful in providing information for further study. tal clinics or designated counters. Commercial providers could also be encouraged to provide safe sharps disposal Conclusion options in public places (e.g., bus stops) as a longer-term The study shows that a majority of the patients inter - solution. viewed, disposed of sharps using indiscriminate and The study shows that only a few of the recruited potentially hazardous means. A feasible method that patients had been educated regarding methods of correct could be proposed for immediate implementation in disposal of sharps. This can be considered an opportunity Sri Lanka is to encourage the patients to handover their lost as the majority who received information on dis- sharps retainer to the hospital during their monthly posal found to have disposed of sharps cautiously. Educa- clinic visits, just before obtaining the free consignment tion of patients has the potential to minimise hazards to of insulin. Public willingness to pay for sharps disposal patients themselves and also to family members. Meth- services or desire to pay extra for insulin products where ods to educate Sri Lankan patients can include the use of the pharmaceutical provider will bear the responsibility informational videos, supplemental reading material and of collecting and properly disposing of sharps can also teaching sessions during clinic time. The clinicians need be explored. Education of patients living with diabetes to encourage their patients to use and dispose of sharps regarding acceptable methods of disposal of sharps via safely, and these clinical interactions can be a good point patient education programs and even via development of contact for education as it can encompass full cover- of national guidelines is hence, essential and urgent. Fol- age of all types of patients with Diabetes. Patients, their lowing implementation of national guidelines, a penalty family members, and local healthcare workers need to be system could also be introduced where inappropriate educated on the importance of proper disposal of sharps. disposal will be fined or penalized. Developing publicly Local healthcare workers, especially of the public health placed resources for the disposal of sharps too needs service can be requested to propagate the message to urgent consideration by authorities. families. Locally available resources such as a local hospi- tal can be asked to open-up the sharps handling program Authors’ contributions SW and KW developed the research idea. The development of the study tool, to the general public of the area. Identifying cost-effec - data collection, and compilation of the data set was carried out by all the tive methods in disposing of sharps is also needed for the authors, collectively. The analysis of data and manuscript preparation was longer term. done by SW, KW, and KA. RS reviewed the findings and final manuscript for submission. All authors read and approved the final manuscript. The limitations of this study include having only a lim - ited number of patients, poor collection of data on eth- Author details nicity, religion and socio-demographic data and being Department of Physiology, Faculty of Medical Sciences, University of Sri Jayewardenapura, Nugegoda, Sri Lanka. Centre for Online Health, School a single center study. Furthermore, very few patients of Medicine, University of Queensland, Brisbane, Australia. General Practi- had used insulin pens. In the private health sector in Sri tioner, Colombo, Sri Lanka. Senior Registrar in Ophthalmology, National Eye Lanka, most patients use insulin pens as affordability Hospital, Colombo, Sri Lanka. Atukorala et al. Asia Pac Fam Med (2018) 17:12 Page 7 of 7 Acknowledgements 6. Mekuria A, et al. Knowledge and self-reported practice of insulin The authors would like to thank the North Colombo Teaching Hospital (NCTH), injection device disposal among diabetes patients in Gondar Town, Ragama, Sri Lanka for approving for the study to be carried out at its outpa- Ethiopia: a cross-sectional study. J Diabetes Res. 2016. https ://doi. tient clinics. Also, authors would like to thank all the patients who participated org/10.1155/2016/18975 17. and to the data collectors of the study. 7. Crawshaw G, Irwin DJ, Button J. Disposal of syringes, needles, and lancets The Initial findings of this study have been published in the Ceylon Medi- used by diabetic patients in North East Essex. Commun Dis Public Health. cal Journal as a letter to the editor. We kindly request the applicable fees to be 2002;5(2):134–7. waived. 8. Ishtiaq O, Qadri AM, Mehar S, Gondal GM, Iqbal T, Ali S, et al. Disposal of syringes, needles, and lancets used by diabetic patients in Pakistan. J Infect Public Health. 2012;5(2):182–8. Competing interests 9. Musselman K. Patients’ knowledge of and practices relating to the dis- The authors declare that they have no competing interests. posal of used insulin needles. Innovat Pharm. 2010;1:2. 10. Bouhanick B, et al. What do the needles syringes lancets and reagent stris Availability of data and supporting materials of diabetic patients become in the absence of common attitude? Diab Please contact the author for data requests. Metab (paris). 2000;26:288–93. 11. Govender D, Ross A. Sharps disposal practices among diabetic patients Consent for publication using insulin. S Afr Med J. 2012;102:3. Not applicable. 12. Majumdar A, Sahoo J, Roy G, Kamalanathan S. Improper sharp disposal practices among diabetes patients in home care settings: need for con- Ethics approval and consent to participate cern? Indian J Endocrinol Metab. 2015;19(3):420–5. Ethical clearance was approved by the ethical clearance board of the Faculty 13. Udofia, et al. Solid medical waste: a cross sectional study of household of Medicine, University of Kelaniya, Sri Lanka (P/15/02/2014). disposal practices and reported harm in Southern Ghana. BMC Public Health. 2017;17:464. https ://doi.org/10.1186/s1288 9-017-4366-9. Funding 14. Olowokure B, et al. The disposal of used sharps by diabetic patients living None. at home. Int J Environ Health Res. 2003;13:117–23. 15. Markkanen P, et al. Understanding sharps injuries in home health care: the safe home care qualitative methods study to identify pathways Publisher’s Note for injury prevention. BMC Public Health. 2015;15:359. https ://doi. Springer Nature remains neutral with regard to jurisdictional claims in pub- org/10.1186/s1288 9-015-1673-x. lished maps and institutional affiliations. 16. Cunha G, et al. Insulin therapy waste produced in the households of people with diabetes monitored in primary care. Rev Bras Enferm. Received: 7 April 2016 Accepted: 3 December 2018 2017;70(3):618–25. https ://doi.org/10.1590/0034-7167-2016-0406. 17. Costello J, et al. The sticking point: diabetic sharps disposal practices in the community. J Gen Intern Med. 2013;28(7):868–9. https ://doi. org/10.1007/s1160 6-013-2350-3. 18. Quiwa L, Jimeno C. Knowledge attitudes and practices on the disposal of References sharps in patients of the up-philippine general hospital diabetes clinic. J 1. Jayawardena R, Ranasinghe P, Byrne NM, Soares MJ, Katulanda P, Hills AP. ASEAN Fed Endocrine Soc. 2014;29:2. Prevalence and trends of the diabetes epidemic in South Asia: a system- 19. Environmental Protection Authority. Medical Waste. 2016. https ://www. atic review and meta-analysis. BMC Public Health. 2012;12:380. epa.gov/rcra/medic al-waste . Accessed 10 Jan 2017. 2. Katulanda P, Sheriff MH, Matthews DR. The diabetes epidemic in Sri 20. Gold K, et al. 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Malays J Med diabetes on insulin therapy. Ceylon Med J. 2016;61(2):91. Sci. 2016;23(1):44–55. Ready to submit your research ? Choose BMC and benefit from: fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

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Asia Pacific Family MedicineSpringer Journals

Published: Dec 7, 2018

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