Educational exposure and sustainability-related outcomes among pharmacy students in Bulgaria: a cross-sectional study.

INTRODUCTION: Pharmaceutical sustainability is important for environmentally responsible health care, yet evidence regarding pharmacy students' preparedness remains limited. This cross-sectional study assessed sustainability-related awareness, educational exposure, attitudes, knowledge of medication disposal, and behavior among pharmacy students in Bulgaria. METHODS: An anonymous questionnaire was completed by 74 students from the Medical Universities of Plovdiv, Pleven, and Varna between April and December 2025. Descriptive statistics, chi-square tests, non-parametric tests, effect sizes, and exploratory binary logistic regression were applied. RESULTS: Among 73 participants with valid data, 23 (31.5%) were familiar with sustainable pharmacy, 28 (38.4%) were partially familiar, and 22 (30.1%) were unfamiliar. Only 14 participants (18.9%) reported sustainability training, whereas 57 (77.0%) supported mandatory sustainability education. Thirty-two participants (43.2%) knew unused medicines could be handed over safely. Familiarity was associated with previous training (p < 0.001; Cramér's V = 0.532) and year of study (p = 0.010; Cramér's V = 0.371). Trained participants reported higher attitude scores (p = 0.030; r = 0.25). In the adjusted model, year of study was associated with safe-handover knowledge (p = 0.013), although estimates were imprecise. CONCLUSION: These findings identify gaps between positive attitudes, limited educational exposure, and knowledge. Structured sustainability education warrants further development and evaluation.