OUR LADY OF FATIMA UNIVERSITY

ANTIBIOTICS OVER THE COUNTER: AN INVESTIGATION ON

ANTIBIOTIC DISPENSATION WITHOUT A
PRESCRIPTION OF LOCAL DRUGSTORE

A Thesis Paper
Presented to
The Biology Department
Our Lady of Fatima University

In Partial Fulfillment
of the Requirements for the Degree
Bachelor of Science in Biology

Jemimah Chan
Ela Sophia B. Khu
Sean Ashley R. Laborte
Keem Bryan A.Pornobi
Jenalyn B. Rubante
Mary Ann Tesorero

March 2023
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APPROVAL SHEET

This is to certify that this Thesis titled, “ANTIBIOTICS OVER THE COUNTER: AN
INVESTIGATION ON ANTIBIOTIC DISPENSATION WITHOUT A
PRESCRIPTION OF LOCAL DRUGSTORE” was prepared and submitted by
Jemimah Chan, Ela Sophia B. Khu, Sean Ashley R. Laborte , Keem Bryan A. Pornobi,
Jenalyn B. Rubante, Mary Ann Tesorero In Partial Fulfillment of the Requirements for
the Degree Bachelor of Science in Biology, is hereby recommended for Oral
Examination.

ERNESTO B. GUEVARRA, MD, MPH

Adviser

PANEL OF EXAMINERS
Examined and approved by the Panel of Examiners in an Oral Examination with a Grade
of ____ on __________ _____, 2023.

Chairperson
Member
Member

Accepted as partial fulfillment of the requirements for Biological Research(BIOR 411)

Dean of College of Arts and Sciences

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CERTIFICATE OF ORIGINALITY

I hereby certify that this Thesis is our work and that, to the best of our knowledge
and belief, and it contains no material previously written or published by another person
or organization or any material which has been accepted for the award of any other
degree or diploma from a university or institution of higher learning except where due
acknowledgement is made there of.

Furthermore, we declare that the intellectual content of this research is the product
of our work although we have received assistance from others on the manner of
organization, presentation, language, and style.

Jemimah Chan, Ela Sophia B. Khu, Sean Ashley R. Laborte , Keem Bryan A. Pornobi,

Jenalyn B. Rubante, Mary Ann Tesorero

Candidates

Date March 2023

Attested by:

Adviser:
Date: 2023
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ACKNOWLEDGEMENT
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ABSTRACT

ANTIBIOTICS OVER THE COUNTER: AN INVESTIGATION ON ANTIBIOTIC

DISPENSATION WITHOUT A PRESCRIPTION OF LOCAL DRUGSTORE

by

Jemimah Chan
Ela Sophia Khu
Sean Ashley Laborte
Keem Bryan A.Pornobi
Jenalyn Rubante
Mary Ann Tesorero
March 2023
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TABLE OF CONTENTS

Page

Title Page………………………………………………………………

Approval Sheet ………………………………………………………..

Certificate of originality ………………………………………………

Acknowledgments………………………………………………………

Abstract…………………………………………………………………

Table Of Contents………………………………………………………

List of Appendices………………………………………………………

CHAPTER

1 The Problem of its Background

Introduction …………………………………………………….

Statement of the Problem………………………………………..

Hypothesis of the study………………………………………….

Significance of the study ……………………………………….

Scope and limitations of the study ……………………………..

Definition of Terms …………………………………………….

2 Review of Related Literature …………………………………..

Maternal and Infant Care in Covid-19 Pandemic………………

Maternal Health Care in the Philippines ………………………

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Quality Maternal and Infant Health Service …………………...

Theoretical Framework……………………………………………

Conceptual Framework…………………………………………..

Research Paradigm……………………………………………….

3 Research Methodology

Research Design………………………………………………

Locale Of the Study…………………………………………..

Population Of the Study………………………………………

Research Instrument…………………………………………

Validation and Reliability of the Instrument ……………….

Potential Ethical Considerations ……………………………

Data Gathering Procedure …………………………………..

Appendices ………………………………………………………………..

Bibliography……………………………………………………………….

Curriculum Vitae…………………………………………………………..

LIST OF APPENDICES

Appendix

A Letter of intent to Conduct Study…………………….

B Assessment Survey Questionnaire ( English ) ……….

Assessment Survey Questionnaire ( Tagalog)………..

C Informed Consent Form ( English )……………………

Informed Consent Form ( Tagalog)…………………..

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CHAPTER 1
PROBLEM AND ITS BACKGROUND
Introduction
Medicinal practices is a common work in the Philippines especially in different
remote areas and one of our cultures is to pass down practices from our ancestors and one
common is treating ailments without proper knowledge, causing it to be harmful due to
self-medication. Thus, it causes a great trend in the increase of local drugstores in every
region of the country because of its accessibility for Filipino people who cannot afford to
travel faraway to buy medicine in hospitals and it is much cheaper in price. The FDA
Circular No. 2014-025 issued the implementation of new rules and regulations on the
licensing of drugstores and similar outlets, which shows the requirements, inspection, and
responsibilities of the certain business. Nevertheless, with this FDA regulation there are
still drugstores that lack the responsibility of dispensing medicine especially antibiotics,
which is one of the medicines to be most misused causing a lot of problems in terms of
antibiotic resistance and some health risk factors due to inadequate knowledge of the
certain antibiotic.

