Social Determinants of Antibiotic Prescribing in China

231 Pages·2017·3.3 MB·English

UCLA
UCLA Electronic Theses and Dissertations
Title
Social Determinants of Antibiotic Prescribing in China
Permalink
https://escholarship.org/uc/item/6bd7k6xr
Author
Wang, Nan
Publication Date
2017

Peer reviewed|Thesis/dissertation
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ABSTRACT OF THE DISSERTATION

Social Determinants of Antibiotic Prescribing in China

by

Nan Wang
Doctor of Philosophy in Sociology
University of California, Los Angeles, 2017
Professor John Heritage, Co-chair
Professor Tanya J. Stivers, Co-chair

Antibiotic over-prescribing and bacterial resistance is one of the biggest public health crises
in the world today. Despite high prescription rates and growing resistance rates in China, our
understanding of the contributors to the problem is still lacking. The existing literature has mostly
concluded that antibiotic over-prescription is a supply-side problem driven by physicians’ financial
incentives; however, the role of demand-side factors has been largely neglected and unattended to.
This dissertation is motivated by this gap.
Using a community-based and cross-sectional survey, I examined caregivers’ pre-visit
behavior and attitudes regarding antibiotics for children’s common cold symptoms. The results
showed that 38% of the respondents used non-prescribed oral antibiotics before they visited
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physicians, and this behavior was not only associated with their desires for physicians’ antibiotic
prescriptions, but also with them receiving antibiotics during the medical visit.
To understand the process of antibiotic prescribing in medical interactions, I used
Conversation Analysis to investigate physician-caregiver communication behavior in pediatric
encounters. The results revealed that, first, compared to the American pediatric context, caregivers
not only advocated for antibiotic treatment more overtly in Chinese context, but also did so more
frequently (9% vs. 54%); second, physicians did not promote antibiotics enthusiastically – although
antibiotics were prescribed 59% of the time, they were initially recommended by physicians 40% of
the time; in addition, when examining the effect of caregivers’ treatment advocacy on physicians’
prescriptions, it was found that caregivers’ overt advocacy for antibiotics increased the likelihood of
physicians’ prescriptions by over 9 times (OR=9.23, 95% CI: 3.30-33.08), and the effect was
particularly strong on IV drip antibiotic prescriptions (OR=14.03, 95% CI: 5.77-38.70).
In conclusion, this dissertation has revealed that demand-side factors played an important
role in antibiotic over-prescribing in China. Contrary to the prevailing theory that over-prescribing is
a supply-side problem, I found that physicians’ prescribing behavior was significantly influenced by
caregiver treatment advocacy during the medical visit. Based on the findings, I recommended that
first, regulations of non-prescribed antibiotics should be strictly enforced; second, health education
campaigns about the rational use of antibiotics can be implemented among key population groups;
and third, physicians can be given training in communication skills for resisting caregiver treatment
advocacy.

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The dissertation of Nan Wang is approved.

Donald E. Morisky
Hongyin Tao
Stefan Timmermans
John Heritage, Committee Co-chair
Tanya J. Stivers, Committee Co-chair

