Household Pharmaceutical Waste Management Practices in the Johannesburg Area, South Africa

Pharmaceutical wastes are expected to increase given the increasing population growth rates and rapidly rising economic burden of human diseases. This challenge calls for appropriate measures for the management of such hazardous wastes. The purpose of this survey was to document and investigate existing practices for the handling, storage, and disposal of household pharmaceutical wastes (HPWs) in the Johannesburg area. Primary data were collected via online surveys with self-administered questionnaires completed by respondents. The research found that 77% (n = 286) of respondents claimed some knowledge about HPWs. Types of medicines that contributed to HPWs included painkillers or analgesics (73%, n = 270) and drugs for treating colds and flu-related illnesses (52%; n = 193). Although there were a few exceptions, the respondents generally exhibited strong disagreements with environmentally unfriendly and health-threatening disposal practices. Moreover, most participants were willing to return expired medicines to pharmacies (40.7%, n = 151), whereas only 8.6% (n = 32) opposed this solution. Awareness levels tended to vary with employment status, educational qualifications, and place of residence. However, place of residence and household size did not correlate with types of pharmaceutical waste. Additionally, the study found that education attainments significantly influenced the willingness of respondents to return pharmaceutical wastes. Finally, there were no significant differences amongst respondents in terms of waste disposal practices. Altogether, the findings suggest the need for targeted efforts to bring about sustainable waste management at a household level.


Introduction
The world human population exceeded 7 billion in the year 2017, and it is likely to reach 9.7 billion by 2050; therefore, more pharmaceutical products and medicines will be needed to deal with the growing economic and public health burdens of human diseases [1]. For example, since December 2019, there has been an increased global demand for the manufacturing of ventilators and drugs needed to treat patients affected by the COVID-19 pandemic. Nearly 1.42 trillion USD was spent on medicines in 2021, an increase from 887 billion USD in 2010 [2]. The figure is expected to reach about 1.8 trillion USD during the year 2026 [2]. Similarly, in India, it is projected that the sales of over-the-counter medicines are expected to increase from approximately USD 125 billion in 2016 to approximately USD 273 billion by the year 2024 [3]. Inevitably, with such high consumption rates of medicines, there will be an increase in pharmaceutical wastes from pharmaceutical companies and pharmacies where drugs and associated products are manufactured and dispensed, including hospitals and health-care centres, and even in households where most people keep medicines to treat their ill-health and wellness problems.
Pharmaceutical wastes entail expired drugs and nutraceuticals, unused medicines, discarded wellness products, and even medicines that are no longer needed because

Study Design and Research Methods
In order to address the aim of the present study, a quantitative survey research design was adopted. Quantitative surveys have been extensively by various researchers [23][24][25][26] in waste management research. A survey is a systematic method of gathering primary data from samples of entities that belong to a larger population [27]. Thus, the 'ultimate goal is to learn more about a large population by surveying only a sample of that population' [28]. The targeted unit of analysis in this survey was respondents representing residential households in Johannesburg (South Africa), the main purpose being to understand management practices associated with their HPWs.

Questionnaire Design
An online digital questionnaire was designed to collect primary data. The instrument had four main sections, and they are summarized as follows: • Section A (demographical aspects); • Section B (awareness of HPWs); • Section C (storage and disposal practices);

Study Design and Research Methods
In order to address the aim of the present study, a quantitative survey research design was adopted. Quantitative surveys have been extensively by various researchers [23][24][25][26] in waste management research. A survey is a systematic method of gathering primary data from samples of entities that belong to a larger population [27]. Thus, the 'ultimate goal is to learn more about a large population by surveying only a sample of that population' [28]. The targeted unit of analysis in this survey was respondents representing residential households in Johannesburg (South Africa), the main purpose being to understand management practices associated with their HPWs.

