Medicine Storage Knowledge Survey among Pharmacy Students from Universitas Gadjah Mada

Background: Proper drug storage is very important to ensure drug safety, quality and efficacy. Drug storage is closely related to drug expiration which includes Expiry Date (ED) and Beyond Use Date (BUD). The aim of this research was to measure the level of knowledge of Pharmacy students at Gadjah Mada University regarding drug storage and drug expiration. Materials and Methods: This research uses a cross-sectional study design with an instrument in the form of a questionnaire. The sample was UGM Pharmacy Students taken randomly by convenience sampling, in the data collection period October-November 2023, there were 132 respondents. A questionnaire covering sociodemographic data, storage domains and drug expiration time, was distributed in Google form. Data were analysed descriptively and with statistical tests of Chi-square with p<0.05. Results: The results of the study showed that 87.88% (N= 116) Pharmacy Students from Universitas Gadjah Mada had a good level of knowledge about drug storage, and 85.85% (N= 112) had a poor level of knowledge about drug expiration. There was no relationship between gender (p=0.307); age (p=0.639); semester (p=0.791); monthly income (p=0.897); paren’ts occupation (p=0.155); and current state of residence (p=0.904) with knowledge of drug storage. There is a relationship between age (p value 0.012); semester (p=0.015); and current state of residence (p=0.019) with knowledge of drug expiration. Conclusion: Medicine Storage Knowledge is necessary to increase pharmacy students' literacy about drug expiration to ensure drug safety.


Introduction
Proper storage of medicines is essential to ensure their safety, quality and efficacy.Certain drugs have storage criteria to maintain drug stability.These storage criteria include storage temperature, storage room humidity, and storage conditions (1).Some information on how to store medicines properly and correctly includes sorting medicine storage containers by type, storing medicines in original packaging that is labelled and tightly closed, storing at room temperature, or as stated on the packaging label, keeping out of the reach of children, and routinely selecting medicines that have expired or are damaged (2).
Before a drug is used, it must be known whether the drug is still suitable for consumption.The parameters of a drug that is still suitable are expiry date (ED) and beyond use date (BUD).Expiry date is the time limit for using the medicine before the packaging is opened, which is published by the pharmaceutical manufacturer.The ED is usually listed on the medicine packaging.The beyond use date is the time limit for using the medicine after the medicine has been compounded and prepared or after the primary packaging of the medicine has been opened or tampered with.BUD information is generally not included on the medicine packaging (3).
Despite the differences between ED and BUD, both are intended to minimize patient risks associated with changes that may occur to the drug during storage.These changes are different for each drug and are influenced by a wide variety of factors ranging from the excipients added during compounding to the storage container and temperature (3).
Knowledge about medicine storage is a basic understanding that must be possessed by the community.Based on the results of the Basic Health Research (Riskesdas) in 2013, 35.2% of Indonesians stored medicine at home.The percentage of types of drugs stored included 35.7% hard drugs, 82% over-the-counter drugs, 27.8% antibiotics, 15.7% traditional drugs, and 6.4% unidentified drugs.Data on the status of drugs stored in households showed that the percentage of drugs being used was 32.1%, for supplies 42.2%, and leftover drugs 47% (4).
Public knowledge about drug storage is still relatively minimal.Based on the results of Nanda's research (2019), the level of public knowledge about how to store medicines in West Semper Village, North Jakarta in July 2019 was still low (54.12%)(5) .In Savira et al research (2020) on drug storage in the family, as many as 94.3% of respondents stored drugs at home and 13.6% of them still stored drugs in expired conditions (6).General information about drug storage is actually listed on drug packaging, but often people ignore and do not understand properly.
Providing public education by health workers about drug storage is one of the important responsibilities of pharmacists to prevent a decrease in drug efficacy.Pharmacy students from Universitas Gadjah Mada as prospective pharmacists must be ensured to know information about how to store drugs before going into the field.This study was conducted with the aim of measuring the level of knowledge of students about drug storage, ED, and BUD.

