Beyond Awareness: Social and Structural Barriers to Expired Medication Disposal Among Rural Older Adults in China

Beyond Awareness: Social and Structural Barriers to Expired Medication Disposal Among Rural Older Adults in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Awareness: Social and Structural Barriers to Expired Medication Disposal Among Rural Older Adults in China Zhanghao Yu, Tianran He, Ziyu Liu, Chengchao Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7100179/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The improper disposal of expired medications poses great public health and environmental risks, particularly in rural settings where institutional infrastructure is limited. Despite government efforts to establish take-back programs, participation remains low among older adults who are both frequent medication users and particularly vulnerable to associated risks. Understanding the behavioral and contextual barriers to proper disposal is essential for improving engagement. Methods This qualitative study explored the psychosocial and normative factors influencing expired medication disposal among older adults in Rushan, a rural county in eastern China with an underutilized formal recycling program. Guided by the Theory of Planned Behavior and the Norm Activation Model, we conducted 45 semi-structured interviews. Participants were selected through purposive sampling. Data were analyzed thematically using a hybrid coding approach that combined predefined theoretical domains with inductively derived sub-themes. Results Four themes and eleven sub-themes emerged, capturing attitudes toward disposal, subjective norms, perceived behavioral control, and internal motivations. While most participants recognized the importance of safe disposal, action was often constrained by limited awareness of available channels, doubts about personal efficacy, weak normative cues, and inaccessible infrastructure. Family influence focused more on medication safety than on disposal, and health providers reported lacking authority or continuity to promote recycling. Conclusions Findings suggest that raising awareness alone is insufficient to drive behavior change. Effective interventions must activate local social norms, embed a sense of responsibility within existing community structures, and address logistical gaps. These insights offer practical guidance for designing culturally grounded and community-driven pharmaceutical waste policies in resource-constrained rural settings. Expired medications Theory of Planned Behavior Norm Activation Model Recycling behavior Rural older adults Figures Figure 1 1. Introduction The improper disposal of expired medications poses escalating threats to public health and environmental sustainability [ 1 ] . Pharmaceutical compounds often persist in aquatic environments even after wastewater treatment, contributing to ecosystem contamination and posing risks to population health [ 2 ] . Studies have documented the ecological consequences of pharmaceutical residues, including endocrine disruption in aquatic species and population declines in scavengers due to exposure to non-steroidal anti-inflammatory drugs [ 3 , 4 ] . These risks are amplified in rural areas, where environmental protections and waste management systems remain underdeveloped, and improper disposal methods, such as burning or landfilling, further degrade soil and water quality. Despite growing awareness of these hazards, safe and standardized disposal systems remain insufficient globally, particularly in rural China, where public awareness is limited and infrastructure for pharmaceutical waste management is lacking [ 5 , 6 ] . While high-income countries have established effective national drug take-back systems, such as Australia’s National Return and Disposal of Unused Medicines [ 7 ] , Canada’s implementation of the National Return of Unwanted Medicines (NatRUM) program [ 8 ] , and the U.S. Food and Drug Administration’s drug take-back initiatives [ 9 ] , China has yet to implement a coordinated national strategy. In some urban areas, pilot programs like the “Expired Medicine Collection & Change-for-Free” initiative have emerged, but rural regions remain largely excluded due to the absence of supportive policy frameworks and institutional coordination mechanisms [ 10 ] . Older adults are particularly vulnerable in this context. As primary users of medications, they are more likely to accumulate expired or unused drugs due to challenges in adherence, polypharmacy, and limited awareness of proper disposal procedures [ 11 , 12 , 13 ] . In rural areas, these challenges are compounded by lower health literacy and poor access to formal recycling infrastructure, further elevating environmental and health risks [ 5 , 6 , 14 ] . Although various policy and programmatic interventions have been introduced to promote safe medication disposal, their effectiveness has remained limited, primarily due to persistently low levels of public engagement and the predominance of passive, compliance-based participation [ 15 ] . This disconnect highlights a critical implementation gap where formal policy provisions fail to translate into meaningful behavioral uptake at the community level. To address this, the present study investigates the psychosocial and contextual factors that condition older adults’ participation in expired medication disposal in rural China, offering empirical insights to inform more effective, community-responsive policy design. 2. Method 2.1. Study design This study employs a qualitative research design to investigate the factors influencing rural older adults’ participation in expired medication disposal within the context of the government-designated recycling programs. Qualitative research is particularly suited for examining context-dependent behaviors shaped by social norms, resource accessibility, and individual motivation [ 16 , 17 ] . Unlike previous domestic studies that have primarily relied on survey-based descriptive analyses of household drug accumulation and disposal [ 18 , 19 ] , this study draws on in-depth qualitative inquiry to capture the complex psychosocial and structural dynamics underpinning disposal behaviors. By exploring the lived experiences and perspectives of participants, this approach provides a deeper and more comprehensive understanding of the factors shaping prescription take-back behaviors among older adults in rural settings. 2.2 Study setting This study was conducted in Rushan, a county-level city in eastern Shandong Province, China, where the urbanization level remains relatively low and much of the population resides in rural towns and villages. In 2021, it implemented a pharmaceutical waste take-back program as part of a broader municipal initiative led by the Weihai government. The program introduced designated collection points in village clinics and pharmacies, public information campaigns, and small material incentives to encourage the return of expired medications [ 20 ] . While the program has been in place for over four years, how local residents engage with it remains insufficiently understood. Like many rural regions in China, Rushan faces structural constraints that may shape participation, including population aging, uneven access to formal disposal infrastructure, and relatively low levels of awareness for health and environment. These conditions reveal a gap between policy design and behavioral response, and underscore the importance of examining how individual motivations, social expectations, and contextual constraints shape engagement with formal medication disposal initiatives. 2.3 Theoretical foundation To examine the factors shaping older adults’ engagement in expired medication disposal, this study draws on two complementary behavioral models: the Theory of Planned Behavior (TPB) [ 21 ] and the Norm Activation Model (NAM) [ 22 ] . Together, these frameworks provide a structured lens for analyzing both externally regulated behavior, such as responses to perceived social expectations or institutional facilitation, and internally motivated actions informed by personal values and moral obligation. The TPB posits that behavior is shaped by three components: attitudes (evaluations of the behavior), subjective norms (perceived social pressure), and perceived behavioral control (belief in one’s ability to act) [ 21 , 23 ] . This model is particularly useful in understanding intentional, non-habitual actions such as participation in formal take-back programs [ 24 , 25 ] . The NAM emphasizes personal moral norms as key behavioral drivers. Behavior is more likely to occur when individuals are aware of the negative consequences of inaction and feel personally responsible for mitigating them [ 26 , 27 ] . This perspective highlights the ethical and normative dimensions of behavior, particularly in areas where regulatory mechanisms exist but participation remains inconsistent. In this study, the two models are integrated to capture both the rational-intentional and moral-normative dimensions of medication disposal behavior. As illustrated in Fig. 1 , the conceptual framework links structural and psychosocial variables, including attitudes, subjective norms, perceived behavioral control, awareness of consequences, and moral obligation, to behaviors. This integrative model informed the development of the interview guide and guided the initial thematic coding strategy. 2.4 Sampling and recruitment A purposive sampling strategy was used to recruit rural older adults with diverse experiences relevant to expired medication disposal. Sampling aimed to capture variation in age, sex, education level, and medication-related practices, in alignment with the study’s behavioral focus. Participants were recruited from multiple villages in Rushan, with support from local healthcare providers such as village doctors and clinic staff. These providers served as trusted intermediaries due to their familiarity with the local population and their routine involvement in medication distribution and use. Inclusion criteria were: (1) being aged 60 or above (in line with China’s statutory threshold for older adults); (2) residence in a rural area for at least one year; (3) personal or household experience with prescription or over-the-counter medications; and (4) sufficient cognitive and physical ability to participate in an interview. Individuals were excluded if they resided outside rural areas, lacked relevant medication experience, or had cognitive impairments that substantially hindered communication. In addition to older adults, a small number of village doctors and one village councilor were purposively included as key informants [ 28 ] , given their direct involvement in medication distribution, health communication, and disposal coordination at the community level. Their perspectives were essential for contextualizing individual behaviors within the broader institutional and governance environment. Sampling and analysis proceeded iteratively. Recruitment continued until thematic saturation was reached. That is, when additional interviews no longer produced novel codes or conceptual variation [ 29 , 30 ] . 