Questionnaire Design
An online digital questionnaire was designed to collect primary data. The instrument had four main sections, and they are summarized as follows: • Section A (demographical aspects); • Section B (awareness of HPWs); • Section C (storage and disposal practices); • Section D (willingness to return unused/expired or discarded medicines and associated accessories back to local hospitals and pharmacies).
Whereas some of the questions in the questionnaire were straightforward or closeended, thus requiring only a yes or no answer, others were based on a Likert scale. With a Likert scale, it is possible to rate the extent to which respondents are agreeing or disagreeing with formulated statements [5,[29][30][31]. For example, based on a Likert scale of 1 to 5, where 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Disagree nor Agree, 4 = Agree and 5 = Strongly Agree, respondents in the present survey were requested to indicate the extent to which they agreed or disagreed with each of the statements on household storage and disposal practices of HPWs and their willingness to return such wastes to hospitals and pharmacies. Furthermore, the internal validity of the formulated questions was pre-tested by means of the Cronbach alpha (α) coefficient, whose formula is depicted below: where N denotes the number of scale or items, c-bar represents the average inter-item covariance among the scale items, and v-bar is the average variance [32]. The value of the coefficient ranges from 0 to 1, and coefficient values closer to 1 show a higher internal consistency of the variables in the scale. In the present study, this coefficient was 0.68, thus indicating that the questionnaire was reliable.

Primary Data Collection
Primary data were collected online by means of a self-administered questionnaire completed by respondents during the August-November 2021 period. In the questionnaire, respondents were asked questions that allowed them to share (i) the types of HPWs they generate at home and their level of awareness on this waste stream, (ii) their practices regarding the storage and disposal of HPWs, and (iii) their willingness to return their unused medicines back to local pharmacies.
Potential respondents above the age of 18 years old were students at the University of Johannesburg (Auckland Park Kingsway Campus). They were contacted via digital communication applications or platforms, such as e-mail, WhatsApp, and Telegram. In total, 434 individuals were contacted, of which only 371 responded, thus giving a response rate of about 85%.
The students who were willing to consent and participate received an online digital consent form along with a digital questionnaire (i.e., Google Form). The students were also asked to send the initial digital link and questionnaire to other people they knew living in the Johannesburg area, thus broadening the initial base of respondents by means of snowball leads or chain referrals. While many contacts were made during the primary data collection, it is imperative to acknowledge that the approach we followed brought some inevitable limitations to the research. Thus, the respondents without access to electronic devices were inevitably excluded from the sampling framework. Consequently, the results generated may not be widely generalizable to all households in Johannesburg. Despite this limitation, the findings revealed important patterns regarding HPW practices among the youthful, educated and the digitally connected population in the City of Johannesburg.

Data Analyses
Especially for the first three research objectives, to determine (i) the types of HPWs they generate and their level of awareness about this waste stream, (ii) people's practices for the storage and disposal of HPWs, and (iii) to document people's willingness to return back unused medicine to local pharmacies, descriptive statistics and the percentages (%) of respondents were calculated. However, to test the following four hypotheses, an analysis of variance (ANOVA) was conducted on the collected data: • Hypothesis 1. Household awareness about pharmaceutical waste is related to the demographical properties of households.
• Hypothesis 2. There are no statistically significant differences in the various classes of pharmaceutical wastes according to the income level, place of residence, and household size of the respondents.
• Hypothesis 3. Household willingness to return pharmaceutical wastes does not vary according to the age, education, gender and place of residence of respondents.
• Hypothesis 4. There are statistically significant differences amongst respondents in terms of their selection of specific waste disposal waste practices.
Factors that were significantly associated with household waste disposal practices were also selected. The p values were set at 0.05.

Ethical Procedures
As far as ethical protocols are concerned, the Code for Academic and Research Ethics of the University of Johannesburg (UJ) was duly complied with, and the research project was approved with the following reference: 2021-04-01/Magagula/Rampedi. The university's code of conduct makes the following provisions mandatory to ensure that any risk of dealing with internal or external stakeholders in the primary data collection phase and beyond is significantly reduced, if not eliminated: • Employees, students, and affiliates must always respect the rights of research participants to freedom, dignity, privacy (including the right to anonymity), and bodily and psychological integrity; • Research partners and associates may be used as research participants only if they have given their written and informed consent to become participants in a research project; • Commencement/execution of research projects is dependent on the adherence to all government and UJ regulations related to the COVID-19 pandemic, thus preventing the risk of viral infections and associated distress.