According to Henry Selvaraj (2019), the main reason antibiotics are overused is
because they are available even without presenting any prescription over the counter.
Center for Disease Dynamics, Economics & Policy. (2019) reported that over the counter
antibiotics are being sold through online shops that root misusing of leftover drugs.
Adding, one of the primary causes of misused antibiotics is the passing or sharing of
previous prescriptions in friends and relatives. Researchers implied that selling antibiotics
should cause legible and new prescriptions to prevent some issues causing infectious
disease and people that should set awareness to the public on antibiotics ill effects. The
study recommendation concludes that excess antibiotics should also be asked for and
returned to the pharmacies.
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According to the World Health Organization’s (WHO) global report on
surveillance of antimicrobial resistance (2016), non- penicillin-susceptible microbial
chains have been identified. In all WHO regions, awareness of using antibiotics without
any prescriptions has adverse effects and knowledge of safe antibiotic practices and
antibiotic resistance is high, mostly in the urban population and among the university
students. Worldwide, approximately 700,000 people die because of drug-resistant
infection and a recent report estimates that by 2050, 10 million people will die every year
due to antimicrobial resistance (AMR) if there is no action (Ahmad et al., 2022). There is
a widespread irrational and inappropriate use of antibiotics in the Asian regions and it is a
major contributor of antimicrobial resistance (Singh, 2017). Inappropriate use of
antibiotics is commonly seen for a self-limited viral infection like URTIs (Upper
respiratory tract infections), acute diarrhea ,and also for some bacterial infections
including UTIs (Urinary tract infections) and self-medication in the community is a great
contributing factor to inappropriate consumption of antibiotics (Ahmad et al.,2022)

In Pakistan , 96% of community pharmacies dispense antibiotics without

prescriptions (Saleem et al.,2020). Therefore, community pharmacists are dispensing
antimicrobials even without prescriptions to avoid losing their clients to a neighboring
competitor (Figueiras et al.,2018). In the region of Hazara in Pakistan, antibiotics were
supplied without a prescription, to 90.5% with antibiotics being dispensed in 92.9% and
88.1% is for URTI and UTI. In non-prescription antibiotics, 9.5% of pharmacies declined
to dispense antibiotics without prescription.

The Sub-Saharan African (SSA) countries, non-prescribed dispensing of

antibiotics in community drug retail outlets (CDROs) has been flagged as one of the
contributing factors for the widespread misuse of antibiotics in the community. The
overall pooled proportion of non-prescription antibiotics requests or consultations that
resulted in supply of antibiotics without prescription was 69% (95% CI 58–80). Upper
respiratory tract infections and/or acute diarrhoea were the most frequently presented
case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed
antibiotics to treat those symptoms. (Belachew et al., 2021)
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The latest PhilCare Wellness Index 2021 reveals that self-medication remains
prevalent among Filipinos (Ciriaco, 2022). Self-medication is a self-care practice defined
as the use of medical products by an individual to treat self-diagnosed symptoms, or as
the unsuitable administration of prescribed medicinal products, including the prolonged
and improper use of antibiotics (Geneva, 2017). Self-medication with antibiotics is
problematic, as it is a major contributor to antibiotic resistance (Bartoloni et al., 2019).
Recent meta-analyses have estimated that 38% of the world population engages self-
medication and sharing of antibiotics (Morgan, 2019). However, Self-medication varies
globally, with the highest prevalence in the Southeast Asia and Western Pacific region of
WHO (58-64%) (Morgan, 2019). The Philippines has a documented history of prevalent
antibiotic misuse including one of the highest rates of antibiotic sharing (Kardas, 2020).
Globally, the Philippines has also had one of the smallest percentages of prescriptions
filled by physicians, with non-medical sources being the most common source of
antibiotics (Kardas, 2020). The reported prevalence of antibiotic self-medication in the
Philippines has ranged from 31% to 66% reporting all prevalence than Southeast Asia
(Lansang et al., 2020).

In the Philippines many Filipinos still rely on advertisements, previous medical

prescriptions, and the opinions of their relatives, families, and friends as the basis for
their self-diagnosis and self-medication. Open access to health information over the
internet also adds to the confidence of Filipinos to self-medicate, as supported by the
findings of the latest PhilCare Wellness Index (Ciriaco, 2020). A review by Radyowijati
et al. (2017) highlighted the deficit in sharing and dispensing antibiotics; it revealed that
the major studies in self-medication with antibiotics have examined antibiotic prescribing
and the purchasing of antibiotics rather than informal antibiotic dispensing within a
community. With the current pharmaceutical laws enforced in the Philippines, the
community finds difficulties buying antibiotics (Ramos, 2018). However, over-the-
counter antibiotics, such as topical antibiotics, an antibiotic in the form of soap, cream or
treatment, don't require a prescription when purchased (Chua, 2019). Dispensing without
prescriptions is irrational and can hasten the emergence and spread of antibiotic
resistance (Bahta et al., 2019).
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Department of Health (DOH) warns public to stop misusing or overusing
antibiotic to prevent Antimicrobial Resistance (AMR). Antimicrobial Resistance (AMR)
is when the microorganism is being exposed to any antimicrobial drugs such as antibiotic,
the microorganism can resist medicines. As per Maribel Cruz, Pharmacist III of DoH 5
we can only hope to change people's behavior when it comes to taking antibiotics by
being stringent with prescriptions and organizing more informational caravans. She
added that misusing of antibiotics can leads to low effectiveness of medicines when it
intakes and can cause infection to grow rapidly. One example of AMR is what we called
Multi-drug Resistant TB (MDRTB), this MDRTB can resist atleast four Anti-TB drugs,
as shown by data from the World Health Organization (WHO). According to records
from 2017, 368 persons in Bicol, predominantly men between the ages of 25 and 54,
were diagnosed with MDRTB. DoH personnel warn the public to follow and finish
correct procedures to take medicine, and also they remind pharmacists to sell antibiotics
with prescriptions. Addressing the gap in knowledge the research extends to the
pharmacies’ dispensation of antibiotic for consumer without prescription literature by
using exploratory sequential method.

The aim of the study was to investigate the attitudes, practices, reason/s, and
level of awareness of both the pharmacy and consumer subsequently establish
meaningful insight regarding antibiotic dispensation without prescription in local
pharmacy.