2.5 Data collection Data were collected through semi-structured interviews conducted in August 2024 in Rushan. Interviews generally followed a focused structure and varied in length depending on participants’ responsiveness. All sessions were audio-recorded with informed consent and transcribed verbatim. Sampling continued until thematic saturation was observed in the collected data. The interview manual (Table 1 ) was structured with reference to the key dimensions extracted from TPB and NAM, which also served as the theoretical foundation for the themes and sub-themes explored in the interviews. The questions in the manual were designed to assess participants’ attitudes toward recycling, perceived social pressures (subjective norms), perceived behavioral control, and personal moral obligations. The interview manual was pilot tested and revised to ensure clarity and relevance to the study’s objectives. Table 1 Interview manual Questions in the semi-structured interviews Have you ever participated in the recycling program for expired medications? What is your impression of this recycling program for expired medications? What do you know about expired medicines? Have you ever been requested by family members, neighbors, or children to inspect for expiration dates and ensure the proper disposal of outdated medications in a timely fashion? Has anyone publicized the risks associated with expired pharmaceuticals, the specific channels for their recycling, or related policies, and provided an interpretation of these policies? What might motivate or discourage you from participating in an expired drug take-back? 2.5 Data analysis A primarily deductive thematic analysis was conducted, following Braun and Clarke’s six-phase framework [ 31 ] . While the analysis was guided by theoretical constructs from TPB and NAM, coding remained open to inductively derived subthemes that emerged within each predefined conceptual domain. The analytic process began with familiarization, during which the research team transcribed and repeatedly reviewed the interview materials to identify salient content. A structured codebook was developed based on five core constructs from TPB and NAM: attitudes, subjective norms, perceived behavioral control, awareness of consequences, and moral obligation. While these categories guided the initial coding structure, the framework was iteratively refined to incorporate context-specific subthemes that emerged during analysis. Coding and data management were supported by MAXQDA. Initial codes were grouped into higher-order themes aligned with the theoretical framework and research objectives. These themes were reviewed and refined through iterative team discussions to ensure internal consistency, cross-case coherence, and conceptual clarity. The final thematic structure was synthesized into an interpretive narrative, supported by illustrative quotations, offering a theory-informed account of the psychosocial and contextual factors shaping expired medication disposal behaviors among rural older adults. 2.6 Ethical considerations Ethical approval was obtained from the Ethics Review Board of the School of Medicine at Shandong University (No. LL20240345). Participants were informed that the interviews would be audio-recorded and the data would be transcribed and anonymized to protect their privacy. All participants provided informed consent by signing a document confirming their voluntary participation. Furthermore, all researchers involved in processing raw interview data signed a data processing agreement to ensure data confidentiality and integrity. 3. Results 3.1 Demographic characteristics of participants A total of 45 participants, comprising 19 women and 26 men (see Table 2 for details), took part in the study. Among them, 7 were village doctors, and 1 was a village councilor, purposively included as key informants to capture community-level perspectives. Table 2 a Demographic characteristic of older adult participants Characteristics Age Sex Educational Attainment (Years) Chronic Disease C-01 77 Male 2 Y C-02 71 Female 1 Y C-03 82 Female 6 Y C-04 79 Female 9 Y C-05 79 Male 6 N C-06 80 Male 6 N C-07 80 Male 6 Y C-08 87 Male 6 Y C-09 67 Female 7 Y C-10 80 Male 6 Y C-11 74 Female 6 Y C-12 74 Female 0 Y C-13 76 Female 3 Y C-14 68 Male 9 Y C-15 70 Female 0 Y C-16 75 Female 6 Y C-17 72 Female 4 Y C-18 70 Male 4 N C-19 70 Female 6 Y C-20 75 Male 7 Y C-21 67 Female 10 Y C-22 74 Male 4 N C-23 79 Female 0 Y C-24 71 Male 9 Y C-25 67 Female 6 N C-26 79 Male 6 N C-27 79 Male 8 N C-28 72 Male 6 Y C-29 65 Male 6 Y C-30 73 Male 4 Y C-31 79 Female 6 N C-32 75 Male 10 Y C-33 75 Female 0 Y C-34 82 Male 7 Y C-35 71 Male 2 Y C-36 72 Male 12 N C-37 73 Male 6 Y Table 2 b Demographic characteristics of key informants Characteristics Age Sex Educational Attainment (Years) Chronic Disease D-01 81 Male 2 Y D-02 69 Male 4 N D-03 79 Female 1 Y D-04 74 Female 3 N D-05 81 Male 5 Y D-06 73 Male 9 Y D-07 75 Male 0 Y D-08 67 Female 9 N C = community older adults; D = village doctor or local official (key informants); Y = presence of chronic diseases; N = No chronic diseases. 3.2 Overview of Themes, Sub-Themes, and Representative Codes Table 3 summarizes the analytical framework derived from participant interviews, including 4 themes, 11 sub-themes, and s set of representative codes. The themes reflect core psychosocial and contextual factors influencing expired medication disposal behaviors, while sub-themes delineate specific patterns within each domain. Codes were inductively generated from the data and serve to illustrate the thematic structure. Table 3 Overview of emerged themes, sub-themes, and representative codes Themes Sub-Themes Representative Codes Attitudes toward Expired Medication Disposal Supportive Attitude: Perceived Risk and Civic Responsibility “Concern for health” “Public-benefit” “Environmental safeguarding” Indifferent Attitude: Low Perceived Risk and Lack of Relevance “Low risk perception” “Minimal impact” “Unawareness of importance” Opposed Attitude: Perceived Complexity and Lack of Understanding “Recycle too complicated” “Low perceived relevance” Subjective Norms: Influence of Family Members, Healthcare Authorizes and Local Community Influence of Family Members “Family reminders” “Children encourage safety” Influence of Healthcare Authorities “Doctor influence” “Healthcare guidance needed” Community Norms and Awareness “Community support” “Lack of public awareness” Perceived Behavioral Control: Awareness, Accessibility and Incentives Awareness and Trust in Recycling Programs “Trust in authority” “Lack of recycling awareness” Accessibility and Convenience of Disposal “Recycling point needed” “Difficulty in access” Incentives for Participation “Rewards needed” “Incentives induced” Internal Motivations: Environmental Awareness and Sense of Responsibility Environmental Impact Awareness “Fear of environmental damage” “Pollution/waste awareness” Sense of Responsibility and Civic Duty “Moral duty to recycle” “Community health priority” 3.3 Attitudes toward Expired Medication Disposal Participants expressed three types of attitudes toward expired medication disposal: supportive, indifferent, and opposed. These perspectives reflected different levels of perceived risk, responsibility, and behavioral relevance, which directly shaped their willingness to engage in proper disposal practices. 3.3.1 Supportive Attitude: Perceived Risk and Civic Responsibility Most participants viewed proper disposal positively, emphasizing its significance for personal health, environmental safety, and public well-being. They considered disposal a responsible act aligned with broader social and governmental expectations. “Expired medicines are harmful to health and the environment. Recycling helps keep everyone safe, and it’s beneficial for both the public and the government.” (C-01) "Whether there are small gifts or rewards doesn’t matter; it makes no difference. As long as the recycling activity benefits health, that’s enough." (C-35) Many participants explicitly connected improper disposal with environmental risks and viewed the formal return of expired drugs as a necessary preventive measure. “Throwing expired drugs in the trash could end up polluting our water or soil. Recycling is a better way to handle it.” (C-31) In addition to environmental concerns, some participants emphasized civic responsibility. Participation in disposal activities was perceived not only as a health-preserving behavior but also as alignment with government initiatives and a contribution to collective well-being. “Expired medicines are harmful to health and the environment. Recycling helps keep everyone safe, and it’s beneficial for both the public and the government.” (C-01) 3.3.2 Indifferent Attitude: Low Perceived Risk and Lack of Relevance Some participants expressed indifference toward expired medication disposal. While not explicitly opposed, they did not view the behavior as meaningful or personally relevant. This often resulted in passive attitudes and low motivation to participate. “Whether we recycle or not, it doesn’t make much difference. If it’s expired, I just keep it until I get around to throwing it away.” (C-02) Some participants questioned the actual risks associated with expired drugs, expressing uncertainty or indifference toward their safe disposal. Others noted that they did not typically store medications at home, which made the disposal issue feel largely irrelevant to their everyday lives. “It’s not poisoned, is it? I’m not sure. Normally I just throw them in the trash. I don’t care about those things either.” (C-21) “We don’t have any medicine at home. We just buy some when we’re sick.” (C-32) 3.3.3 Opposed Attitude: Perceived Complexity and Lack of Understanding A few participants expressed opposition to expired medication disposal, often based on perceptions of inconvenience or unclear purpose. Some considered the disposal process burdensome and questioned its necessity, while others view that positioned medication disposal as a governmental responsibility, rather than an individual obligation. “We don’t know what’s the point of recycling expired drugs.” (C-33) “I think recycling expired medications is the government’s responsibility, not ours.” (C-02) 3.4 Subjective Norms: Influence of Family Members, Healthcare Authorizes and Local Community Participants’ intentions toward expired medication disposal were shaped not only by personal attitudes but also by social expectations from family, healthcare providers, and community norms. These normative influences varied in salience and consistency, shaping perceptions of responsibility and reinforcing or weakening disposal behaviors. 3.4.1 Influence of Family Members Many participants identified family members, especially children, as important sources of reminders about expired medications. However, these reminders primarily concerned safe use rather than encouraging formal disposal practices. “My children always remind me to check if the medicines are expired. If they are, they tell me not to take them…just throw them away or leave them aside.” (C-35) In households where family members were less involved or lived away from home, participants reported fewer reminders and less awareness of disposal practices, which weakened the salience of safe disposal as a behavioral concern. “The kids are away at work. We usually not talk about this when they contact me.” (C-29) 3.4.2 Influence of Healthcare Authorities Healthcare authorities, such as village doctors and local officials, played an important role in shaping participants’ perceptions of normative expectations. In communities where these actors actively promoted safe disposal, residents were more likely to view proper disposal as a community-supported and socially responsible behavior. “Our doctor would ask us whether we have expired medications and would tell us about the danger of taking expired medications during yearly check-ups.” (D-03) However, some healthcare authorities reported limited autonomy in promoting medication disposal. Their involvement was largely reactive, contingent on directives from higher-level authorities rather than driven by sustained local initiative. As a result, disposal was not institutionalized as a routine public health activity, but rather perceived as a temporary or non-essential task. “We follow the directions of county-level government. If they assign medication recycling task to us, we have to do that, otherwise, it’s not something we focus on.” (D-07) 3.4.3 Community Norms and Awareness Community norms also shaped participants’ understanding of expired medication disposal. In villages where disposal was occasionally publicized or discussed, residents were more likely to regard it as a socially supported practice. However, most participants reported a general absence of public education or visible endorsement, which limited its presence as a behavioral norm. “In our village, there is no publicity or education about expired medications and their hazards. I guess those who can access Internet might know about it. The danger of taking expired medicine and the need for recycling are not something that we discuss often.” (C-05) In this context, the absence of discussion or modeling made proper disposal less salient and reduced individuals’ motivation to engage. “No one has ever shown us how to recycle, and if someone did, I could show it to someone else.” (C-30) In contrast, participants from communities with more frequent messaging, either via village broadcasts or by door-to-door visits, were more likely to perceive disposal as both beneficial and socially encouraged. “We frequently delivering this kind of information, either through