University of California, Los Angeles
2017

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LIST OF TABLES & FIGURES

Table 1-1. Social health insurance programs 10
Table 1-2. Rural three-tier health delivery network 15
Table 1-3. Urban three-tier hospital-based delivery system 17
Table 1-4. Service provision distribution in urban three-tier hospitals 18
Table 2-1. Socio-demographic Characteristics of Respondents 44
Table 2-2. Visit-related Characteristics 45
Table 2-3. Self-medication Before the Visit 46
Table 2-4. Caregiver Desires for the Visit 47
Table 2-5. Prescribing Decisions 47
Table 2-6. Effect of Caregiver Desires for Antibiotic Prescriptions on Antibiotic Prescriptions 49
Table 2-7. Predictors of Caregiver Use of Non-Prescribed Antibiotics Before Medical Visits 53
Table 2-8. Predictors of Caregiver Desires for Antibiotic Prescriptions 54
Table 2-9. Predictors of Caregiver Desires for IV Drip Antibiotic Prescriptions 55
Table 3-1. Caregiver Overt Advocating Actions for Antibiotic Treatment 78
Table 3-2. Type of Antibiotic Treatment Being Advocated For 79
Table 3-3. Local Sequential Placement of Overt Advocating Actions 124
Table 3-4. Global Sequential Placement of Overt Advocating Actions 126
Table 3-5 Prescribing Outcomes 128
Table 3-6. Test statistics for use of advocating action vs. prescribing outcome 129
Table 3-7. Test statistics of use of advocating action vs. prescribing outcomes 130
Table 4-1. Type of treatment Initially recommended by physicians 145
Table 4-2. Type of treatment Initially recommended by physicians 147
Table 4-3. Type of Treatment Initially Recommended & Ultimately Prescribed by Physicians 147
Table 4-4. Physicians' treatment recommendation actions 150
Table 4-5. Physicians' treatment recommendation actions & treatment recommended 151
Table 4-6. Caregiver-initiated discussions of treatment plans 175
Table 4-7. Physicians' responses to caregiver overt advocacy for antibiotic treatment 177
Table 4-8. Physicians' treatment recommendation actions & treatments being recommended 179
Table 4-9. Treatment recommendation actions and caregiver responses 180
Table 4-10. Type of treatment being recommended and caregivers' responses 180
Table 4-11. Physicians’ treatment recommendation actions and prescribing outcome 181
Table 4-12. Type of treatment being recommended and prescribing outcome 181
Table 4-13. Initiator of treatment discussion and prescribing outcome 182
Table 4-14. Caregiver-initiation of discussion about antibiotics and prescribing outcome 183
Table 4-15. Caregiver-initiation of discussion about drip antibiotics and prescribing outcome 183
Table 4-16. Effect parameters of physician-caregiver actions on antibiotic prescriptions 185
Table 4-17. Effect parameters of physician-caregiver actions on IV drip antibiotic prescriptions 186

Figure 2-1. The indirect and direct effects of X and M on Y. 50

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ACKNOWLEDGEMENTS

I would like to thank Professor John Heritage and Professor Tanya Stivers for their
extraordinary guidance and selfless support throughout this project. I would like to thank Donald
Morisky, Hongyin Tao, and Stefan Timmermans for their expert advice and kind encouragement in
this dissertation process. I am grateful for the brilliant insights and comments from Steven Clayman,
Jennie Brand, Ka-Yuet Liu, and Wei Zhang at various stages of this project. Thank you to my
colleagues Clara Bergen, Alexandra Tates, Caroline Tietbohl, Ruey-Ying Liu, Amanda McArthur,
Amelia Hill, Saskia Maltz, Keith Cox, Luis Manuel Olguin, Anne White, Laura Loeb, Lisa Kietzer,
Chase Raymond, and Matthew Fox for constantly helping me and inspiring me. My sincere thanks
also go to all the people who have agreed to participate in this project and the research staff who
have assisted in data transcribing and data entry.

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VITA
Education
University of California, Los Angeles
• C.Phil. in Sociology Awarded 06/2015
• MA in Sociology Awarded 06/2013

City University of Hong Kong
• M.Phil in Applied Linguistics Awarded 01/2011

Jiangsu University
• BA in English Awarded 06/2008

Fellowships and Grants
University of California, Los Angeles
• Dorothy L. Meier Dissertation Fellowship, UCLA Department of Sociology, 2017-2018, 2016-2017
• Travel Grant for the 55th Annual Meeting of the Association of Computational Linguistics (ACL), NSF, 2017
• Travel Grant for ACL WiNLP Workshop, ACL Organizing Committee, 2017
• Graduate Fellowships, UCLA Department of Sociology, 2011-2012, 2016
• STAR Award for Student Presenter, International Communication Association, Fukuoka, Japan, 2016
• Departmental Summer Research Award, UCLA Department of Sociology, 2013-2014, 2015-2016
• Department Summer Travel Grant, UCLA Department of Sociology, 2015-2016
• Summer Research Fellowship, UCLA Center for Chinese Studies, 2013-2014
• Chancellor’s Prize, UCLA Graduate Division, 2011-2012, 2012-2013
• UC System Pacific Rim Research Grant Finalist, UC System, 2012-2013

City University of Hong Kong
• Outstanding Academic Performance Award, Chow Yei Ching Graduate School, 2009-2010
• Graduate Fellowships and Stipends, Chow Yei Ching Graduate School, 2009-2010, 2008-2009
• Research Fieldtrip Grant, Chow Yei Ching Graduate School, 2009-2010

Jiangsu University
• National Award for Outstanding Undergraduates, 2008
• University Award for Outstanding Academic Performance 2007-2008, 2006-2007, 2005-2006