Statement of the Problem

This study was directed towards its main objective of making an investigation
regarding the dispensing of antibiotics without prescription on local drugstores in an
exploratory sequential approach. Specifically, the researchers sought answers to the
following questions:

1. How does the profile of the drug store be described in terms of:

1.1 Number of years operating

1.2 Age of pharmacist

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1.3 Gender of pharmacist

2. How does the profile of the consumer can be described in terms of:

2.1 Age (18-24/25-34/35-44/45-54/55-64)

2.2 Gender (Male or Female)

3. Are these drugstores dispensing an antibiotic drug without prescription?

4. What are the attitudes of these drugstores when dispensing an antibiotic drug?

5. What are the attitudes of the consumers when using antibiotics?

6. What are the possible reason/s why consumers buy antibiotics without prescription?

7. What is the level of awareness of consumers that antibiotics require prescription?

8. What is the level of awareness of pharmacists on microbial resistance?

9. What is the level of awareness of consumers on microbial resistance?

10. Is there a significant difference between the attitudes of the consumers when using
antibiotics and their age and gender?

11. Is there a significant difference between the possible reason/s why consumers buy
antibiotics without prescription and their age and gender?

12. Is there a significant difference between the level of awareness that antibiotics
require prescription and the age and gender of the consumer?

13. Is there a significant difference between the awareness of consumers on microbial

resistance and their age and gender?

14. Is there a significant relationship between the dispensation of antibiotic drugs

without prescription of drugstores and the number of years they are operating?

15. Is there a significant relationship between the attitudes of these drugstores when
dispensing an antibiotic drug and the number of years they are operating?

16. Is there a significant relationship between the dispensation of antibiotic drugs

without prescription of drugstores and the age and gender of pharmacists?
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17. Is there a significant relationship between the attitudes of these drugstores when
dispensing an antibiotic drug and the age and gender of pharmacists?

18. Is there a significant relationship between the level of awareness of pharmacists on

microbial resistance and their age and gender ?

Hypothesis

Based on the particular problems, the following hypotheses were developed:

1. There is no significant difference between the attitudes of the consumers when using
antibiotics and their age and gender

2. Is there a significant difference between the possible reason/s why consumers buy
antibiotics without prescription and their age and gender

3. There is no significant difference between the level of awareness that antibiotics

require prescription and the age and gender of the consumer

4. There is no significant difference between the awareness of consumers on microbial

resistance and their age and gender

5. There is no significant relationship between the dispensation of antibiotic drugs

without prescription of drugstores and the number of years they are operating

6. There is no significant relationship between the attitudes of these drugstores when

dispensing an antibiotic drug and the number of years they are operating

7. There is no significant relationship between the dispensation of antibiotic drugs

without prescription of drugstores and the age and gender of pharmacists

8. There is no significant relationship between the attitudes of these drugstores when

dispensing an antibiotic drug and the age and gender of pharmacists

9. There is no significant relationship between the level of awareness of pharmacists

on microbial resistance and their age and gender
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Significance of the Study

This research study aims to provide information and knowledge on dispensing of

antibiotics in local drugstores without prescription. The result of this study will help the
individuals and organization to gain appropriate knowledge for them to be aware about
irrational misusing of antibiotics. This investigation could be significant and beneficial to
the following:

Consumer - This will benefit the community since they will be abounded with a lot of
knowledge in misusing antibiotics that are not known. They will be more aware and
knowledgeable about the risks that they are taking.

Local Government Unit - This will provide data to the local government unit to identify
problems on how the local pharmacies utilizes the dispensing of antibiotics without any
prescriptions and how the community is engaging in the use of antibiotics. They may
formulate efficient strategies that may lead to better plans towards the improvement of
dispensing and the right way in using antibiotics. So, local government units may present
information and prevention which has favorable effects on individuals and organizations.

Local Pharmacy - The results of this study could give them ideas or possible outcomes
to the issue of dispensing antibiotics without prescription. It may influence and encourage
other local pharmacies to use the antibiotics in the right way in view of the fact that it is
their responsibility to dispense antibiotics to the individuals.

Students - This study will provide knowledge for students that are undertaking similar
studies and may be used as reference data and a guide in conducting new research that
will give them background or an overview in misusing antibiotics.

The Researcher - The outcome of this study will guide the researchers in their further
research and will be an instrument as reference material since this study will add to their
knowledge to determine what are the inadequate or the gaps in their future studies that
are applicable in their topics. The researchers will also gain significance on enhancing
their strategy and expands their knowledge if ever they encounter this topic.
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Future Researcher - The proposed study will give them guidance in their future research
that can provide a baseline information and the significance that they will gain may be
used as a reference in their new research. It will be useful to future researchers since it
may be a factor to their next major study.

Scope and Delimitation

The investigation of antibiotic dispensation without prescription will be conducted in

Valenzuela City. This study will only include the drugstores and consumers located and
residing in District 2 of Valenzuela City that is composed of the Barangays' Gen. T. de
Leon, Karuhatan, Bagbaguin, Mapulang Lupa, Marulas, Maysan, Parada, Paso de Blas
and Ugong. The research will assess the experience of the respondents towards
antibiotics, such as knowledge, history of buying, effectiveness of various education and
research information, and awareness of the required prescription for the antibiotics.
Furthermore, the study will look into the respondent’s attitude towards antibiotic taking
and the possible reason why consumers buy antibiotics without a prescription The study
will investigate whether there is a significant difference between the consumer's
perception of risk in taking antibiotics even if their doctor does not prescribe them and
their attitude toward the risk of taking antibiotics. This study will investigate whether
there are differences in the consumer's perception of taking a risk with antibiotics,
attitudes, knowledge, and awareness when their profile is taken into account.

Definition of Terms

Antibiotic practices- preventing or controlling of consuming of antibiotic

Antibiotics - medicines that fight bacterial infections in people and animals. They work
by killing the bacteria or by making it hard for the bacteria to grow and multiply.