broadcast or deliver the message door-to-door.” (D-01) “Sometimes it was publicized through the village radio system, and sometimes the doctor in the infirmary told us.” (C-36) 3.5 Perceived Behavioral Control: Awareness, Accessibility and Incentives Participants’ sense of control over expired medication disposal was shaped by three key factors: their awareness and trust in formal disposal programs, the accessibility and convenience of disposal facilities, and the presence of external incentives. These factors influenced not only their perceived ability to dispose properly, but also their motivation to do so. 3.5.1 Awareness and Trust in Recycling Programs A lack of awareness and trust in formal disposal mechanisms emerged as a major barrier to participation. Many participants reported having little to no exposure to public communication or education on expired medication disposal, and few recalled receiving guidance from local institutions. In the absence of clear information, expired drugs were often discarded as ordinary waste. “Yes. We didn’t know that expired medicines could be collected, but if we had, I would have given them to you.” (C-03) “No one or organization has addressed this issue, so we just throw them away directly.” (D-07) Trust in institutional actors was also central to participants’ willingness to engage. Many indicated that they would be more inclined to participate if disposal activities were clearly overseen by trusted entities, such as medical professionals or government authorities. “We feel more reassured if professionals or government authorities are in charge; they know how to handle it safely.” (C-30) 3.5.2 Accessibility and Convenience of Disposal The accessibility and convenience of disposal locations played a critical role in shaping participants’ engagement. Most participants expressed a preference for disposal points situated within the village, such as village committee offices or local health clinics, where they could also seek guidance if needed. Proximity to familiar sites was perceived as an important facilitator of participation. “It would be best to have a collection point at the clinic. If there’s something we don’t understand, we can ask the doctor right there.” (C-14) However, some village leaders and healthcare providers noted logistical challenges in maintaining village-level sites. They suggested that town-level collection points might be more sustainable, particularly given the limited understanding of disposal procedures among residents and the absence of a standardized program. "Setting the recycle box up in the village is generally not ideal. It would be better to establish it in the town, as the residents here don’t always fully understand the process. So far, no comprehensive program has been implemented." (D-01) In addition to physical accessibility, the simplicity of the disposal process was seen as essential. Cumbersome procedures were identified as a deterrent, particularly for older adults or those with limited mobility. Participants emphasized the importance of straightforward steps, and some suggested that door-to-door collection services could further reduce barriers to participation. “It should be more convenient. If it’s complicated, people won’t give it away.” (C-35) 3.5.3 Incentives for Participation External incentives were identified as an important motivator for expired medication disposal. Many participants noted that rewards, such as small financial compensation or practical items like soap or detergent, could greatly increase participation. These incentives were seen as valuable, practical benefits that would encourage individuals to actively engage in disposal efforts. “If there is a reward, there will be more people involved in recycling. If there is no reward, fewer people will participate in recycling.” (C-06) 3.6 Internal Motivations: Environmental Awareness and Sense of Responsibility Participants’ internal motivations for expired medication disposal were shaped by two key factors: their awareness of environmental risks and their sense of personal or civic responsibility. These individual-level drivers shaped how participants evaluated the importance of proper disposal, even in the absence of external incentives. 3.6.1 Environmental Impact Awareness Participants demonstrated differing levels of awareness regarding the environmental consequences of improper medication disposal. Many recognized that expired drugs, if discarded improperly, could lead to soil and water pollution. For these individuals, safe disposal was seen as a way to protect their immediate environment and uphold ecological responsibility. “Yes, it pollutes environment. Pollutes the ground, pollutes the water.” (C-07) “Littering surely destroys the environment. I always throw it in the trash.” (C-24) However, others perceived the environmental impact as minimal, particularly when expired medications were mixed with general household waste and later incinerated. This perception diminished the urgency they attached to proper disposal. “Do you think expired medicines pollute the environment? There’s not much harm to the environment.” (D-03) 3.6.2 Sense of Responsibility and Civic Duty For some participants, a sense of personal and civic responsibility served as a key motivator for engaging in proper medication disposal. These individuals regarded safe disposal not only as a matter of personal health, but also as a contribution to collective well-being. They viewed adherence to recommended practices as an ethical obligation aligned with public health guidance. “It’s our duty to recycle, not just for ourselves but for the whole community’s health.” (C-30) “We don’t buy much medicine each year. We only get a little when we are not feeling well, and then we go back for more if we need it.” (C-01) By contrast, other participants expressed limited personal responsibility, believing that the management of expired medications should be handled by government agencies or healthcare institutions rather than individuals. “I think recycling expired medications is the government’s responsibility, not ours.” (C-02) 4. Discussion This study examined the factors influencing older adults’ participation in expired medication disposal in rural China, focusing on how community-level mechanisms operate in a typical county with formal but underutilized recycling infrastructure. These findings provide actionable insights for other settings facing both institutional and behavioral obstacles to safe medication disposal. They highlight how individual engagement is shaped by environmental awareness, social norms, and infrastructural constraints embedded in local contexts. Most participants expressed a favorable attitude toward the safe disposal of expired medications, citing its relevance for both public health and environmental protection. This attitude was primarily informed by an awareness of potential harms such as water and soil contamination. These findings are in line with prior studies that link environmental awareness with increased engagement in pro-environmental behaviors [ 32 ] . However, the extent and specificity of risk perception varied. While participants generally understood the dangers of consuming expired medications, few had access to information about formal disposal procedures. This lack of knowledge about appropriate disposal options appeared to reduce motivation to take action, despite general risk awareness. A notable finding was the absence of consistent community-level guidance on medication disposal, which further limited motivation to participate. Without accessible and clearly communicated pathways, participants tended to underestimate the importance of proper disposal. This observation supports previous research indicating that low perceived risk is associated with reduced likelihood of engaging in safe disposal behaviors [ 33 , 34 , 35 , 36 ] . Participants frequently emphasized the role of trusted local figures, including village leaders and healthcare providers, in shaping their understanding of public health behaviors. In the absence of continuous engagement from these actors, safe disposal was not perceived as a community priority. Additionally, participants who expressed indifferent or dismissive attitudes often believed that expired medications posed minimal harm, further diminishing their motivation. Addressing this perceptual gap requires public health messaging that highlights both environmental and health risks, particularly tailored for older populations with limited access to information. Social norms emerged as an important determinant of disposal behaviors. Family members, especially adult children, influenced participants’ medication management routines, though this influence focused more on safe use than disposal. This echoes previous findings that family involvement can enhance immediate health-related behaviors but may not extend to environmentally oriented actions such as recycling [ 37 ] . At the community level, village committees and local healthcare professionals had mixed effectiveness in promoting disposal practices. Where these actors were proactive, safe disposal was more likely to be perceived as a collective responsibility. However, in the absence of structured mandates and consistent messaging, their role remained marginal. This reflects broader challenges identified in public health governance, where decentralized actors lack the capacity or authority to promote behaviors that are not institutionally embedded [ 38 ] . Strengthening the role of these intermediaries through targeted training and resources could foster more consistent community engagement. Practical barriers related to accessibility, convenience, and incentives were also critical. Many participants expressed a preference for disposal sites located within the village, particularly in familiar places like health clinics or village offices. This preference aligns with prior studies on rural recycling behaviors, which show that physical proximity and ease of access are key facilitators for older populations [ 9 , 39 , 40 , 41 , 42 ] . Some respondents suggested that simplified procedures or mobile collection services could reduce barriers for those with limited mobility. Although incentives such as small household items were frequently cited as motivators, participants generally viewed them as supplementary. Many regarded the health and environmental benefits as the primary justification for participation. This distinction reflects prior findings that extrinsic rewards may encourage initial engagement but are unlikely to sustain behavior in the absence of intrinsic motivation [ 43 ] . A combined approach that integrates modest incentives with long-term educational strategies may be more effective. A recurring theme in this study was participants’ reliance on institutional support and professional guidance for proper disposal practices. Many older adults expressed a preference for recycling initiatives led by healthcare professionals or government agencies, which reflects a reliance on perceived expertise due to limited confidence in their own knowledge about safe disposal. This aligns with findings from other studies, where limited health literacy often leads individuals to defer to institutional authority for public health behaviors [ 35 , 44 ] . Clear communication and visible regulatory frameworks from trusted institutional figures could increase participation rates. Furthermore, participants noted that clear government policies and visible regulation of recycling initiatives would enhance their sense of responsibility and trust in the process. When individuals believe that recycling practices are managed effectively, they are more likely to engage in safe disposal behaviors [ 45 , 46 ] . In regions where there is strong trust in local governance, involving local leaders in public health initiatives can greatly enhance community engagement. These findings highlight the need for a multifaceted, policy-oriented approach that addresses informational, logistical, and motivational barriers. First, public awareness campaigns must communicate clearly the risks of improper disposal, targeting populations with limited exposure to environmental and pharmaceutical safety information. Second, accessibility should be improved through the placement of collection sites in familiar and frequently visited locations. For communities with mobility constraints, door-to-door services could offer an effective alternative. Third, empowering local health workers and village committee members with the resources, training, and institutional support needed to advocate for safe disposal can enhance participation and trust. Finally, modest material incentives may serve as useful entry points, but long-term engagement should be supported by strategies that cultivate a sense of shared responsibility and intrinsic motivation within communities. 