Demographic Attributes of Respondents
Of the total number (n = 371) of respondents in the survey, 72.8% (n = 270) were men and 27.2% (n = 101) were women. Other demographical characteristics are depicted in Table 1. The majority (80.6%, n = 299) of respondents were in the 20-29 years category. This outcome is traceable to the selection and sampling of respondents, especially as the initial contacts for the survey were mainly students at the University of Johannesburg. Besides this main group, nearly 12% of respondents were in the 30-39 years category, while other age groups were less represented. In terms of employment status, 52.6% (n = 195) were students enrolled at various academic institutions in South Africa, meanwhile 25.9% (n = 96) were employed full-time. The proportion of those who were working part-time (8.1%, n = 30) or unemployed (7.8%, n = 29) was nearly the same. Based on the highest academic qualification achieved, most of the respondents were not only literate but had acquired important academic qualifications. For instance, the percentage of those who had completed a bachelor's university academic program was 32.1% (n = 119) whereas those who had postgraduate degrees amounted to 27.2% (n = 101). Regarding annual income levels (Table 1), a relatively large proportion (40.7%, n = 173) of respondents had income levels of up to ZAR 50,000 (USD~3160), whilst 27.1% (n = 115) had income levels between ZAR 100,000 (USD~6320) and ZAR 300,000 (USD~18,960). As further shown in Table 1, 18.4% (n = 78) indicated that they had incomes between ZAR 301,000 (USD~19,023) and ZAR 500,000 (USD~31,600). The smallest proportion of the respondents (3.3%, n = 14) had incomes ranging from 750,000 (USD~47,400) to ZAR 1,000,000 (USD~63,200). On the whole, the majority of residents in Johannesburg had an income of less than ZAR 500,000 (USD~31 600). The statistics provided by the City of Johannesburg Metropolitan Municipality [33] indicate that about 57% of the residents in Johannesburg live on less than ZAR 400,000 (USD~25,280) per annum [33].

Awareness and Types of HPWs
In terms of awareness about HPWs, 77% (n = 286) of respondents claimed to have some knowledge of such waste materials, while 23% were not aware. Therefore, investigating the different types of medicines kept at home is important as far as their contribution to the generation of HPWs is concerned. In Figure 2, the proportions of respondents who mentioned specific types of medicines used and kept in their homes are indicated. Most respondents mentioned the use of painkillers or analgesics (73%, n = 270) to reduce bodily pain and medicines applied to treat colds and flu-related illnesses (52%; n = 193). Another important class of medicines was anti-allergic drugs (23%, n = 85), medications for women's health (21%, n = 75), and antibiotics (33%, n = 122) for treating various types of infections. These findings bear some similarities with some previous studies. For example, analgesics were the most frequently (46%, n = 115) reported medicines amongst households in Mauritius [34] as well as in the community cross-sectional survey (29%, n = 149) conducted in the Tigray Region of Northern Ethiopia [35]. Similarly, in Cape Town (South Africa), about 64% (n = 104) of respondents reported painkillers as part of unused medicines in their homes [36]. Another commonly reported group of household drugs are antibiotics, which were documented in various studies, thus denoting their prevalence in many households [35,37,38]. In terms of household types, the majority (56.3%, n = 209) of respondents lived in individual or privately owned households, while 16.2% (n = 60) resided in flats or rented apartments (Table 1). By contrast, households located on the estates (6.7%, n = 25) and in communes (3.2%, n = 12) were less frequent. Nearly half (46.6%, n = 173) of the respondents lived in households occupied by 4-6 persons, and this was closely followed (38.5%, n = 143) by households with 1-3 persons (Table 1). Larger households with 7-9 persons accounted for 10.5% of respondents, while households occupied by more than 9 persons were very few (4.3%).

