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 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.