5. Conclusion This study deepens understanding of expired medication disposal by revealing how behavioral, normative, and contextual factors jointly shape the actions of older adults in rural China. Although participants acknowledged the risks of improper disposal, engagement was limited by informational blind spots, low perceived efficacy, and the absence of normative cues from trusted local actors. These findings highlight the limitations of top-down interventions in contexts lacking localized social endorsement. Promoting safe disposal in such settings requires more than infrastructure, it calls for strategies that activate community norms, embed moral responsibility in everyday practices, and mobilize trusted relationships. By integrating behavioral theory with context-specific insights, this study offers a framework for culturally responsive, community-driven approaches to pharmaceutical waste governance. Abbreviations TPB Theory of Planned Behavior NAM Norm Activation Model NatRUM National Return of Unwanted Medicines Declarations Ethics approval and consent to participate The research protocols and ethics were reviewed and approved by the Ethics Committee of School of Public Health, Shandong University (the number is LL20240345). The informed consent was obtained from all participants in this study. All methods were performed according to the relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Science Foundation of China (grant numbers 72274109, 72404174), the Shandong Provincial Natural Foundation (grant number: ZR2021QG018). Authors' contributions Zhanghao Yu conceived and designed the study, performed data analysis and drafted the manuscript. Ziyu Liu provided the critical feedback, critically revised the manuscript. Chengchao Zhou directed its implementation, including the data collection and analysis. Tianran He participated in the collection and consolidation of initial data. All authors read and approved the final manuscript. 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Nursing Journal of Chinese People’s Liberation Army. 2018; 35(10): 20-24. Alfian S D, Adhinagoro B, Winardi D O, Angela F, Griselda M, Gathera V A, Abdulah R. Pharmacist-Led Interventions in Addressing Improper disposal Practices of unused and expired household Medication: A Systematic review. Heliyon. 2024; 10(18): e37764. Schwarze M L, Kaji A H, Ghaferi A A. Practical guide to Qualitative analysis. JAMA Surgery. 2020; 155(3): 252. Denny E, Weckesser A. Quality not quantity. BJOG an International Journal of Obstetrics & Gynaecology. 2022; 129(10): 1799–1800. Jiali C, Wenhao Z, Yuan Z. A Survey on the Recycling of Expired Medicines by Foshan Citizens. China Economic & Trade Herald. 2021; 06: 129-131. Gaofeng Z, Yueyue P, Rui C. Survey on the Disposal of Expired Medicines in Guiyang City Residents’ Households. Chinese Journal of Rural Medicine and Pharmacy. 2021; 28(17): 52-54. Weihai Market Supervision Administration. Notice on the Issuance of Administrative Measures for the Recycling and Destruction of Household Expired Drugs in Weihai Cityz. https://www.weihai.gov.cn/flash/0/84c8393941fc4627b72588bbe52ac4ab.pdf(2021). Accessed 10 Jul 2025. Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991; 50(2): 179–211. Schwartz S H. Normative influences on altruism. Advances in experimental social psychology. 1977; 10: 221–279. Joung H, Park‐Poaps H. Factors motivating and influencing clothing disposal behaviours. International Journal of Consumer Studies. 2011; 37(1): 105–111. Wen-Ting D, Guang-Rong J. A review of the theory of planned behavior. Advances in Psychological Science. 2008; 16(2): 315-320. De Groot J, Steg L. General Beliefs and the Theory of planned Behavior: The role of Environmental Concerns in the TPB. Journal of Applied Social Psychology. 2007; 37(8): 1817–1836. Black J S, Stern P C, Elworth J T. Personal and contextual influences on househould energy adaptations. Journal of Applied Psychology. 1985; 70(1): 3–21. Thφgersen J. The ethical consumer. moral norms and packaging choice. Journal of Consumer Policy. 1999; 22(4): 439–460. Patton M. Qualitative Research and Evaluation Methods. 4th Ed. Thousand Oaks: Sage Publications; 2015. Guest G, Bunce A, Johnson L. How many interviews are enough? Field Methods. 2006; 18(1): 59–82. Francis J J, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles M P, Grimshaw J M. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychology and Health. 2010; 25(10): 1229–1245. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2): 77–101. Lima M L, Luís S, Poggio L, Aragonés J I, Courtier A, Roig B, Calas-Blanchard C. The importance of household pharmaceutical products disposal and its risk management: Example from Southwestern Europe. Waste Management. 2020; 104: 139–147. Aluko O, Imbianozor G, Jideama C, Ogundele O, Fapetu T, Afolabi O, Odewade O. The perception and disposal practices of unused and expired medicines by households in an urban municipality, southwest Nigeria: A comparative cross-sectional study. Waste Management. 2022; 140: 121–132. Quadra G R, Silva P S, Paranaíba J R, Josué I I, Souza H, Costa R, Fernandez M, Vilas-Boas J, Roland F. Investigation of medicines consumption and disposal in Brazil: A study case in a developing country. The Science of the Total Environment. 2019; 671: 505–509. Toe J, Orok E, Erah P. Assessment of knowledge and disposal practices of unused and expired household medicines in a community in Liberia. Exploratory Research in Clinical and Social Pharmacy. 2023; 12: 100369. Srijuntrapun P, Maluangnon K. The management of unused and expired medications in Thai households: Influencing factors and prevailing practices. PLoS ONE. 2024; 19(8): e0309266. De Groot J I M, Steg L. Morality and Prosocial Behavior: The role of awareness, responsibility, and norms in the norm activation model. The Journal of Social Psychology. 2009; 149(4): 425–449. Xiaoping J, Shuwen Y. Legitimacy motives and selective strategies: the generative logic of the paradox of burden reduction at the rural grassroots level. Administrative Tribune. 2024; 31(04): 145-154. Amoabeng I A, Otoo B A, Darko G, Borquaye L S. Disposal of Unused and Expired Medicines within the Sunyani Municipality of Ghana: A Cross‐Sectional Survey. Journal of Environmental and Public Health. 2022; 2022(1): 6113346. Jun G, Yi H, Luman W, Qingyu Y. Current Situation of the Recycling of Family Expired Drugs in Zhengzhou Residents and the Research on Countermeasures. Chinese Journal of Medicinal Guide. 2023; 25(05): 543-548. Hehua B, Shimin Y. Research on the current situation and countermeasures on the recycling of family expired drugs in xi’an. Northwest Pharmaceutical Journal. 2018; 33(02): 267-270. Xiaojuan F, Yuanjuan Y, Yun W, Jing B, Bin W. Survey on resident behavior of expired drugs disposal in chongqing families and suggestions for drug recycling. China Pharmacy. 2018; 29(07): 999-1005. Promberger M, Marteau T M. When do financial incentives reduce intrinsic motivation? Comparing behaviors studied in psychological and economic literatures. Health Psychology. 2013; 32(9): 950–957. Hajj A, Domiati S, Haddad C, Sacre H, Akl M, Akel M, Tawil S, Abramian S, Zeenny R M, Hodeib F, Salameh P. Assessment of knowledge, attitude, and practice regarding the disposal of expired and unused medications among the Lebanese population. Journal of Pharmaceutical Policy and Practice. 2022; 15: 107. Kusturica M P, Golocorbin-Kon S, Ostojic T, Kresoja M, Milovic M, Horvat O, Dugandzija T, Davidovac N, Vasic A, Tomas A. Consumer willingness to pay for a pharmaceutical disposal program in Serbia: A double hurdle modeling approach. Waste Management. 2020; 104: 246–253. Hiew S Y, Low B Y. The knowledge, attitude, and practice of the public regarding household pharmaceutical waste disposal: a systematic review (2013–2023). International Journal of Pharmacy Practice. 2024; 32(2): 120–132. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7100179","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489941032,"identity":"94548775-af3d-4a4c-993a-aef581c17cc0","order_by":0,"name":"Zhanghao Yu","email":"","orcid":"","institution":"Department of Social Medicine and Health Management, School of Public Health, Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Zhanghao","middleName":"","lastName":"Yu","suffix":""},{"id":489941033,"identity":"bb992b21-5670-4655-bfc7-f7a391e0a7d7","order_by":1,"name":"Tianran He","email":"","orcid":"","institution":"Department of Social Medicine and Health Management, School of Public Health, Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Tianran","middleName":"","lastName":"He","suffix":""},{"id":489941034,"identity":"0e5e9988-4bcc-47db-acc6-85dab1b95167","order_by":2,"name":"Ziyu Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYDACZhBRIMHAz8BgAOMSo8VAgkGygWgtYABUbHCAWC3y7TxmEgwGFombzx/eJsFQYZ3YwH72AF4tjM1gLRKJ226klUkwnElPbODJS8CrhZkZrgXIYGw7nNggwWOAVwsbTMvm/jNALf+I0MID07KBIQeopYEILRLMbMUWCQYSxjNupAEZx9KN23hy8GuR7z+88caHijrZfjCjxlq2n/0Mfi0MDBwGDAkwNojBRkA9ELA/IKxmFIyCUTAKRjYAAFL3N6/Ji1bqAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Social Medicine and Health Management, School of Public Health, Cheeloo College of Medicine, Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Ziyu","middleName":"","lastName":"Liu","suffix":""},{"id":489941035,"identity":"828fa66d-d07f-433b-87e7-13dbcb617d2e","order_by":3,"name":"Chengchao Zhou","email":"","orcid":"","institution":"Department of Social Medicine and Health Management, School of Public Health, Cheeloo College of Medicine, Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Chengchao","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2025-07-11 09:38:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7100179/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7100179/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87693311,"identity":"b9181cd6-a760-4ccd-b2f9-3919508e36c0","added_by":"auto","created_at":"2025-07-28 05:31:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70720,"visible":true,"origin":"","legend":"\u003cp\u003eTheoretical framework.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7100179/v1/341400e47cc6f410a43ecbd9.png"},{"id":104993566,"identity":"4e910287-a45a-4580-97fb-ccc1e6f9cefa","added_by":"auto","created_at":"2026-03-19 15:56:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1362789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7100179/v1/07b76d6e-f422-48aa-b227-46c527a651fa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Awareness: Social and Structural Barriers to Expired Medication Disposal Among Rural Older Adults in China","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe improper disposal of expired medications poses escalating threats to public health and environmental sustainability\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Pharmaceutical compounds often persist in aquatic environments even after wastewater treatment, contributing to ecosystem contamination and posing risks to population health\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Studies have documented the ecological consequences of pharmaceutical residues, including endocrine disruption in aquatic species and population declines in scavengers due to exposure to non-steroidal anti-inflammatory drugs\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. These risks are amplified in rural areas, where environmental protections and waste management systems remain underdeveloped, and improper disposal methods, such as burning or landfilling, further degrade soil and water quality.