Antibiotics resistance - occurs when bacteria change in response to medicines and

develop the ability to defeat drugs. While antibiotic resistance occurs naturally, the
overuse and misuse of antibiotics has accelerated the process.

Antimicrobial resistance- microorganisms develop the ability to stop or evade the drugs
designed to kill them. While this process can occur naturally over time through genetic
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changes, the misuse and overuse of antibiotics in humans and animals has accelerated the
process.

Drug-resistant infection- illnesses that have been caused by resistant microbes, resulting
in an infection that is much harder or potentially impossible to treat.

Local drug store- is a small operational drugstore located in a community only.

Multi-drug resistance- when a single bacterium is resistant to more than one antibiotic it
is said to be multidrug-resistant.

Prescription- order for medicine which a doctor writes, and which is given to a
pharmacist to prepare and administer the medicine.

Self-diagnosis- process of diagnosing or identifying a medical condition in yourself.

Majority of the time, people google a symptom or medical sign and try to figure out if
they have a condition, this is self diagnosing.

Self-limited viral infection- term used in clinical medicine to refer to any disease whose
natural history is to resolve without treatment.
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CHAPTER 2

REVIEW OF RELATED LITERATURE

This chapter presents the related local studies, foreign studies, local literatures,
and foreign literatures. It includes information that are relevant and to give better
understanding to the study.

Foreign Studies

In the study of Belachew et.al (2021), about “Non-prescription dispensing of

antibiotic agents among community drug retail outlets in Sub-Saharan African countries”,
they pointed out that one of the contributing factors of widespread misuse of antibiotics
in their community is because of the drug retail outlets that dispensed antibiotics without
prescription. As of their result, they gathered around 69% overall proportion of non-
prescription antibiotics request or consultation with mostly common cases of the
following medical conditions: Upper respiratory infection and Acute Diarrhea. For most
frequently dispensed antibiotics to treat these symptoms are amoxicillin and co-
trimoxazole.

Likewise, according to the study of Batista et.al (2020) about “Antibiotic

Dispensation without a Prescription Worldwide”, they also believed that one of the
drivers of global health problem of antibacterial resistance is due to dispensing of
antibiotics without a proper prescription in the communities pharmacy worldwide. Their
record worldwide obtains that low-and middle-income countries practiced this commonly.
Also, the result shows the most sold antibiotics worldwide were amoxicillin with 86.9%,
azithromycin with 39.3%, ciprofloxacin with 39.3%, and amoxicillin-clavulanic acid with
39.3%. With this antibiotics, it shows association with respiratory system problems
(100.0%), diarrhea (40.0%), and Urinary Tract Infections (30.8%).

On the other hand, Barker et.al (2017) studies the factors that drive inappropriate
dispensing of antibiotics practices of pharmacies in the village of India to better
understand the perspective of the employee. They have recruited 24 community
pharmacy employees along with their profiles and background. Their results show that
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75% of these employees were unlicensed practitioners and the majority has least
knowledge and understanding of antibacterial resistance. They also recorded that these
practices are common to those patients who struggled or had limited access to a licensed
physician due to inadequate economic or logistic reasons. As for their conclusion they
suggested a need for training on antibiotic prescribing and resistance especially in the
areas of limited healthcare access and that they should put accountability to the people
who are responsible, and to better prevent antibiotic misuse.

In the study of Farah, R., et.al (2018) concludes that overuse of antibiotics is a
component of the global spread of antimicrobial resistance. Their previous investigations,
mostly in underdeveloped nations, demonstrated an excessive use of antibiotics obtained
through community pharmacies without a prescription. Studies examining the part played
by neighborhood pharmacists in the abuse of antibiotics are scarce. The study found that
both higher and lower lower socioeconomic groups have access to over-the-counter
antibiotics: overall, 32% of antibiotics were given out without a doctor's
prescription with a higher frequency in lower socioeconomic areas. In lower
socioeconomic areas, it was substantially more common to dispense both an association
of 2 antibiotics and injectable antibiotics without a prescription. Children and the elderly
were given antibiotic prescriptions more frequently by pharmacists working in lower
socioeconomic areas. The research concludes that Community pharmacies in Beirut
frequently dispense antibiotics without a doctor's prescription, especially in areas with
lower socioeconomic status. The social, educational, and legislative spheres should all be
involved in addressing this public health issue.

Connection to that being said in Wemrell, M., et.al (2022) study investigates if
antibiotic use in society has a direct correlation to the growing threat that antimicrobial
resistance poses to global public health. Actions aimed at maximizing the use of
antibiotics should be put into place on a fair basis and in accordance with the needs of the
community. The research found that there are no significant differences in the
dispensation of antibiotics between socio-economic groups, despite the fact that women
and high earners had the highest prevalence of antibiotic dispensation. Instead of
targeting certain demographics, public health initiatives to encourage the optimal and
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reduced use of antibiotics should target the entire Swedish population. Consequently,
interventions aiming at enhancing medical practitioners' antibiotic prescribing patterns do
not call for a greater emphasis on socio-economic or demographic characteristics.

