Type 2 Diabetes Mellitus (DM) is the most common form of diabetes. The World Health Organization (WHO) reported that the global prevalence of diabetes has grown from 4.7% in 1980 to 8.5% in 2014 [1
]. Over the past decade, the prevalence has risen faster in low- and middle-income countries, including Malaysia [1
]. According to a report by the Ministry of Health (MOH), the prevalence of Type 2 DM among Malaysians adults aged 18 years and over had escalated by 50% within a 10 year duration, from only 11.6% in 2006 to 17.5% in 2015 [2
Due to the great therapeutic effect towards achieving optimal glycemic control in Type 2 DM patients as compared to oral hypoglycemic agents, insulin therapy has been recognized as the foundation of diabetes care and is aggressively being prescribed by physicians in Malaysia [4
]. The recent National Diabetes Registry, which tracks the care and management of DM in MOH health clinics, reported an increase of over 80% in insulin use within 4 years, from 2009 until 2012 [5
]. Patients’ acceptance towards insulin therapy was also driven by the new innovation of an insulin pen with smaller gauge needles to administer insulin, and the availability of convenient home blood monitoring devices [6
All these procedures for diabetes self-care then generate a considerable amount of sharp waste within the household setting. Therefore, Type 2 DM patients, primarily those who are insulin-dependent, are identified as the largest group of patients who use medical sharps on a consistent basis in the community [8
]. WHO defined sharps as medical devices with sharp points or edges that can puncture or cut skin [8
]. In the case of diabetic patients, the sharps commonly used for home treatment are insulin pen needles, insulin syringes, lancets, reusable insulin pens, disposable insulin pens, insulin vials or cartridges, and insulin pump devices [10
Even though diabetic patients have persistently used medical sharps as part of their daily diabetic care, as reported by previous studies in different countries, their level of knowledge regarding safe community sharp disposal was generally low [7
]. The majority of them were not aware of any local safe sharp disposal options in their community, meaning they did not know how to properly dispose of their sharps [7
]. Knowledge on the possible risks of blood borne disease transmission following unsafe sharp disposal was also low [13
]. The postulated reason for this low level of knowledge was never being educated on sharp disposal during regular diabetic consultation [7
Owing to that, improper sharp disposal practice among diabetic populations is reported to be widespread, especially in most developing countries [12
]. Large numbers of diabetic patients discard sharps directly into common household bins, burned sharps, or buried them in their household compounds [7
]. Some of them even flushed down the sharps in the toilet, or threw them into old wells, rivers, or canals [19
]. A relatively small proportion of diabetic patients managed to return their used sharps in proper containers to central collection areas, primarily to health care facilities, for final disposal [11
Improperly discarded sharps in the community are of particular concern because of the possible threats and implications they pose to human health and the surrounding environment [16
]. A large and growing body of literature shows that unsafe sharp disposal habits increase the risk of the occurrence of needle stick injuries and other sharp related injuries, both to patients themselves and to people near them. Needle stick injuries in the community also increase the risk of blood borne infectious disease transmission later on [22
]. In addition, improper sharp disposal in household and community settings also accelerates land and water pollution, which can later impose harm to human health as well [16
In developed countries like United States, Australia, and United Kingdom, specific ordinances and policies to regulate sharp disposal in community setting are in place to deal with sharp waste generated from home-based care activities [25
]. Standardized community sharp disposal programs and specific education are available to cultivate safe disposal behavior among their chronic disease patients who require self-injecting medication, especially those with diabetes [14
]. Unfortunately, in Malaysia, sharps waste at the community setting has not been given much attention yet. Until now, no local policy or community sharp disposal program has been made available to handle sharps used by these patients.
As medical sharps waste will be consistently being produced by a growing Malaysian diabetic population, hence, there is a need to develop a structured diabetes education program integrating a locally adapted sharp disposal option, to be offered to these patients. Therefore, this current study aimed to evaluate the effectiveness of the Diabetes Community Sharp Disposal Education Module on improving knowledge and sharp disposal practices among Malaysian Type 2 diabetic patients. The results perhaps can provide evidence on the effectiveness and acceptability of the newly developed module, before it is implemented later on a nationwide scale.
The evidence for the use of structured diabetes education programs in diabetes management is growing and has resulted in a positive effect on knowledge and diabetic self-care behaviors [39
]. However, the evidence of theoretically based diabetes education programs are scanty in Malaysia, and none highlighted medical sharp waste disposal issue in the community. Therefore, the Diabetes Community Sharp Disposal Education Module was developed as a health educational tool to improve knowledge and sharp disposal behavior among Malaysian’s diabetic patients in the community.
4.1. Effect of Intervention on Knowledge Scores
The results in this study showed that Diabetes Community Sharp Disposal Education Module was effective in improving the knowledge pertaining to sharp disposal among Malaysian’s diabetic patients. There was a statistically significant increase in sharp disposal knowledge score among participants in the intervention group, from baseline to one month follow up and from baseline to three months follow up.