\u003c/p\u003e\u003cp\u003eDespite growing awareness of these hazards, safe and standardized disposal systems remain insufficient globally, particularly in rural China, where public awareness is limited and infrastructure for pharmaceutical waste management is lacking\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. While high-income countries have established effective national drug take-back systems, such as Australia\u0026rsquo;s National Return and Disposal of Unused Medicines\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, Canada\u0026rsquo;s implementation of the National Return of Unwanted Medicines (NatRUM) program\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, and the U.S. Food and Drug Administration\u0026rsquo;s drug take-back initiatives\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, China has yet to implement a coordinated national strategy. In some urban areas, pilot programs like the \u0026ldquo;Expired Medicine Collection \u0026amp; Change-for-Free\u0026rdquo; initiative have emerged, but rural regions remain largely excluded due to the absence of supportive policy frameworks and institutional coordination mechanisms\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOlder adults are particularly vulnerable in this context. As primary users of medications, they are more likely to accumulate expired or unused drugs due to challenges in adherence, polypharmacy, and limited awareness of proper disposal procedures\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In rural areas, these challenges are compounded by lower health literacy and poor access to formal recycling infrastructure, further elevating environmental and health risks\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAlthough various policy and programmatic interventions have been introduced to promote safe medication disposal, their effectiveness has remained limited, primarily due to persistently low levels of public engagement and the predominance of passive, compliance-based participation\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. This disconnect highlights a critical implementation gap where formal policy provisions fail to translate into meaningful behavioral uptake at the community level. To address this, the present study investigates the psychosocial and contextual factors that condition older adults\u0026rsquo; participation in expired medication disposal in rural China, offering empirical insights to inform more effective, community-responsive policy design.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1. Study design\u003c/h2\u003e\n \u003cp\u003eThis study employs a qualitative research design to investigate the factors influencing rural older adults\u0026rsquo; participation in expired medication disposal within the context of the government-designated recycling programs. Qualitative research is particularly suited for examining context-dependent behaviors shaped by social norms, resource accessibility, and individual motivation\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Unlike previous domestic studies that have primarily relied on survey-based descriptive analyses of household drug accumulation and disposal\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, this study draws on in-depth qualitative inquiry to capture the complex psychosocial and structural dynamics underpinning disposal behaviors. By exploring the lived experiences and perspectives of participants, this approach provides a deeper and more comprehensive understanding of the factors shaping prescription take-back behaviors among older adults in rural settings.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Study setting\u003c/h2\u003e\n \u003cp\u003eThis study was conducted in Rushan, a county-level city in eastern Shandong Province, China, where the urbanization level remains relatively low and much of the population resides in rural towns and villages. In 2021, it implemented a pharmaceutical waste take-back program as part of a broader municipal initiative led by the Weihai government. The program introduced designated collection points in village clinics and pharmacies, public information campaigns, and small material incentives to encourage the return of expired medications\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. While the program has been in place for over four years, how local residents engage with it remains insufficiently understood. Like many rural regions in China, Rushan faces structural constraints that may shape participation, including population aging, uneven access to formal disposal infrastructure, and relatively low levels of awareness for health and environment. These conditions reveal a gap between policy design and behavioral response, and underscore the importance of examining how individual motivations, social expectations, and contextual constraints shape engagement with formal medication disposal initiatives.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Theoretical foundation\u003c/h2\u003e\n \u003cp\u003eTo examine the factors shaping older adults\u0026rsquo; engagement in expired medication disposal, this study draws on two complementary behavioral models: the Theory of Planned Behavior (TPB)\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e and the Norm Activation Model (NAM)\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Together, these frameworks provide a structured lens for analyzing both externally regulated behavior, such as responses to perceived social expectations or institutional facilitation, and internally motivated actions informed by personal values and moral obligation.\u003c/p\u003e\n \u003cp\u003eThe TPB posits that behavior is shaped by three components: attitudes (evaluations of the behavior), subjective norms (perceived social pressure), and perceived behavioral control (belief in one\u0026rsquo;s ability to act)\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. This model is particularly useful in understanding intentional, non-habitual actions such as participation in formal take-back programs\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The NAM emphasizes personal moral norms as key behavioral drivers. Behavior is more likely to occur when individuals are aware of the negative consequences of inaction and feel personally responsible for mitigating them\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. This perspective highlights the ethical and normative dimensions of behavior, particularly in areas where regulatory mechanisms exist but participation remains inconsistent.\u003c/p\u003e\n \u003cp\u003eIn this study, the two models are integrated to capture both the rational-intentional and moral-normative dimensions of medication disposal behavior. As illustrated in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, the conceptual framework links structural and psychosocial variables, including attitudes, subjective norms, perceived behavioral control, awareness of consequences, and moral obligation, to behaviors. This integrative model informed the development of the interview guide and guided the initial thematic coding strategy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Sampling and recruitment\u003c/h2\u003e\n \u003cp\u003eA purposive sampling strategy was used to recruit rural older adults with diverse experiences relevant to expired medication disposal. Sampling aimed to capture variation in age, sex, education level, and medication-related practices, in alignment with the study\u0026rsquo;s behavioral focus.\u003c/p\u003e\n \u003cp\u003eParticipants were recruited from multiple villages in Rushan, with support from local healthcare providers such as village doctors and clinic staff. These providers served as trusted intermediaries due to their familiarity with the local population and their routine involvement in medication distribution and use. Inclusion criteria were: (1) being aged 60 or above (in line with China\u0026rsquo;s statutory threshold for older adults); (2) residence in a rural area for at least one year; (3) personal or household experience with prescription or over-the-counter medications; and (4) sufficient cognitive and physical ability to participate in an interview. Individuals were excluded if they resided outside rural areas, lacked relevant medication experience, or had cognitive impairments that substantially hindered communication.\u003c/p\u003e\n \u003cp\u003eIn addition to older adults, a small number of village doctors and one village councilor were purposively included as key informants\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, given their direct involvement in medication distribution, health communication, and disposal coordination at the community level. Their perspectives were essential for contextualizing individual behaviors within the broader institutional and governance environment.\u003c/p\u003e\n \u003cp\u003eSampling and analysis proceeded iteratively. Recruitment continued until thematic saturation was reached. That is, when additional interviews no longer produced novel codes or conceptual variation\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Data collection\u003c/h2\u003e\n \u003cp\u003eData were collected through semi-structured interviews conducted in August 2024 in Rushan. Interviews generally followed a focused structure and varied in length depending on participants\u0026rsquo; responsiveness. All sessions were audio-recorded with informed consent and transcribed verbatim. Sampling continued until thematic saturation was observed in the collected data. The interview manual (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) was structured with reference to the key dimensions extracted from TPB and NAM, which also served as the theoretical foundation for the themes and sub-themes explored in the interviews. The questions in the manual were designed to assess participants\u0026rsquo; attitudes toward recycling, perceived social pressures (subjective norms), perceived behavioral control, and personal moral obligations. The interview manual was pilot tested and revised to ensure clarity and relevance to the study\u0026rsquo;s objectives.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview manual\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuestions in the semi-structured interviews\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHave you ever participated in the recycling program for expired medications?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhat is your impression of this recycling program for expired medications?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhat do you know about expired medicines?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHave you ever been requested by family members, neighbors, or children to inspect for expiration dates and ensure the proper disposal of outdated medications in a timely fashion?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHas anyone publicized the risks associated with expired pharmaceuticals, the specific channels for their recycling, or related policies, and provided an interpretation of these policies?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhat might motivate or discourage you from participating in an expired drug take-back?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Data analysis\u003c/h2\u003e\n \u003cp\u003eA primarily deductive thematic analysis was conducted, following Braun and Clarke\u0026rsquo;s six-phase framework\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. While the analysis was guided by theoretical constructs from TPB and NAM, coding remained open to inductively derived subthemes that emerged within each predefined conceptual domain.\u003c/p\u003e\n \u003cp\u003eThe analytic process began with familiarization, during which the research team transcribed and repeatedly reviewed the interview materials to identify salient content. A structured codebook was developed based on five core constructs from TPB and NAM: attitudes, subjective norms, perceived behavioral control, awareness of consequences, and moral obligation. While these categories guided the initial coding structure, the framework was iteratively refined to incorporate context-specific subthemes that emerged during analysis. Coding and data management were supported by MAXQDA.\u003c/p\u003e\n \u003cp\u003eInitial codes were grouped into higher-order themes aligned with the theoretical framework and research objectives. These themes were reviewed and refined through iterative team discussions to ensure internal consistency, cross-case coherence, and conceptual clarity. The final thematic structure was synthesized into an interpretive narrative, supported by illustrative quotations, offering a theory-informed account of the psychosocial and contextual factors shaping expired medication disposal behaviors among rural older adults.