Local Studies

In the Philippines, self-medication is a major problem among Filipinos. Estimated

that 38% of the world's population engage in self-medication with antibiotics (Morgan,
2019). Radyowijati (2019) highlighted the deficit in antibiotic sharing that the majority of
studies including the dispensing of antibiotics have examined antibiotic prescribing and
dispensing antibiotics without prescription in the community. According to DOH (2017)
dispensing/selling antibiotics without prescription is strictly prohibited. However, the
community tends to share antibiotics in their lifetime because antibiotics are accessible
on drugstores and they can purchase it without a prescription (Ybanez, 2017). Recent
study by Ybanez et. al (2019) points out the correlation of antibiotic sharing in the
Philippines for the antibiotic misconceptions and community level access to non-medical
sources of antibiotics. The antibiotic knowledge of the respondents was moderate. 88% of
the respondents understood that antibiotics treat infections, however 81-85% of the
respondents believe that antibiotics can treat viral infection, common colds and cough.
On the other hand, 55% did not know that antibiotics could have side effects and 70% did
not understand the potential of developing antibiotic resistance from improper antibiotic
use. 65% indicated that they find it difficult to purchase antibiotics even without
prescription, 55% agreed that it was easy to access antibiotics without prescription. Some
of the respondents believe in some misconceptions and misuses of antibiotics like taking
small doses and putting crushed antibiotics into wounds. Lastly, a sizable proportion
agreed that a regular administration of antibiotics could prevent HIV. The study findings
demonstrate that misconceptions were more strongly associated with antibiotic sharing
and the accessibility of antibiotics in the community. The study shows that majority of
the people in the community engaging antibiotic misuse and misconceptions in their self-
medication

On a qualitative study on the design and implementation of the National Action

Plan on Antimicrobial resistance (AMR) in the Philippines (2022) stated that in order
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improve the Infection, presentation and control (IPC) is the establishment of Infection
control committee (ICC) which was composed of management staff, pharmacists,
physicians and other health care workers to aware people for the antimicrobial resistance.
Also, to guide the community on the recent policies, guidelines and procedures to avoid
microbial infection. In this way, the community can prevent unwanted infection of
bacteria and they're not going to self-medicate with prescribed antibiotics that may lead
to AMR.

Foreign Literature

In a study conducted by Jaffar, A. and Hisham, M (2020), . Health-care systems

are under stress, and mortality and morbidity go up. By encouraging antibiotic
stewardship and supporting the development of new drugs, healthcare workers may
combat the growing AMR. It is comforting to know that new agents are still being
created in spite of the scientific and economic obstacles. New antibiotics that are in
development are covered in this overview. We looked up approved and upcoming
antibiotics in phase 3 or new medication applications in the literature using Medline,
Clinicaltrials.org, and pertinent pharmaceutical companies (NDA). They discovered a
number of novel antibiotics and evaluated their stage of development, mechanism of
action, range of activity, and approved uses. The phase 3 clinical trials included studies
that were mostly used for the treatment of acute bacterial skin and skin structure
infections, community-acquired bacterial pneumonia, and pneumonia contracted in
healthcare settings. These agents only affect a small number of high priority organisms.
The discovered antibiotics were primarily based on known compounds or already
existing antibacterial substances. They concluded that Antibiotics that are effective
against high priority microorganisms including carbapenem-resistant Enterobacteriaceae
and multi-drug resistant Pseudomonas aeruginosa are few. There is an urgent need for
new antimicrobial medicines targeted at the highest priority species as listed by the
World Health Organization

According to Stig Wall (2019), In the previous 70 years, there has been a dramatic
improvement in world health, and antibiotics have become the mainstay for the treatment
of infectious diseases. Antibiotic resistance is ranked by the World Health Organization
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as a "global security issue" that is as significant as terrorism and climate change and has
an influence on global health, food security, and development. This research examines,
through a scoping analysis of the literature produced in the last 20 years, the volume of
peer-reviewed and Grey literature that addresses antibiotic resistance, in particular, the
degree to which "prevention" has been at the center. Finding know-do gaps and ABR
prevention techniques is the ultimate goal. The review includes searches from 2000 to
2017 in four major databases: Web of Science, Medline, Scopus, and Ebsco. Antibiotic
OR antimicrobial resistance was a more general search term that produced 431,335 hits.
There were 1062 titles left after limiting the search to "Prevention of antibiotic OR
antimicrobial resistance." 622 of these had unique titles. Following a relevancy check on
the 622 titles, 420 abstracts were read, and of these, 282 full papers were read. From
these publications, 53 more references were found, and 64 works from 2018 and 2019
were also included. 399 publications made up the final scoping review database as a
result. When categorizing articles in various subject areas, a thematic framework
developed that acted as a stand-in for the research community's professed interest. About
half of the 399 papers that were published during the course of the study's four-year span
show how the research field is still developing. Particularly in lower- and middle-income
countries, epidemiological modeling needs to be strengthened and there is a need for
additional and better surveillance systems. The local, national, and international uses and
abuses of antibiotics are extensively documented. Programs for education and
stewardship essentially lack proof. Numerous research talk about what the general public
and doctors know. Numerous ominous assessments from domestic and international
agencies express the lessons for policy. The literature has tended to have descriptive
goals rather than theoretical ones. The necessary methods are not being used if we wish
to comprehend and explain the antibiotic issue better from a behavioral standpoint. We
provide a paradigm for an epidemiological causal chain that underlies ABR and might be
used to pinpoint potential entry points for interventions.