Awareness and Types of HPWs
In terms of awareness about HPWs, 77% (n = 286) of respondents claimed to have some knowledge of such waste materials, while 23% were not aware. Therefore, investigating the different types of medicines kept at home is important as far as their contribution to the generation of HPWs is concerned. In Figure 2, the proportions of respondents who mentioned specific types of medicines used and kept in their homes are indicated. Most respondents mentioned the use of painkillers or analgesics (73%, n = 270) to reduce bodily pain and medicines applied to treat colds and flu-related illnesses (52%; n = 193). Another important class of medicines was anti-allergic drugs (23%, n = 85), medications for women's health (21%, n = 75), and antibiotics (33%, n = 122) for treating various types of infections. These findings bear some similarities with some previous studies. For example, analgesics were the most frequently (46%, n = 115) reported medicines amongst households in Mauritius [34] as well as in the community cross-sectional survey (29%, n = 149) conducted in the Tigray Region of Northern Ethiopia [35]. Similarly, in Cape Town (South Africa), about 64% (n = 104) of respondents reported painkillers as part of unused medicines in their homes [36]. Another commonly reported group of household drugs are antibiotics, which were documented in various studies, thus denoting their prevalence in many households [35,37,38]. Amongst other types of wasted medicines, unused pills or tablets were disposed of by 29.4% (n = 109) of the respondents, which is relatively low compared to the results from Amongst other types of wasted medicines, unused pills or tablets were disposed of by 29.4% (n = 109) of the respondents, which is relatively low compared to the results from other studies. For instance, as much as 70% (n = 354) of respondents mentioned unused tablets amongst some households in the Ethiopian Tigray region [35]. Such high proportions of respondents can be ascribed to the high number of over-the-counter drugs that are frequently being bought nowadays without any medical prescriptions. Furthermore, a very large proportion (96%; n = 359) of respondents refuted the contribution made by unused portable health monitoring devices to the household waste stream. Such items included blood pressure or blood sugar monitoring machines and thermometers, probably because they are used for chronic medical conditions. Such utilization means that they can be kept for longer periods at home without being part of the pharmaceutical waste stream up until they are eventually discarded. The same result was also recorded for unused liquid-based medicines (84.6%, n = 314) and unused injections (96.5%, n = 358). Lastly, apart from wasted drugs, Table 2 also indicates other waste items, such as the packaging materials associated with pharmaceutical products. These items were widely acknowledged by respondents in the present survey: small paper bags (42.6%), plastic bottles (49.1%), and small plastic bags (67.9%). Such packaging waste materials were not considered or mentioned in several studies conducted in South Africa [8,9] and even abroad [39][40][41].

HWS Storage and Disposal Practices
In Table 3, the results of the degree to which the respondents agreed or disagreed with statements on specific storage methods are summarized according to a Likert scale. To a larger degree, the majority of respondents did not store their pharmaceutical products according to the different storage options presented in the survey, although there were few exceptions. For example, 41% (n = 152) of respondents strongly disagreed with the statement 'I store them inside a fridge', with a further 10.5% (n = 39) of respondents disagreeing with the same statement. This high level of disagreements suggests some malpractices in the storage of medicines in the present study. According to drug manufacturers, medicines must be stored under a certain temperature profile and moisture conditions, with no exposure to light or accessibility to children. Therefore, violating these storage conditions poses a serious health risk to both patients and children within households. Similarly, improper storage practices may affect the clinical efficiency of medicines in a negative manner, apart from their potential contribution towards the generation of medicinal wastes [42][43][44]. Nonetheless, close to 191 (51%) respondents agreed that they stored their medications inside medicine boxes, which is good practice as long as they are not accessible to children and the vulnerable.
Furthermore, the respondents were asked to indicate how they disposed of their pharmaceutical wastes from households. The results are shown in Table 4. Even though there were few exceptions, the respondents generally exhibited strong disagreements with environmentally unfriendly and health-threatening disposal practices. Just over half (52.6%, n = 195) of the respondents did not flush their unused medicines in kitchen sinks and toilet drains, although a few (11.3%, n = 42) of them used this method. This kind of disposal practice has been widely criticized in many countries as one of the prime pathways for the presence and dissemination of medication compounds into the environment [5,[45][46][47][48][49]. Once released into the environment, discarded drugs can negatively affect the development of biological species. In a recent study, it was established that the release of the drug diclofenac into the environment was responsible for renal failure amongst vultures in South East Asia, while trace amounts of ethinylestradiol derived from over-the-counter medicines is impairing the sexual maturity and the feminization of fish species in some of the European water bodies [49,50]. To a greater extent, amongst the respondents in the present survey, unused medicines were not given to sick people for re-use (72.5%, n = 269), which is good practice, although they were also not returned to hospitals and pharmacies (68.2%, n = 253) due to the lack of take-back programs in South Africa. Furthermore, 235 (~63%) respondents agreed to varying degrees that they disposed of their medicine waste by mixing it with their general household domestic waste. This latter finding is similar to the results from the industrial area of Malaysia, where 63.1% of their respondents simply discarded their medicinal wastes into domestic rubbish bins without any segregation [5]. Lastly, keeping unwanted medicines indefinitely at home was strongly refuted by most (42.3%, n = 157) respondents, thus suggesting that once medicines were used or had expired, they were disposed of unless the patients were still undergoing treatment. In view of the negative environmental and ecological impacts caused by the release of HPWs into the environment, pharmaceutical take-back schemes are widely regarded as a potential solution to reduce these impacts, although their feasibility and success differ amongst countries [51][52][53]. In the present survey, the household willingness for participation in pharmacy take-back programs was estimated ( Table 5). The results indicated that most of the respondents expressed a willingness to participate in such schemes (Table 5) although there is currently no national regulatory framework in South Africa to enforce such programs. Strong agreements amongst the respondents were expressed for the following suggestions, and they were given in the following order of magnitude: (1) returning expired medicines to pharmacies (40.7%, n = 151), (2) highly recommending such programs to other people (42%, n = 156), and (3) a willingness to follow any helpful advice given by health care providers for the safe disposal of such wastes (44.5%, n = 165). Only a few respondents strongly agreed with the statement that they were not doing anything to improve the situation (8.6%, n = 32), thus expressing their preparedness to maintain the status quo. By contrast, 42% (n = 156) of respondents were prepared to recommend any future take-back schemes to other people even, though such programs do not exist yet. This finding demonstrates the need to develop a national framework in South Africa that can guide the handling and disposal of HPWs at the household level.