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e\n \u003cp\u003eEthical approval was obtained from the Ethics Review Board of the School of Medicine at Shandong University (No. LL20240345). Participants were informed that the interviews would be audio-recorded and the data would be transcribed and anonymized to protect their privacy. All participants provided informed consent by signing a document confirming their voluntary participation. Furthermore, all researchers involved in processing raw interview data signed a data processing agreement to ensure data confidentiality and integrity.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Demographic characteristics of participants\u003c/h2\u003e\u003cp\u003eA total of 45 participants, comprising 19 women and 26 men (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e for details), took part in the study. Among them, 7 were village doctors, and 1 was a village councilor, purposively included as key informants to capture community-level perspectives.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ea Demographic characteristic of older adult participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducational Attainment (Years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChronic Disease\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC-37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eb Demographic characteristics of key informants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducational Attainment (Years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChronic Disease\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eY\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD-08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;community older adults; D\u0026thinsp;=\u0026thinsp;village doctor or local official (key informants); Y\u0026thinsp;=\u0026thinsp;presence of chronic diseases; N\u0026thinsp;=\u0026thinsp;No chronic diseases.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Overview of Themes, Sub-Themes, and Representative Codes\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the analytical framework derived from participant interviews, including 4 themes, 11 sub-themes, and s set of representative codes. The themes reflect core psychosocial and contextual factors influencing expired medication disposal behaviors, while sub-themes delineate specific patterns within each domain. Codes were inductively generated from the data and serve to illustrate the thematic structure.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverview of emerged themes, sub-themes, and representative codes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-Themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRepresentative Codes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAttitudes toward Expired Medication Disposal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupportive Attitude: Perceived Risk and Civic Responsibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Concern for health\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Public-benefit\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Environmental safeguarding\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndifferent Attitude: Low Perceived Risk and Lack of Relevance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Low risk perception\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Minimal impact\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Unawareness of importance\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpposed Attitude: Perceived Complexity and Lack of Understanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Recycle too complicated\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Low perceived relevance\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSubjective Norms: Influence of Family Members, Healthcare Authorizes and Local Community\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInfluence of Family Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Family reminders\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Children encourage safety\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInfluence of Healthcare Authorities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Doctor influence\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Healthcare guidance needed\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity Norms and Awareness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Community support\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Lack of public awareness\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePerceived Behavioral Control: Awareness, Accessibility and Incentives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAwareness and Trust in Recycling Programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Trust in authority\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Lack of recycling awareness\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccessibility and Convenience of Disposal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Recycling point needed\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Difficulty in access\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncentives for Participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Rewards needed\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Incentives induced\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eInternal Motivations: Environmental Awareness and Sense of Responsibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnvironmental Impact Awareness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Fear of environmental damage\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Pollution/waste awareness\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSense of Responsibility and Civic Duty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Moral duty to recycle\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Community health priority\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Attitudes toward Expired Medication Disposal\u003c/h2\u003e\u003cp\u003eParticipants expressed three types of attitudes toward expired medication disposal: supportive, indifferent, and opposed. These perspectives reflected different levels of perceived risk, responsibility, and behavioral relevance, which directly shaped their willingness to engage in proper disposal practices.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Supportive Attitude: Perceived Risk and Civic Responsibility\u003c/h2\u003e\u003cp\u003eMost participants viewed proper disposal positively, emphasizing its significance for personal health, environmental safety, and public well-being. They considered disposal a responsible act aligned with broader social and governmental expectations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Expired medicines are harmful to health and the environment. Recycling helps keep everyone safe, and it\u0026rsquo;s beneficial for both the public and the government.\u0026rdquo; (C-01)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Whether there are small gifts or rewards doesn\u0026rsquo;t matter; it makes no difference. As long as the recycling activity benefits health, that\u0026rsquo;s enough.\" (C-35)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMany participants explicitly connected improper disposal with environmental risks and viewed the formal return of expired drugs as a necessary preventive measure.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Throwing expired drugs in the trash could end up polluting our water or soil. Recycling is a better way to handle it.\u0026rdquo;\u003c/em\u003e (C-31)\u003c/p\u003e\u003cp\u003eIn addition to environmental concerns, some participants emphasized civic responsibility. Participation in disposal activities was perceived not only as a health-preserving behavior but also as alignment with government initiatives and a contribution to collective well-being.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Expired medicines are harmful to health and the environment. Recycling helps keep everyone safe, and it\u0026rsquo;s beneficial for both the public and the government.\u0026rdquo;\u003c/em\u003e (C-01)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2 Indifferent Attitude: Low Perceived Risk and Lack of Relevance\u003c/h2\u003e\u003cp\u003eSome participants expressed indifference toward expired medication disposal. While not explicitly opposed, they did not view the behavior as meaningful or personally relevant. This often resulted in passive attitudes and low motivation to participate.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Whether we recycle or not, it doesn\u0026rsquo;t make much difference. If it\u0026rsquo;s expired, I just keep it until I get around to throwing it away.\u0026rdquo;\u003c/em\u003e (C-02)\u003c/p\u003e\u003cp\u003eSome participants questioned the actual risks associated with expired drugs, expressing uncertainty or indifference toward their safe disposal. Others noted that they did not typically store medications at home, which made the disposal issue feel largely irrelevant to their everyday lives.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not poisoned, is it? I\u0026rsquo;m not sure. Normally I just throw them in the trash. I don\u0026rsquo;t care about those things either.\u0026rdquo;\u003c/em\u003e (C-21)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t have any medicine at home. We just buy some when we\u0026rsquo;re sick.\u0026rdquo;\u003c/em\u003e (C-32)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3 Opposed Attitude: Perceived Complexity and Lack of Understanding\u003c/h2\u003e\u003cp\u003eA few participants expressed opposition to expired medication disposal, often based on perceptions of inconvenience or unclear purpose. Some considered the disposal process burdensome and questioned its necessity, while others view that positioned medication disposal as a governmental responsibility, rather than an individual obligation.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t know what\u0026rsquo;s the point of recycling expired drugs.\u0026rdquo;\u003c/em\u003e (C-33)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think recycling expired medications is the government\u0026rsquo;s responsibility, not ours.\u0026rdquo;\u003c/em\u003e (C-02)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Subjective Norms: Influence of Family Members, Healthcare Authorizes and Local Community\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; intentions toward expired medication disposal were shaped not only by personal attitudes but also by social expectations from family, healthcare providers, and community norms. These normative influences varied in salience and consistency, shaping perceptions of responsibility and reinforcing or weakening disposal behaviors.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Influence of Family Members\u003c/h2\u003e\u003cp\u003eMany participants identified family members, especially children, as important sources of reminders about expired medications. However, these reminders primarily concerned safe use rather than encouraging formal disposal practices.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My children always remind me to check if the medicines are expired. If they are, they tell me not to take them\u0026hellip;just throw them away or leave them aside.\u0026rdquo;\u003c/em\u003e (C-35)\u003c/p\u003e\u003cp\u003eIn households where family members were less involved or lived away from home, participants reported fewer reminders and less awareness of disposal practices, which weakened the salience of safe disposal as a behavioral concern.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The kids are away at work. We usually not talk about this when they contact me.\u0026rdquo;\u003c/em\u003e (C-29)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Influence of Healthcare Authorities\u003c/h2\u003e\u003cp\u003eHealthcare authorities, such as village doctors and local officials, played an important role in shaping participants\u0026rsquo; perceptions of normative expectations. In communities where these actors actively promoted safe disposal, residents were more likely to view proper disposal as a community-supported and socially responsible behavior.