Hansen, R. and Francisco J.( 2020),Over-the-counter (OTC) medications are

considered to be safe medications opposite to the prescribed and illegal medications, but
misuse is increasingly being observed (Cooper, 2013).One of the agencies, particularly in
Finland, who is assigned in the monitor misuse and regulate OTC medications in the
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market is Fimea.The functions of Fimea are improving the health of the people by
controlling medicinal, tissue and blood products and improving the pharmaceutical
factors (Levanen and Gurung, 2011). It is the Fimea’s aim to be improve the people of
Finland’s pharmaceutical service, enhance the safety, appropriateness and economy of
the distribution of medicines.During of the 2000s, the consumption of OTC medications
went up by nearly 50% while wholesale reached up to estimated 155 million euros and
for approximately 228 million euros in 2013 (Fimea, 2015). According to national
statistics it made by Fimea in 2013, 50% of consumers had used OTC medications
during the week, and one out of ten Finnish adult uses them every day.at this point, they
let people Finnish the OTC medications are usually designated in the self-service area
like pharmacies, where a pharmacist is ready for counselling.it is allowed to buy OTC
medication from a cashier without the counsel of a pharmacist in the event of urgency
like rush hours or if a consumer hesitated to ask pharmaceutical advise (Ylä-Rautio,
Siissalo & Leikola, 2020).Self-medication is where the treatment of common health
issues with medicines which are intended for use with non-prescription of health
professionals and authorized as safe and effective. Self medication is a vital part of self-
care that is important in a generation of growing chronic diseases and well-informed
health care clients (International Council of Nurses or ICN and World Self Medication
Industry or WSMI, 2012).the threats regarding OTC medications are often being
overlooked by patients, and the improper use of some medications can result in patient in
danger (Ylä-Rautio, Siissalo & Leikola 2020). the researchers will be using the word
“misuse” when referring to the improper use of OTC medications.This study will address
only the promotion of OTC medication’s safe use in the healthcare system. Over-the-
counter medicines (OTC) can be considered as harmful as prescribed medications if not
properly consumed.the safe use of OTC medications is essential (Consumer health care
products association, 2010).This is the capability of encouraging everyone to have good
health, avoid diseases, and to adjust with conditions with or without the consultation from
a medical professional (WHO, 2020). While Fimea (2018) stated that in accordance with
the Finnish pharmaceutical policy, self-care should always be a priority in health care.

The World Health Organizations (2019), in dispensing and prescribing of

antibiotics.It was reported that a prescription is required to obtain antibiotics from a
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pharmacy in all countries and areas. There two thirds of respondents (11/17; 65%)
suggested that these regulations are enforced, but respondents from six indicated that
pharmacists “regularly” sell OTC antibiotics without prescription, and respondents from
a further eight said this occurred “occasionally”. Respondents indicated these OTC sales
included oral agents (14 countries and areas) and injection formulations , along with
topical, eye and ear drop antibiotic formulations . there was Eleven reported other ways
that patients can obtain antibiotics apart from with a prescription from a doctor.Most of
the systems also allowed reporting of concerns about quality of antibiotic products, but
the extent to which such reporting mechanisms are used varies enormously; in some, it
seems that the systems exist but are not used to any meaningful extent.

Local Literature

According to the Research Institute for Tropical Medicine (2017), Antimicrobial

resistance (AMR) is a major public health concern. AMR develops when antimicrobials
are misused and overused, and it can spread and can transfer to humans directly via direct
contact to resistant organisms through ingestion of the products or through environmental
runoff exposures. Resistance can pass on from one person to another and spread beyond
local borders, especially if proper infection control is not practiced. The spread of
resistant organisms can strain and challenge the already dwindling antimicrobial options
available. This can lead to what experts have termed as the “post-antibiotic era” wherein
even minor infections may lead to death. Medical management and surgeries will be
difficult to perform because of possible infection during and after the procedures.

As mentioned by Cruz of the Department of Health (2018), misusing antibiotics

would render medicines and lead to infections in the body, which can increase the risk of
spreading the disease to others. She also added that AMR also threatens the effective
prevention and treatment of an ever-increasing range of infections caused by bacteria,
parasites and fungi. Records from 2017 registered a total of 368 people in Bicol afflicted
with MDRTB, mostly males aged 25 to 54.Cruz advised the public to consult a doctor
before taking antibiotics, follow and finish the correct regimen when taking medicines,
and desist from giving excess antibiotics to others.When coughing or sneezing, cover the
mouth to prevent bacteria from spreading, she added. Cruz also reminded the public that
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drugstores have been told not to dispense antibiotics without prescriptions. To strengthen
their thrust of preventing AMR, DOH conducts lectures as part of most of its programs
and observes the Philippine Antibiotic Awareness Week in November of each year.

Theoretical Framework

A study named "Pharmacist dispensing antibiotics without a prescription: A

qualitative pilot study" by Amin & Chewning (2011) uses a grounded theory approach
which states that the primary causes of antimicrobial resistance (AMR) is the
inappropriate use of certain antibiotics. The researchers conducted an one-on-one
interview with open-ended questions to 7 local community pharmacists. Grounded theory
is a systematic methodology where the researchers construct theories and hypotheses by
the application of inductive reasoning. The researchers end up with possible reasons for
dispensing antibiotics: (1) profit (2) ease of obtaining antibiotics from other local
drugstores (3) patron's insistence on getting an antibiotic and (4) inability to access a
physician. On the other hand, the primary reasons why local pharmacists not dispense
antibiotic is: (1) requested antibiotic is hazardous (2) the complexity of the patron's
condition exceeds a pharmacist's expertise and need the involvement of a physician and
(3) patron's condition is not worthy of an antibiotic. And reasons that the pharmacist are
more likely to pick a specific antibiotic is: (1) safe, (2) suitable for the patron's condition,
(3) taken in a small number of doses or produces a quick improvement, (4) matched to
the patron's financial status,i.e., expensive for rich patrons and cheap for poor patrons and
(5) familiar to the pharmacist. The researchers gathered data to allow them to construct a
theory/hypothesis to analyze and for the solution of the problem of the study.

According to (Wood et al., 2007) despite commonalities across experiential

approaches, the approach to analysis in grounded theory or phenomenological approach
will, or should, look slightly different. While in grounded theory study we may aim to
develop a meta-theory from the empirical data of why GPs may prescribe broad-spectrum
antibiotics, this data analysis will be strongly linked to the methodology chosen.

Young (2009) stated that a grounded theory would be more suited to questions
around nurses’ views and sense making of antibiotic prescriptions. Cabral et al., (2019)
used a comprehensive coding scheme, created based on findings from previously
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published conversation analysis studies, and deductively coded the majority of their
transcripts using this framework. Combining inductive and deductive approaches can also
be useful in order to explore views while in addition drawing on a relevant
theory.Courtenay et al., (2019) focused on understanding influences on antibiotic
prescribing by nurses and pharmacist prescribers; they inductively coded interviews but
then mapped these codes onto an existing theory, thus allowing a systematic examination
of the influences.