Research Design
This research design is quantitative using cross sectional study.This research was conducted with instruments in the form of questionnaires using surveys and seeking information collected in the form of primary data related to the level of knowledge of drug storage and drug expiration of Pharmacy Students from Universitas Gadjah Mada.This research was conducted at October 2023 to November 2023 online for students of Faculty of Pharmacy, Universitas Gadjah Mada.

Data Collection
The method of data collection was by distributing questionnaires online through Google Form, the link was then disseminated through social media with a brief introduction to the research and a consent form.Only students who agreed to fill out the form and were eligible were allowed to complete the questionnaire.
The population in this study were Pharmacy undergraduate students from Universitas Gadjah Mada in semesters 1, 3, 5, and 7 who performed drug storage activities.The Ethics Commission of the Faculty of Medicine, Universitas Gadjah Mada (KE/FK/1678/EC/2023) approved this research.The sampling method used was convenience sampling.Determination of the sample size was carried out using the following sample formula: The sample size uses the Slovin formula with an error tolerance limit (e) of 10%.So that the sample size is calculated as 90.5 and rounded up to 91 respondents as the final sample size.
Data were collected using a questionnaire and the instrument was compiled based on previously published research articles.Then the instrument was carried out reliability testing on 30 respondents outside the research respondents, based on the results of the reliability test showed that the questionnaire was reliable as evidenced by the Cronbach Alpha value of 0.657 so that it met the requirements (>0.6).Then the validity of the instrument is carried out with content validity evaluated by expert judgement discussion with the supervisor, the questionnaire consists of four parts as follows: The first section consists of an introduction that contains the respondent's willingness to participate in the study, the second section is the respondent's identity containing name, address, gender, age, semester, pocket money, parent's occupation, and current living conditions.Then in the third section is a statement about drug storage and the fourth section is a statement about drug expiration.

Data Analysis
Data was analyzed using SPSS software, firstly the data was transferred into IBM SPSS.Then descriptive statistics such as mean, median, min, max, and standard deviation were used to reveal various parameters.Normality test using Kolmogorov-Smirnov, relationship testing for both variables using Chi-square test, decision making in Chi-square test using cross tabulation in SPSS program with significance level p<0.05.

Results
The characteristics of the respondents are shown in Table 1.From the total of 132 respondents, the semester level in this study was mostly semester 1 with a percentage of 32%, the gender of most respondents was female as much as 83% and the age range in the 17-19 years group was 51%.The amount of pocket money for respondents in this study was mostly Rp 1,001,000 -Rp 2,000,000 as much as 35%.The parent's occupation is dominated by the non-healthcare workers sector by 83% and the respondents' living conditions are mostly in boarding houses/dormitories with a percentage of 67%.
Based on the test results in Table 2 regarding the level of knowledge of drug storage and drug expiration among Pharmacy students from Universitas Gadjah Mada, out of 132 respondents, 116 (87.88%) respondents had a good level of knowledge of drug storage and 16 (12.12%)had a poor level of knowledge.As for the level of knowledge of drug expiration, 20 (15.15%) respondents had a good level of knowledge and 112 (85.85%) respondents had a poor level of knowledge.
. Table 3 presents the distribution of respondents' answers for each item of the drug storage statement.The highest knowledge of respondents was in statements number one and three, namely "Medication is stored at room temperature and protected from direct sunlight or as stated on the packaging" and "Solid preparations are stored in a medicine box and kept out of reach of children" with 99.24% (n = 131) of respondents answering correctly.Meanwhile, the lowest knowledge of respondents was in statement number ten, namely "After opening, insulin can be stored at room temperature (25ºC-30 ºC)" with 57.58% (n = 76) of respondents answering incorrectly.
Based on Table 3, the respondents' knowledge regarding drug expiry is presented.The highest knowledge was in statement number two, namely "Expiry Date (ED) is the date when the drug should no longer be used when the packaging or seal has not been opened" with 84.09% (n=111) of respondents answering correctly.Furthermore, the lowest knowledge regarding drug expiration was in statement number eight, namely "The use of concoction ointment can be used for 3 months" with 68.18% (n=90) of respondents answering incorrectly.Based on the Chi-square test shown in Table IV, there is no statistically significant relationship between gender and the level of knowledge of drug storage and drug expiration (p>0.05).In this study, it was found that there was a significant relationship between age and the level of knowledge of drug storage (p<0.05),but there was no significant relationship between age and the level of knowledge of drug expiration (p>0.05).The statistical test results showed that there was a significant relationship between semester and the level of knowledge of medicine storage.
In the sociodemographic factor of pocket money based on the results of statistical tests in Table 4, it can be concluded that there is no statistically significant relationship between pocket money and the level of knowledge of drug storage and drug expiration (p>0.05).The results showed that there was a significant relationship between the current living situation and the level of knowledge of drug storage (p<0.05).