Testing of Hypotheses Based on ANOVA
As mentioned earlier, several hypotheses were formulated in order to shed more light on the association between the perceptions of HPWs by respondents according to some of their demographical characteristics. Each hypothesis is analysed below according to the data generated from the ANOVA.

Hypothesis 1.
This study tested the hypothesis that household awareness about pharmaceutical wastes is significantly related to the demographical properties of respondents. Such properties entailed their gender, age, income level, educational level, employment status, place of residence, household size and household type. The results from the ANOVA are presented in Table 6. It was found that awareness of pharmaceutical wastes was not significantly related to demographic variables, such as gender (p = 0.969 > 0.05), age (p = 0.074 > 0.05), income level (p = 0.369 > 0.05), household type (p = 0.412 > 0.05) and household size (p = 0.938 > 0.05). However, awareness was found to be significantly related to employment status (p = 0.011 < 0.05), educational qualifications (p = 0.014 < 0.05), and place of residence (p = 0.014 < 0.05). Thus, awareness levels tended to vary by employment status, educational levels and place of residence, whilst other demographic characteristics (gender, age, income level, household size and household type) exhibited no influence on awareness levels. Regarding this hypothesis, there were statistically significant differences in the mean scores representing the various classes of HPWs in terms of income levels (p = 0.039 < 0.05; Table 7), meaning that classes of pharmaceutical wastes vary according to the income levels of respondents. On the contrary, the results show that there were no statistical differences in the means for the different classes of pharmaceutical wastes and places of residence (p = 0.534 > 0.05) and household sizes (p = 0.078 > 0.05). This means that there was homogeneity in the sample in terms of places of residence and household sizes. Thus, places of residence and household sizes were not connected with the different classes of HPWs. The ANOVA test confirmed that household willingness to return pharmaceutical wastes was not a function of gender (p = 0.250 > 0.05), age (p = 0.863 > 0.05) and places of residence (p = 0.567 > 0.05) ( Table 8). This implies that there were no statistically significant differences between the mean scores of the variables involved. Thus, places of residence, age, and gender did not influence the willingness of households to return pharmaceutical wastes in the study area. However, the results indicated that household willingness to return pharmaceutical wastes was statistically related to level of education (p = 0.017 < 0.05). This finding raises the need to increase willingness via appropriate educational interventions where weaknesses or shortfalls in this practice exist. Hypothesis 4. Table 9 shows the results of the ANOVA to test whether there were statistically significant differences amongst respondents in terms of pharmaceutical waste disposal practices. The test statistics for all the constructs on waste disposal practices, except for "I throw it away into household domestic waste bin" (p = 0.000 < 0.05), "I flush it down the toilet drain" (p = 0.030 < 0.05) and "I return it to hospitals and pharmacies" (p = 0.000 < 0.05), exhibited p-values greater than 0.05, thus demonstrating no significant statistical differences amongst respondents in terms of waste disposal practices.