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Our doctor would ask us whether we have expired medications and would tell us about the danger of taking expired medications during yearly check-ups.\u0026rdquo;\u003c/em\u003e (D-03)\u003c/p\u003e\u003cp\u003eHowever, some healthcare authorities reported limited autonomy in promoting medication disposal. Their involvement was largely reactive, contingent on directives from higher-level authorities rather than driven by sustained local initiative. As a result, disposal was not institutionalized as a routine public health activity, but rather perceived as a temporary or non-essential task.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We follow the directions of county-level government. If they assign medication recycling task to us, we have to do that, otherwise, it\u0026rsquo;s not something we focus on.\u0026rdquo;\u003c/em\u003e (D-07)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Community Norms and Awareness\u003c/h2\u003e\u003cp\u003eCommunity norms also shaped participants\u0026rsquo; understanding of expired medication disposal. In villages where disposal was occasionally publicized or discussed, residents were more likely to regard it as a socially supported practice. However, most participants reported a general absence of public education or visible endorsement, which limited its presence as a behavioral norm.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In our village, there is no publicity or education about expired medications and their hazards. I guess those who can access Internet might know about it. The danger of taking expired medicine and the need for recycling are not something that we discuss often.\u0026rdquo;\u003c/em\u003e (C-05)\u003c/p\u003e\u003cp\u003eIn this context, the absence of discussion or modeling made proper disposal less salient and reduced individuals\u0026rsquo; motivation to engage.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No one has ever shown us how to recycle, and if someone did, I could show it to someone else.\u0026rdquo;\u003c/em\u003e (C-30)\u003c/p\u003e\u003cp\u003e In contrast, participants from communities with more frequent messaging, either via village broadcasts or by door-to-door visits, were more likely to perceive disposal as both beneficial and socially encouraged.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We frequently delivering this kind of information, either through broadcast or deliver the message door-to-door.\u0026rdquo;\u003c/em\u003e (D-01)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes it was publicized through the village radio system, and sometimes the doctor in the infirmary told us.\u0026rdquo;\u003c/em\u003e (C-36)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Perceived Behavioral Control: Awareness, Accessibility and Incentives\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; sense of control over expired medication disposal was shaped by three key factors: their awareness and trust in formal disposal programs, the accessibility and convenience of disposal facilities, and the presence of external incentives. These factors influenced not only their perceived ability to dispose properly, but also their motivation to do so.\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003e3.5.1 Awareness and Trust in Recycling Programs\u003c/h2\u003e\u003cp\u003eA lack of awareness and trust in formal disposal mechanisms emerged as a major barrier to participation. Many participants reported having little to no exposure to public communication or education on expired medication disposal, and few recalled receiving guidance from local institutions. In the absence of clear information, expired drugs were often discarded as ordinary waste.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes. We didn\u0026rsquo;t know that expired medicines could be collected, but if we had, I would have given them to you.\u0026rdquo;\u003c/em\u003e (C-03)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No one or organization has addressed this issue, so we just throw them away directly.\u0026rdquo;\u003c/em\u003e (D-07)\u003c/p\u003e\u003cp\u003eTrust in institutional actors was also central to participants\u0026rsquo; willingness to engage. Many indicated that they would be more inclined to participate if disposal activities were clearly overseen by trusted entities, such as medical professionals or government authorities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We feel more reassured if professionals or government authorities are in charge; they know how to handle it safely.\u0026rdquo;\u003c/em\u003e (C-30)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e3.5.2 Accessibility and Convenience of Disposal\u003c/h2\u003e\u003cp\u003eThe accessibility and convenience of disposal locations played a critical role in shaping participants\u0026rsquo; engagement. Most participants expressed a preference for disposal points situated within the village, such as village committee offices or local health clinics, where they could also seek guidance if needed. Proximity to familiar sites was perceived as an important facilitator of participation.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It would be best to have a collection point at the clinic. If there\u0026rsquo;s something we don\u0026rsquo;t understand, we can ask the doctor right there.\u0026rdquo;\u003c/em\u003e (C-14)\u003c/p\u003e\u003cp\u003eHowever, some village leaders and healthcare providers noted logistical challenges in maintaining village-level sites. They suggested that town-level collection points might be more sustainable, particularly given the limited understanding of disposal procedures among residents and the absence of a standardized program.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Setting the recycle box up in the village is generally not ideal. It would be better to establish it in the town, as the residents here don\u0026rsquo;t always fully understand the process. So far, no comprehensive program has been implemented.\"\u003c/em\u003e (D-01)\u003c/p\u003e\u003cp\u003eIn addition to physical accessibility, the simplicity of the disposal process was seen as essential. Cumbersome procedures were identified as a deterrent, particularly for older adults or those with limited mobility. Participants emphasized the importance of straightforward steps, and some suggested that door-to-door collection services could further reduce barriers to participation.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It should be more convenient. If it\u0026rsquo;s complicated, people won\u0026rsquo;t give it away.\u0026rdquo;\u003c/em\u003e (C-35)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003e3.5.3 Incentives for Participation\u003c/h2\u003e\u003cp\u003eExternal incentives were identified as an important motivator for expired medication disposal. Many participants noted that rewards, such as small financial compensation or practical items like soap or detergent, could greatly increase participation. These incentives were seen as valuable, practical benefits that would encourage individuals to actively engage in disposal efforts.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If there is a reward, there will be more people involved in recycling. If there is no reward, fewer people will participate in recycling.\u0026rdquo;\u003c/em\u003e (C-06)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Internal Motivations: Environmental Awareness and Sense of Responsibility\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; internal motivations for expired medication disposal were shaped by two key factors: their awareness of environmental risks and their sense of personal or civic responsibility. These individual-level drivers shaped how participants evaluated the importance of proper disposal, even in the absence of external incentives.\u003c/p\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003e3.6.1 Environmental Impact Awareness\u003c/h2\u003e\u003cp\u003eParticipants demonstrated differing levels of awareness regarding the environmental consequences of improper medication disposal. Many recognized that expired drugs, if discarded improperly, could lead to soil and water pollution. For these individuals, safe disposal was seen as a way to protect their immediate environment and uphold ecological responsibility.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, it pollutes environment. Pollutes the ground, pollutes the water.\u0026rdquo;\u003c/em\u003e (C-07)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Littering surely destroys the environment. I always throw it in the trash.\u0026rdquo;\u003c/em\u003e (C-24)\u003c/p\u003e\u003cp\u003eHowever, others perceived the environmental impact as minimal, particularly when expired medications were mixed with general household waste and later incinerated. This perception diminished the urgency they attached to proper disposal.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Do you think expired medicines pollute the environment? There\u0026rsquo;s not much harm to the environment.\u0026rdquo;\u003c/em\u003e (D-03)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003e3.6.2 Sense of Responsibility and Civic Duty\u003c/h2\u003e\u003cp\u003e For some participants, a sense of personal and civic responsibility served as a key motivator for engaging in proper medication disposal. These individuals regarded safe disposal not only as a matter of personal health, but also as a contribution to collective well-being. They viewed adherence to recommended practices as an ethical obligation aligned with public health guidance.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s our duty to recycle, not just for ourselves but for the whole community\u0026rsquo;s health.\u0026rdquo;\u003c/em\u003e (C-30)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t buy much medicine each year. We only get a little when we are not feeling well, and then we go back for more if we need it.\u0026rdquo;\u003c/em\u003e (C-01)\u003c/p\u003e\u003cp\u003eBy contrast, other participants expressed limited personal responsibility, believing that the management of expired medications should be handled by government agencies or healthcare institutions rather than individuals.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think recycling expired medications is the government\u0026rsquo;s responsibility, not ours.\u0026rdquo;\u003c/em\u003e (C-02)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study examined the factors influencing older adults\u0026rsquo; participation in expired medication disposal in rural China, focusing on how community-level mechanisms operate in a typical county with formal but underutilized recycling infrastructure. These findings provide actionable insights for other settings facing both institutional and behavioral obstacles to safe medication disposal. They highlight how individual engagement is shaped by environmental awareness, social norms, and infrastructural constraints embedded in local contexts.\u003c/p\u003e\u003cp\u003eMost participants expressed a favorable attitude toward the safe disposal of expired medications, citing its relevance for both public health and environmental protection. This attitude was primarily informed by an awareness of potential harms such as water and soil contamination. These findings are in line with prior studies that link environmental awareness with increased engagement in pro-environmental behaviors\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. However, the extent and specificity of risk perception varied. While participants generally understood the dangers of consuming expired medications, few had access to information about formal disposal procedures. This lack of knowledge about appropriate disposal options appeared to reduce motivation to take action, despite general risk awareness.