Discussion
This study aims to measure the level of knowledge of Pharmacy students at Gadjah Mada University regarding drug storage and drug expiration.Respondents in this study were dominated by first semester students and female respondents.Moreover, this study presents a low level of student pocket money compare with the average in their area.In Yogyakarta, the average student pocket money was IDR 2,240,000 per month in 2017 (7).
In the results of research conducted by Labu et al (2013) on the knowledge and awareness of students on the practice of disposing of unused drugs, it shows that the majority of respondents are in their first year of academic (8).In a study conducted by Lee et al (2017), stated that students who have families who have status as health workers have a higher level of knowledge about medicine when compared to students who do not have families of health workers (9).
As for the level of knowledge of drug expiration, more than a half of respondents had a poor level of knowledge (85.85%).From these results it can be seen that the level of knowledge of drug storage is mostly in the good category and drug expiration in the poor category.The results of drug storage research are in line with research conducted by Puspitasari et al (2022) which found that the level of knowledge and drug storage in the community was in the good category with a percentage of 53% and 83% respectively (10).In the results of research on drug expiration in line with research conducted by Garus (2018) on Beyond Use Date of drugs, it was found that only 33% of people had knowledge related to Beyond Use Date of compounded drugs (11).So, it can be said that the level of public knowledge regarding the BUD of medicinal preparations is still low.In daily practice, it is not uncommon to misunderstand the BUD with the expiration date (ED).Often the ED of the drug after the packaging is opened (BUD) is considered to remain the same as that stated on the packaging, even though the ED of the drug has changed.
The highest knowledge of respondents was in statements of "Medication is stored at room temperature and protected from direct sunlight or as stated on the packaging" and "Solid preparations are stored in a medicine box and kept out of reach of children" with 99.24% (n = 131).From these results, it can be seen that students already understand drug storage in general.According to the Ministry of Health (2022), medicines should be stored at room temperature and out of direct sunlight or as stated on the packaging (12).Some drugs have hygroscopic properties that require special attention in storage.For example, there are drugs that easily become mushy when exposed to outside air, so they must be stored in the original and sealed packaging.
The lowest knowledge of respondents was in statement of "After opening, insulin can be stored at room temperature (25ºC-30 ºC)" with 57.58% (n = 76) of respondents answering incorrectly.From these results, it can be seen that students' understanding of the storage of special preparations such as insulin is still lacking.Insulin that is still closed (unopened) and will not be used must be stored at 2°C -8°C in the refrigerator (do not freeze).When insulin is in use or in reserve, it does not need to be stored in the refrigerator.Insulin used earlier can last approximately 4 weeks at room temperature below 30°C after being taken from the refrigerator (13).
The respondents' knowledge regarding drug expiry is presented in table 3. The highest knowledge was in statement number two, namely "Expiry Date (ED) is the date when the drug should no longer be used when the packaging or seal has not been opened".From this result, it can be seen that most students already know the definition of ED.According to USP (2020), Expiry Date (ED) is the date when the drug should no longer be used when the packaging or seal has not been opened.
The lowest knowledge regarding drug expiration was in statement number eight, namely "The use of concoction ointment can be used for 3 months" with 68.18% of respondents answering incorrectly.From these results, it can be seen that students' knowledge about BUD, especially for concoction preparations, is still lacking.According to USP (2020), in Semisolid preparations (Ointment, Cream, Gel, Paste) the maximum beyond use date for compounded semisolid preparations is 35 days (3).