In the study conducted by Amin and Chewning (2011) titled "Pharmacist

administering antibiotics without a prescription: A qualitative pilot study," inappropriate
use of some antibiotics is one of the main causes of antimicrobial resistance (AMR).
Seven (7) community pharmacists in their area were interviewed one-on-one by the
researchers using open-ended questions. There are various unique methodological
subgenres under grounded theory, including constructivist GT (related with Charmaz),
evolved GT (connected with Strauss, Corbin, and Clarke), and classic GT (associated
with Glaser). Each variation is a development and expansion of the Glaser and Strauss
original GT. Traditional or classic GT is the moniker for the first of these subgenres. The
objective of classic GT, according to Glaser, is to develop a conceptual theory that
explains a pattern of behavior that is important and troublesome for people concerned.
The second genre, developed GT, was inspired by the work of Strauss, Corbin, and
Clarke and is based on symbolic interactionism. A sociological theory called symbolic
interactionism is based on the symbolic significance that people attribute to social
interaction processes. The subjective meaning that people attribute to things, actions, or
events depending on what they hold to be true is addressed by symbolic interactionism.
Constructivist is the foundation of constructivist GT, the third genre created and
explained by symbolic interactionist Charmaz. The theoretical foundations of
constructivist GT concentrate on how participants create meaning in relation to the field
of inquiry. A constructivist collaborates with participants to co-create experience and
meanings. While there are similarities among all GT genres, there are also distinctions
among the approaches, such as the researcher's philosophical viewpoint, the way they use
literature, and how they code, analyze, and construct their theories. There have been
various iterations of GT since Glaser and Strauss.
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Conceptual Framework

In this part of research the illustration of the conceptual framework of the

researchers study about Antibiotics Over-The Counter: An Investigation On Antibiotic
Dispensation Without A Prescription Of Local Drugstores is shown. In the conceptual
framework the Input-Process-Output is used to show the general procedures of the study
in order to investigate the attitudes/practices of drugstores and to know the awareness of
consumers and pharmacists.
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CHAPTER 3

RESEARCH METHODOLOGY

This chapter presents the detailed approach that will be employed to conduct the
study. The topics in this chapter include the justification of methods of research,
description of respondents citing the population and sample frames that are considered to
establish the method of selection or the sampling technique, and the statistical techniques.

Research Design

Exploratory sequential approach was used for this study. A 2-phased approach
was employed to fulfill the investigation. The attitudes, practices and awareness of
antimicrobial resistance of the local drugstores and consumers in Valenzuela city was
evaluated using the Exploratory sequential research design. The attitudes and practices of
dispensing and selling antibiotics was observed and evaluated in a qualitative approach
(Phase 1). The correlation and significant differences between the local drugstores and
consumers profile to the attitudes and practices of local drugstores was evaluated
quantitatively (Phase 2). This research approach also assesses the level of awareness of
antimicrobial resistance of pharmacists in the local drugstores and consumers.

A further investigation, surveys and conducting interviews may occur during the
duration of the study. Drugstore's pharmacists and probable consumers will be asked in
order to achieve the study's goal of investigating the attitudes/practices of local
drugstores in dispensing antibiotics and the consumer's awareness of the antimicrobial
resistance (AMR) due to improper use of antibiotics.

Research Locale

The research will be conducted at the City of Valenzuela. Valenzuela City is a

highly urbanized city in the National Capital Region of the Philippines. This was selected
to be the subject of the study to investigate if the local drugstores are still dispensing
antibiotics without prescription also to assess the knowledge and attitude of both the
pharmacies and consumer regarding the risk of dispensing and taking of antibiotics
without medical diagnosis. With a record of 479 total FDA accredited pharmacies, 233
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are local drug stores which are located only in a small community and owned by a local
of the barangay. The researchers focus mainly on drugstores and consumers located and
residing in District 2 of Valenzuela City within the vicinity of the following Barangays':
Gen. T. de Leon, Karuhatan, Bagbaguin, Mapulang Lupa, Marulas, Maysan, Parada, Paso
de Blas and Ugong. A total of 118 local accredited drugstores are listed in FDA in
District 2.

Population Sampling

The method for population sampling of the study in investigating pharmacies

across Valenzuela City uses Slovin’s formula by gathering the total population of
accredited pharmacies and local drugstores in barangay. The target population was
divided into two groups: the local drugstore and the primary consumers. The Local
drugstore is located in the district 2 which is the sample population for the local
drugstore.

There are a total of 118 local accredited local drugstores listed in the FDA in
District 2 of Valenzuela City . Out of 118 the researchers get the sample size of 91 the
total of drugstores in using the slovins formula . On the other hand, the researchers
employed a non probability purposive sampling technique to choose the target population
for consumers. The researchers will select 50 consumers, 25 of whom are men and 25 of
whom are women that have a history of purchasing antibiotics from a local drugstore
without a prescription, who are at least 18 years old and have purchased antibiotics over-
the-counter at least once between January 2021 and the present.

Research Instrument

The tool for generating data on the study is a guided response type of survey
questionnaire wherein numbers of recall-type questions will be asked to the participants
to recall a set of categories with multiple response questions. Informed consent from the
questionnaire is included in the manuscript. The questionnaire was adopted on the
following literature reviews: Local Survey on Antibiotic Use and Antimicrobial
Awareness (2011) and Knowledge and Awareness of the General Public and Perception
of Pharmacists about Antibiotic Resistance (2018). The researchers added demographic
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data of the respondents. Theresearchers utilized a 4 and 5 point likert scale method to
quantify the response of the sample and for them to swiftly and clearly respond to the
question while comprehending the purpose of this scale. The questionnaire for the
consumer is composed of four sections namely:

The respondents' demographic details are included in the first section, which is
made up of the respondents' social vulnerabilities. The respondent's age and gender, level
of education, are taken into account.