\u003c/p\u003e\u003cp\u003eA notable finding was the absence of consistent community-level guidance on medication disposal, which further limited motivation to participate. Without accessible and clearly communicated pathways, participants tended to underestimate the importance of proper disposal. This observation supports previous research indicating that low perceived risk is associated with reduced likelihood of engaging in safe disposal behaviors\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Participants frequently emphasized the role of trusted local figures, including village leaders and healthcare providers, in shaping their understanding of public health behaviors. In the absence of continuous engagement from these actors, safe disposal was not perceived as a community priority. Additionally, participants who expressed indifferent or dismissive attitudes often believed that expired medications posed minimal harm, further diminishing their motivation. Addressing this perceptual gap requires public health messaging that highlights both environmental and health risks, particularly tailored for older populations with limited access to information.\u003c/p\u003e\u003cp\u003eSocial norms emerged as an important determinant of disposal behaviors. Family members, especially adult children, influenced participants\u0026rsquo; medication management routines, though this influence focused more on safe use than disposal. This echoes previous findings that family involvement can enhance immediate health-related behaviors but may not extend to environmentally oriented actions such as recycling\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. At the community level, village committees and local healthcare professionals had mixed effectiveness in promoting disposal practices. Where these actors were proactive, safe disposal was more likely to be perceived as a collective responsibility. However, in the absence of structured mandates and consistent messaging, their role remained marginal. This reflects broader challenges identified in public health governance, where decentralized actors lack the capacity or authority to promote behaviors that are not institutionally embedded\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Strengthening the role of these intermediaries through targeted training and resources could foster more consistent community engagement.\u003c/p\u003e\u003cp\u003ePractical barriers related to accessibility, convenience, and incentives were also critical. Many participants expressed a preference for disposal sites located within the village, particularly in familiar places like health clinics or village offices. This preference aligns with prior studies on rural recycling behaviors, which show that physical proximity and ease of access are key facilitators for older populations\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. Some respondents suggested that simplified procedures or mobile collection services could reduce barriers for those with limited mobility. Although incentives such as small household items were frequently cited as motivators, participants generally viewed them as supplementary. Many regarded the health and environmental benefits as the primary justification for participation. This distinction reflects prior findings that extrinsic rewards may encourage initial engagement but are unlikely to sustain behavior in the absence of intrinsic motivation\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. A combined approach that integrates modest incentives with long-term educational strategies may be more effective.\u003c/p\u003e\u003cp\u003eA recurring theme in this study was participants\u0026rsquo; reliance on institutional support and professional guidance for proper disposal practices. Many older adults expressed a preference for recycling initiatives led by healthcare professionals or government agencies, which reflects a reliance on perceived expertise due to limited confidence in their own knowledge about safe disposal. This aligns with findings from other studies, where limited health literacy often leads individuals to defer to institutional authority for public health behaviors\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e. Clear communication and visible regulatory frameworks from trusted institutional figures could increase participation rates. Furthermore, participants noted that clear government policies and visible regulation of recycling initiatives would enhance their sense of responsibility and trust in the process. When individuals believe that recycling practices are managed effectively, they are more likely to engage in safe disposal behaviors\u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/sup\u003e. In regions where there is strong trust in local governance, involving local leaders in public health initiatives can greatly enhance community engagement.\u003c/p\u003e\u003cp\u003eThese findings highlight the need for a multifaceted, policy-oriented approach that addresses informational, logistical, and motivational barriers. First, public awareness campaigns must communicate clearly the risks of improper disposal, targeting populations with limited exposure to environmental and pharmaceutical safety information. Second, accessibility should be improved through the placement of collection sites in familiar and frequently visited locations. For communities with mobility constraints, door-to-door services could offer an effective alternative. Third, empowering local health workers and village committee members with the resources, training, and institutional support needed to advocate for safe disposal can enhance participation and trust. Finally, modest material incentives may serve as useful entry points, but long-term engagement should be supported by strategies that cultivate a sense of shared responsibility and intrinsic motivation within communities.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study deepens understanding of expired medication disposal by revealing how behavioral, normative, and contextual factors jointly shape the actions of older adults in rural China. Although participants acknowledged the risks of improper disposal, engagement was limited by informational blind spots, low perceived efficacy, and the absence of normative cues from trusted local actors. These findings highlight the limitations of top-down interventions in contexts lacking localized social endorsement. Promoting safe disposal in such settings requires more than infrastructure, it calls for strategies that activate community norms, embed moral responsibility in everyday practices, and mobilize trusted relationships. By integrating behavioral theory with context-specific insights, this study offers a framework for culturally responsive, community-driven approaches to pharmaceutical waste governance.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTPB\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTheory of Planned Behavior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNAM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNorm Activation Model\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNatRUM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Return of Unwanted Medicines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocols and ethics were reviewed and approved by the Ethics Committee of School of Public Health, Shandong University (the number is LL20240345). The informed consent was obtained from all participants in this study. All methods were performed according to the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request. All data generated or analyzed during this study are included in this published article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Science Foundation of China (grant numbers 72274109, 72404174), the Shandong Provincial Natural Foundation (grant number: ZR2021QG018).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhanghao Yu conceived and designed the study, performed data analysis and drafted the manuscript. Ziyu Liu provided the critical feedback, critically revised the manuscript. Chengchao Zhou directed its implementation, including the data collection and analysis. Tianran He participated in the collection and consolidation of initial data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all investigators who indicated interest to participate in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWu P E, Leong D. What should I know about medication storage and disposal? JAMA Internal Medicine. 2020; 180(11): 1560.\u003c/li\u003e\n \u003cli\u003eKhasawneh O F S, Palaniandy P. Occurrence and removal of pharmaceuticals in wastewater treatment plants. Process Safety and Environmental Protection. 2021; 150: 532\u0026ndash;556.\u003c/li\u003e\n \u003cli\u003eJobling S, Williams R, Johnson A, Taylor A, Gross-Sorokin M, Nolan M, Tyler C R, Van Aerle R, Santos E, Brighty G. 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Health Psychology. 2013; 32(9): 950\u0026ndash;957.\u003c/li\u003e\n \u003cli\u003eHajj A, Domiati S, Haddad C, Sacre H, Akl M, Akel M, Tawil S, Abramian S, Zeenny R M, Hodeib F, Salameh P. Assessment of knowledge, attitude, and practice regarding the disposal of expired and unused medications among the Lebanese population. Journal of Pharmaceutical Policy and Practice. 2022; 15: 107.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKusturica M P, Golocorbin-Kon S, Ostojic T, Kresoja M, Milovic M, Horvat O, Dugandzija T, Davidovac N, Vasic A, Tomas A. Consumer willingness to pay for a pharmaceutical disposal program in Serbia: A double hurdle modeling approach. Waste Management. 2020; 104: 246\u0026ndash;253.\u003c/li\u003e\n \u003cli\u003eHiew S Y, Low B Y. The knowledge, attitude, and practice of the public regarding household pharmaceutical waste disposal: a systematic review (2013\u0026ndash;2023). International Journal of Pharmacy Practice. 2024; 32(2): 120\u0026ndash;132.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Expired medications, Theory of Planned Behavior, Norm Activation Model, Recycling behavior, Rural older adults","lastPublishedDoi":"10.21203/rs.3.rs-7100179/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7100179/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe improper disposal of expired medications poses great public health and environmental risks, particularly in rural settings where institutional infrastructure is limited. Despite government efforts to establish take-back programs, participation remains low among older adults who are both frequent medication users and particularly vulnerable to associated risks. Understanding the behavioral and contextual barriers to proper disposal is essential for improving engagement.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study explored the psychosocial and normative factors influencing expired medication disposal among older adults in Rushan, a rural county in eastern China with an underutilized formal recycling program. Guided by the Theory of Planned Behavior and the Norm Activation Model, we conducted 45 semi-structured interviews. Participants were selected through purposive sampling. Data were analyzed thematically using a hybrid coding approach that combined predefined theoretical domains with inductively derived sub-themes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFour themes and eleven sub-themes emerged, capturing attitudes toward disposal, subjective norms, perceived behavioral control, and internal motivations. While most participants recognized the importance of safe disposal, action was often constrained by limited awareness of available channels, doubts about personal efficacy, weak normative cues, and inaccessible infrastructure. Family influence focused more on medication safety than on disposal, and health providers reported lacking authority or continuity to promote recycling.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFindings suggest that raising awareness alone is insufficient to drive behavior change. Effective interventions must activate local social norms, embed a sense of responsibility within existing community structures, and address logistical gaps. These insights offer practical guidance for designing culturally grounded and community-driven pharmaceutical waste policies in resource-constrained rural settings.\u003c/p\u003e","manuscriptTitle":"Beyond Awareness: Social and Structural Barriers to Expired Medication Disposal Among Rural Older Adults in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 05:31:16","doi":"10.21203/rs.3.rs-7100179/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8205179e-1770-49a6-8f56-133d32943516","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T15:53:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 05:31:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7100179","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7100179","identity":"rs-7100179","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}