Meanwhile, the lowest knowledge of respondents was in statement of "After opening, insulin can be stored at room temperature (25ºC-30 ºC)" with 57.58% of respondents answering incorrectly.From these results, it can be seen that students' understanding of the storage of special preparations such as insulin is still lacking.Insulin that is still closed (unopened) and will not be used must be stored at 2°C -8°C in the refrigerator (do not freeze).When insulin is in use or in reserve, it does not need to be stored in the refrigerator.Insulin used earlier can last approximately 4 weeks at room temperature below 30°C after being taken from the refrigerator (13).
Based on the Chi-square test results, there is no statistically significant relationship between gender and the level of knowledge of drug storage and drug expiration.The difference in gender is not one of the factors that will make a difference in the level of knowledge (14).In this study, it was found that there was a significant relationship between age and the level of knowledge of drug storage, but there was no significant relationship between age and the level of knowledge of drug expiration.The varied results in this study can be caused by the different health conditions of each person, which affects the type of medicine stored.In addition, with today's technological advances, students can easily access information related to medicine easily and does not depend on age.The next sociodemographic factor is semester.The statistical test results showed that there was a significant relationship between semester and the level of knowledge of medicine storage, but there was no significant relationship between semester and the level of knowledge of medicine expiration.The results of the statistical test of the level of knowledge of drug expiration are in accordance with the theory of Notoatmodjo (2014) which states that the factor that has the greatest influence on knowledge is education, because people with higher education can provide a more rational response to the information received (15).
In the sociodemographic factor of pocket money based on the results of statistical tests, it can be concluded that there is no statistically significant relationship between pocket money and the level of knowledge of drug storage and drug expiration.Knowledge about medicine storage and expiry may be influenced by the extent to which a person is interested or needs this knowledge in daily life, regardless of how much pocket money is earned.In addition, people in Indonesia are covered by the National Health Insurance (Jaminan Kesehatan Nasional or JKN), a programme that ensures that people have easy and affordable access to health services (16).
There is no significant relationship between parent's occupation and the level of knowledge of drug storage and drug expiration.This result is in line with research conducted by Ankita and Ipsa (2021) which concluded that no statistically significant differences were found between parent's occupation and standard precautionary knowledge in university students (17).However, as family values are highly upheld in Indonesian culture, drug education programmes should consider working with parents to be more effective.Then the next sociodemographic characteristic is current state of residence.The results showed that there was a significant relationship between the current living situation and the level of knowledge of drug storage, but there was no significant relationship between the current living situation and the level of knowledge of drug expiration.Students who live with their parents may have greater influence from their parents in terms of education and learning.Parents who have good knowledge about health may be able to transfer that knowledge to their children.
This study has several limitations, namely measurements were only made based on the results of questionnaires distributed by researchers, limited research time and sample size, and the research instrument is a closedended statement that does not allow respondents to express their opinions.

Conclusion
Most respondents had a good level of knowledge about medicine storage and less about medicine expiration.There was no relationship between gender, age, semester, pocket money, parents' occupation, and current living situation (p>0.05) with drug storage knowledge.Meanwhile, there was a relationship between age, semester, and current living situation (p<0.05) with drug expiration knowledge.It is necessary to increase the literacy of pharmacy students about drug expiration, especially BUD on various preparations to ensure drug quality and safety.

Table 1 .
Sociodemographic Characteristics of Respondents

Table 2 .
Categories of Knowledge Level of Drug Storage and Drug Expiration

Table 3 .
Distribution of Respondents' Answers Based on Statement Items Drug Storage and Drug Expiration

Table 4 .
Sociodemographic Associations with Knowledge Level of Drug Storage and Drug Expiration Time