The knowledge of the respondents is measured and evaluated in the second

section of the questionnaire determining their awareness about the risks associated with
using antibiotics without a prescription.

The third section has 2 questions that embody the attitude of consumers towards
antibiotics on how long they take antibiotics and what conditions they self-diagnose and
treat with antibiotics.

In the final section of the questionnaire the researchers analyze the practice of the
consumer why they use/take antibiotics without prescription and how they were able to
buy and have the idea of taking the antibiotics over-the-counter.

On the other hand the questionnaire for the Local drugstores the pharmacist was
adopted on the following literature reviews: Local Survey on Antibiotic Use and
Antimicrobial Awareness (2011) and Attitudes and perceptions of community
pharmacists to antibiotic dispensing and microbial resistance. A study in aseer region,
Kingdom of Saudi Arabia (2020). It is also composed of four sections that includes first
the description of the drugstore in terms of how long they operate and age and gender of
its pharmacist. The second section of their questionnaire incorporates the history of it
selling antibiotics without prescription; moreover on the third section emphasize the
attitude of the local drugstores when dispensing antibiotic drugs and the final section of
the instrument aims to assess their awareness in microbial resistance.
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Validation and Reliability of the Instrument

The researchers adopted two (3) survey questionnaires from Ho (2011) Mason, T.
et al. (2018) and Alakhali (2020) . Ho (2011) developed a baseline survey based on the
study Local Survey on Antibiotic Use and Antimicrobial Awareness, which was
published in November 2010, and received 1,569 responses with a 69.2 percent response
rate. In May 2011, a follow-up survey was completed that assessed the level of public
awareness in the neighborhood. to collect, measure, and analyze the gathered data. On the
other hand, the Knowledge and Awareness of the General Public and Perception of
Pharmacists about Antibiotic Resistance published by Mason, T. et. al. (2018), conducted
a pilot study to validate both CPs and public surveys after gaining ethical approval and
doing the necessary data collection, wherein during the pilot phase of the CP survey, the
questionnaire's face and content validity were tested. The five CPs in South London were
casually consulted by the researchers about the questionnaire's topics. Following that, the
CPs were requested to complete the questionnaire and to offer any feedback on the
questions on the selected topics. The CPs found the content to be good, but they felt that
a few small adjustments, including rephrasing a few questions, were necessary. Alakhali
(2020) study on Attitudes and perceptions of community pharmacists to antibiotic
dispensing and microbial resistance. A study in aseer region, Kingdom of Saudi Arabia,
objective was to examine community pharmacists' attitudes, views, and prescribing
practices regarding the use of antibiotics and microbial resistance.A group of specialists
created the systematic questionnaire to assess attitudes and practices regarding the use of
antibiotics, and it was then validated by both professional and nonprofessional experts.
Research assistants conducted the interview, explaining the study's methodology and
obtaining oral consent from each study participant. All of the questionnaire and the test
demonstrated strong internal consistency and reasonable content validity in our setting.
All of the items on the instrument had great reliability, proving that they all measured the
same concept.

Potential Ethical Consideration

The researchers consider possible ethical issues that may encounter during the
duration of the study. When recruiting the participants for the survey, the potential
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respondents are free to choose whether to participate or not, they can withdraw their
participation from the study anytime without any negative reflection (voluntary
participation). The respondents must know the topic of the study that they're participating
in, thus consent takes place. The consents provide all important information about the
study such as, what study is about, the risk and benefits of being part and how long the
study will take (Informed consent). The respondents' data and identification such as
names are optional. They can choose whether to write their identifiable data or not,
furthermore personally identifiable data are not collected (anonymity). The information
and data gathered from respondents are hidden from everyone else, the participant's
responses are confidential to prevent any threats of data privacy (confidentiality). The
respondents are also free to ask for the results of the study if they are interested in it.

Data Gathering Procedure

The professor will validate the questionnaire first in preparation of handing it out
to the respondents. This research will be conducted in District 2 of Valenzuela City. The
researcher's goal is to investigate the dispensing of antibiotics in local drugstores, by
investigating this study it will bring awareness to the community and the researchers.
After approval consent is made for the study with the privacy concern of the local
pharmacies and consumers. The researchers requested that the respondents answer the
questionnaire with honesty. This study uses purposive sampling. Researchers separated
the local and commercial pharmacies to focus only on local drugstores and will make a
printed questionnaire for them. On the other hand for consumers, the researchers will
choose those who will fit the criteria and will send links in google form that can be
answered from 5 to 10 minutes. Afterwards, the data collected from the respondents will
be tabulated and tallied for the interpretation with the help of a statistician that will
determine the appropriate tools to be used in interpreting this study. Based on this study,
the researchers will be able to draw a strong conclusion and recommendation from the
results that have gathered from the respondents.
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Data Analysis

This research involves obtaining primary data through interviews and

questionnaires. To examine the research Hypothesis, t-test, z-test, One Way Analysis of
Variance (ANOVA) and Pearson r will be conducted to determine if there is significant
difference and relationship on the dependent variable by an independent variable.

Both four sectioned questionnaires of the respondents will be measured using the
measure of central tendency. This will cover the frequency, percentage and weighted
mean on the statement of the problem 1-9.

T-test a statistical test comparing two means that statistically assesses the
difference between two variables and One way Analysis of Variance (ANOVA) as the
extension of t-test that is used to compare two or more group means on a continuous
dependent variable or three or more population means equal. This statistical strategy will
be used to assess the significant difference in the statement of the problem number 10-13.

Nevertheless, Pearson r correlation will be used a statistical tool to test the

significant relationship on the variables in statement of the problem numbers 14-18
employing the use of this statistical tool the exact measure of degree of correlation will
be observed.
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