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

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.