Academic Publications
• Wang, N. (2017). Negotiation of Antibiotic Treatment in Medical Consultations: A Corpus-based Study.
Proceedings of the 55th Annual Meeting of the Association for Computational Linguistics - Student Research
Workshop.
• Wang, N., Song, Y. (2017). What Does an Effective Treatment Recommendation Look Like: A Corpus-based
Study on Doctor-Patient Conversation. Proceedings of the 55th Annual Meeting of the Association for
Computational Linguistics - WiNLP Workshop.
• Morisky, D. & Wang, N. (2017). Medication adherence. Paper accepted in Oxford Online Bibliography-Public
Health.
• Chantal, B., Marsen, S., Wang, N., & Yang, Y. (Submitted). Decentering the analysis: the authority of
spectators, journalists and others, in-progress chapter in edited book by Nicolas Bencherki, Frédérik Matte, &
François Cooren: How to analyze power and authority in interaction, Routledge.

Academic Presentations (selected)
• Wang, N. (2016). Is China’s antibiotic overuse problem driven by physicians’ financial incentives? Presentation
at Health Working Group, UCLA Department of Sociology, Los Angeles, USA, Feb. 5, 2016.
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• Wang, N., and Yang, Y. (2016). Analyzing authority and power in interaction: a case analysis of one Q-A
adjacency pair using Conversation Analysis. Paper presented at the preconference workshop at the
International Communication Association Conference, Fukuoka, Japan, June 9, 2016. 

• Yang, Y., and Wang, N. (2016). Analyzing authority and power in interaction: promise of and cautions from
ethnography of communication. Paper presented at the preconference workshop at the International
Communication Association Conference, Fukuoka, Japan, June 9, 2016. 

• Wang, N., Stivers, T., and Heritage, J. (2015). Patient-related factors to antibiotic overuse in China: Self-
medication, desires for antibiotics, and use of IV drip. Paper presented at the roundtable session of the
American Sociological Association (ASA) 2015 Annual Meeting, Chicago, USA, 2015. 

• Wang, N. (2014). Patient lobbying practices in pediatric visits. Paper presented at the 4th International
Conference on Conversation Analysis, Los Angeles, USA, June, 2014. 

• Wang, N. (2013). Doctor-patient relationship and medical care system in the U.S. Brownbag talk at the Institute
of Economics, Chinese Academy of Social Sciences, Beijing, China, Sept. 11, 2013. 

• Wang, N. (2013). Making requests in doctors’ office: data from Chinese pediatric interactions. Paper presented
at the theme session on Conversation Analysis and Multi-modality in Chinese Interaction, International
Cognitive Linguistics Conference (ICLC2013), Edmonton, Canada, June, 2013. 

• Wang, N. (2012). Maximizing patients’ input in medical consultations: a study of patient initiation in Chinese
pediatric interaction. Paper presented in the 3rd Annual Public Conference on Multilingualism in Institutional
Contexts, Los Angeles, USA, November, 2012. 

• Wang, N. (2012). Preliminaries to prescribing: the sequential organization of prescription decisions in Chinese
pediatric consultations. Invited talk in Conversation Analysis Working Group, UCLA Department of
Sociology, Los Angeles, USA, Nov. 18, 2012. 

• Wang, N., and Zhang, W. (2009). Physician-parent interaction in treatment decision in a pediatric department
in a mainland China hospital. Paper presented at Frontiers in Medical and Health Science Education 2009:
Making Sense in Communication, Hong Kong, December, 2009. 


Teaching Experiences
University of California, Los Angeles
• SOCIOL158 Talk & Social Institutions
• SOCIOL111 Social Networks Analysis
• SOCIOL1 Introductory Sociology
City University of Hong Kong
• CTL5408 Sociolinguistics
• CTL2203 Language & Society
• CTL2209 Introduction to Language Studies

Academic Services
• Co-coordinator | Conversation Analysis Working Group, UCLA Department of Sociology, 2016-2017
• Graduate student mentor | Honors Thesis Program, UCLA Department of Sociology, 2016-2017
• Student committee member | Graduate Program Admissions Committee, UCLA Department of Sociology, 2016
• Volunteer | CLIC Conference, UCLA Center for Language, Interaction, and Culture, 2015-2016
• Reviewer | CLIC-GSA Conference, UCLA Center for Language, Interaction, and Culture, 2015-2016
• Volunteer | 4th International Conference on Conversation Analysis, Los Angeles, 2014
• Volunteer | CLIC Conference, UCLA Center for Language, Interaction, and Culture, 2013-2014

Member of Society
• The Association for Computational Linguistics (ACL)
• International Society for Conversation Analysis (ISCA)
• American Sociological Association (ASA)

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