Conclusions, Implications and Recommendations
Given the different environmental pollution and health risks associated with the improper management of expired medicines, associated accessories, and their packaging, the prime purpose of the present study was to document and investigate different practices for the handling, storage and disposal of household pharmaceutical wastes (HPWs) in the Johannesburg area.
The study revealed that most (77%) respondents were aware of HPWs, and the most common medicines kept within households were painkillers (73%), medicines to treat colds and flu-related illnesses (52%) and antibiotics to treat other infections (33%). This household waste stream also comprised small plastic bags (67.9%), soft cardboard boxes (51.8%), and plastic bottles (49.1%), as well as typical medicine waste items, such as unused pills, injections, topical products and health-monitoring devices.
The survey revealed the different practices of storing medicines at household level. Whereas most methods were strongly refuted by the majority of respondents, close to 50% (n = 191) of them indicated that their medicines were stored within medicine boxes. Aside from this storage method, special efforts to store medicines in line with the instructions given by drug manufacturers were seldom made by respondents, thus explaining why some medicines ended up in household waste, which was then disposed of in municipal landfill sites. However, if the amounts of drugs that end up in household waste are to be significantly reduced within households, it is necessary to follow the precautions given when they are dispensed by pharmacies, thus maintaining their clinical efficiency and minimizing their potential wastage.
The most common method for the disposal of unused medicines was mixing them with other household wastes despite their hazardous nature. Close to 235 (63%) respondents agreed that they used this method based on the Likert scale applied in this study. Although this finding bears some resemblance with the findings of previous studies, it is imperative to state that our results were influenced to some extent by the demographical characteristics of the respondents. For instance, almost 80% (n = 299) of respondents were aged 20-29 years, implying that this may affect the type of drugs they use and, consequently, their management methods. The majority of respondents strongly disagreed with disposal methods, such as keeping medicines indefinitely in households (42.3%), throwing them outside (55%), burning them (61%), or returning them to local pharmacies and hospitals where they were dispensed (68%). Although the findings show that these methods are not widely practiced by respondents, the lack of household waste segregation (33.4%) should be a source of environmental concern as this allows for final landfill disposal.
According to the results showing the different degrees of willingness to return unused medicines and associated accessories to hospitals and pharmacies, most respondents expressed a positive disposition towards playing a meaningful role in such medicine take-back schemes. However, the implementation of such programs in many developing countries is fraught with implementation pitfalls due to a lack of environmental awareness, necessary infrastructure, and willingness to pay for such programs [41,[54][55][56]. This constraint also applies to South Africa, where there is no well-defined national legislative and regulatory framework to deal with discarded HPWs in a sustainable manner.
Lastly, a number of hypotheses were tested using the ANOVA. Firstly, it was established that an awareness of pharmaceutical wastes is not significantly related to gender, income level, household type, and household size, although it was significantly related to employment status, educational qualifications, and places of residence. Thus, important factors to enhance the awareness of HPWs would be the introduction of targeted educational interventions at various settings, including workplaces, educational institutions, and places of residence. Secondly, there are statistically significant differences between pharmaceutical wastes specified by respondents and their income levels. This is because income plays an important role in the buying of medicines and associated products; therefore, it is not surprising that classes of HPWs were positively correlated with different income categories. Thirdly, whereas household willingness to return pharmaceutical wastes is not a function of variables such as gender, age and places of residence, the level of education was statistically related to household willingness to return unused or expired medicines. This conclusion raises the need to increase willingness to participate in the take-back programs by means of appropriate educational interventions where they do not exist. Finally, for all constructs considered to characterise waste disposal practices amongst the respondents, statistically significant differences were found only for statements such as "I throw it away into a household domestic waste bin", "I flush it down the toilet drain" and "I return it to hospitals and pharmacies", thus indicating similarities and dissimilarities in the disposal of such wastes.

Institutional Review Board Statement:
The research reported in this paper was approved by the Research Ethics Committee at the Faculty of Science, University of Johannesburg during the year 2021. Details regarding the approval have the following reference for the institution: 2021-04-01/Magagula/Rampedi. In terms of compliance with institutional requirements, prior to data collection from participants, the following requirements were met: (1) The purpose of the study and what was expected from potential participants were fully explained to them. (2) Data were collected only when prior informed consent was given to the researchers, and respondents were free to voluntarily participate or not participate. (3) All the data were collected anonymously, thus protecting the confidentiality and privacy of all respondents.
Informed Consent Statement: Primary data were collected by means of online digital questionnaires. However, prior informed consent was taken into consideration prior to this activity, thus making sure that the participants clearly understood the purpose of the survey and what was required from them. Thus, participation in the study was voluntary and no one was coerced to provide the required data. Moreover, participants were duly informed that they were free to participate or not participate and whatever choice they exercised, there would be no adverse consequences on their well-being, privacy, and confidentiality. Data Availability Statement: Data collected and analysed are available upon request.