In this study, the Diabetes Community Sharp Disposal Education Module is a locally adapted education module, using local Malay language with simple and easy layman terms and words. Three different educational instruments were used, as well as a lecture and printed educational tools in the form of a flip chart and pamphlet, with the intention to deliver a systematically structured and repetitive education on community sharp disposal in an interactive way. This locally adapted module with user-friendly instruments helped diabetic patients to absorb the information and thus resulted in a better understanding of it [14
]. On top of that, the intervention session was conducted face-to-face between the researcher and the patients, which further enhanced the two-way communication [14
]. This would explain the increment in the knowledge level of participants in this study. Similar interventional studies conducted among Type 2 diabetic patients in Egypt also revealed an improved literacy level towards sharp disposal in the community, following a structured education delivered by their physicians [38
The result of this current study showed that knowledge levels among diabetic patients in intervention group substantially increased after the intervention. From one month to three months of follow up, a very slight reduction in the knowledge score was observed, which did not reach statistical significance. This indicated that the information could be sustained for up to three months post intervention. However, the slight reduction warranted the need for continuous and regular education to further sustain the information on sharp disposal, similar to other aspects of diabetes education. This pattern was parallel to recommendations from earlier studies that suggested the community sharp disposal component be integrated into current diabetic education content, and providing education when patients are first being prescribed with insulin [6
]. Furthermore, as the results in previous studies showed, the longer patients have diabetes, the more likely that they would experience diabetes burnout [44
]. They could become exhausted and frustrated from the long-term use of medications and continuous self-management, thus they might gradually neglect their diabetes self-care [44
], including the way they handle and dispose of their sharps.
4.2. The Effect of Intervention on Community Sharp Disposal Practice
As defined by the FDA and EPA, proper community sharp disposal method refers to the proper use of safe sharp containers and final disposal at correct designated collection centers [27
]. Therefore, the second outcome in this study was determining the proportion of patients using the proper community sharp disposal method, concerning the use of sharp containers which were returned to health care facilities for final disposal. The results showed that Diabetes Community Sharp Disposal Education Module was effective in improving sharp disposal practice among Malaysian diabetic patients. There was a statistically significant increase in the proportion of diabetic patients in the intervention group who practiced proper community sharp disposal method over the three months follow up time.
As underlined in the newly developed module in current study, diabetic patients just need to use their own readily available household containers and discard them at health care facilities, whenever they came to clinic for regular follow up. This option probably incurred no or very minimal cost to them, and was convenient for them to comply with. This was in line with earlier studies that suggested a community sharp disposal program should be simple, affordable, and easily accessible to facilitate compliance [15
]. Based on the Health Belief Model, the user-friendly sharp disposal option with a structured community sharp disposal education module in this study acts as a cue or trigger to action, to activate readiness and stimulate overt health-related behaviors for diabetic patients to dispose of sharp waste at proper designated collection centers.
However, despite the provision of education on proper sharp disposal, about half of the patients in the intervention group were observed still not adopting safe sharp disposal practice. Again, using the Health Belief Model as a theoretical framework could help to explain this counterintuitive finding. Cues to action might activate the readiness to change to safer behavior only if the perceived threats and perceived benefits versus perceived barriers are already high [47
]. Some patients in the intervention group still might not adequately perceive that improperly disposed sharps would later cause environmental pollution and injury to themselves and to others, and need to be adequately convinced that the risk would be substantially decreased by engaging safe sharp disposal behaviors. Because of the relatively low perceived threat, initiatives to change disposal practices might be difficult. Therefore, continuous assessment and reinforcement regarding sharp disposal practice during regular consultation is required [15
As no randomization and blinding were applied in this study, attrition bias would probably occur, especially in the control group, and pose a threat to the internal validity of the study [49
]. To minimize this attrition bias, an ITT analysis approach was taken, including by those patients who dropped out in the final analysis. To further assess the impact of non-compliance and those who did not follow up towards the study outcome, an PP analysis approach was also used by including only those patients who strictly adhered to the protocol in the final analysis. However, because of the high retention rate, there were no differences observed in statistical results using both approaches. Therefore, loss of respondents in the current study probably did not produce any effects on the observed outcome.
4.3. Study Limitations
Findings of this study highlighted the valuable impact of the locally adapted Community Sharp Disposal Education Module in improving the knowledge and sharp disposal practice among the Malaysian diabetic population. However, the current study did not look into the attitude aspect towards community sharp disposal. Nevertheless, it is imperative to first acknowledge and overcome the barriers preventing safe sharp disposal behavior, because they heavily affected the observed outcome.
4.4. Future Research
The replication of this study in various settings or with other populations would be very useful to see the spectrum of community sharp disposal aspect at a larger scale. However, to achieve better understanding about sharp disposal behavior in the community, future research in this area should proceed with a study focusing on a number of other factors, especially attitudes and belief, which also made up the main constructs of the Health Belief Model. A cost-analysis study is also required to evaluate and verify the most cost-effective community sharp disposal option in our local Malaysian setting.