Combining data from consumers and traditional medicine practitioners to provide a more complete picture of Chinese bear bile markets

A free Plain Language Summary can be found within the Supporting Information of this article. Unsustainable and illegal wildlife trade (IWT) threatens species plants, animals fungi worldwide, making reduction IWT a global conservation priority. Reducing IWT, while also strengthening legal, sustainable supply chains, requires an in-depth understanding consumer behaviour, which is growing focus attention (Veríssimo et al., 2020). To date, data have been used to evaluate success interventions (e.g. Nuno 2018), design targeted behaviour change Doughty 2019) determine most effective alternatives that tempt consumers away from products (Moorhouse Despite its importance, studying demand for extremely difficult, especially when considering multiple cultural, personal, social psychological factors influence These include nuances in based on specific motivations consumption, as well differences consumption demographic cultural (Margulies 2019; Thomas-Walters While do consider these may still fail strong site-specific evidence base allows robust impact evaluation take place It therefore imperative are rather than assumptions about carefully account complexities (Hinsley & 't Sas-Rolfes, The interplay between various influencing seen clearly markets traditional wildlife-based medicines, where motivated different degrees by health needs, desire use long-established remedies recommendations trusted sources (Cheung 2021; challenging study using self-reported alone, attempt conceal their or socially undesirable (Davis, Crudge, 2019). In addition, many unable provide accurate information, they often unaware whether were wild-sourced farmed (Doughty Liu 2016). This due them focussing more other factors, such price, makes source product less important al. submitted). However, it likely deferring external, sources, including medical practitioners (Wang 2020) family members treatment decisions. relatively few studies medicine taken place, but clear role Traditional Chinese Medicine (TCM) particular significant China Cheung 2018). Considering both practitioner viewpoints determining characteristics complex obtain complete picture medicinal market, we mixed-methods approach triangulate public, TCM doctors pharmacy staff across four provinces mainland (Guangdong, Guangxi, Jilin Sichuan). Our focusses bear bile, ingredient recorded first pharmacopeia 649 A.D (Feng 2009). Bear bile contains Ursodeoxycholic acid (UDCA), with proven ‘Western’ biomedical efficacy treating liver gallbladder diseases variety ailments (Appiah 2017; Vang 2014). TCM, cold medicine, clearing fire heat 2021). included medicines wide range ailments, associated liver, eye hunting bears gallbladders (that contain bile) no longer legal China, farms introduced Asia 1980s onwards market Bile routinely extracted captive without killing them. dried powder now only produced farms, permitted over-the-counter prescription processed products, known ‘patent’ (National Pharmacopeia Committee, means unprocessed legally sold. Since government directive 2004, approved patent registered had carry certification sticker ease identification (www.forestry.gov.cn/sites/main/main/gov/content.jsp?TID=1080). addition trade, there neighbouring countries whole parts gallbladders, raw wild illegally Crudge Defining legality not always straightforward, pre-COVID rapid expansion farming coupled ineffectiveness China's regulatory system tell captive-bred apart, created loophole some laundered animals, local sold (Jiao Lee, populations range, Asiatic black Ursus thibetanus, prime target (Garshelis Steinmetz, Understanding how why people has direct relevance debates around farming. includes evaluating impacts farming, cases individuals stock Vietnam; 2020), indirect effects, centred availability changes (Bulte Damania, 2005; Dutton 2011). Questions effects wild-bile high-level policy discussions, resulting International Union Conservation Nature's (IUCN) World Congress Recommendation (WCC-2012-Rec-139) situation analysis gain information (portals.iucn.org/library/node/44106). implications, subject intense scrutiny animal welfare concerns long-term implications bile-extracted (Bando Poor hygiene standards current post-COVID-19 discussions zoonotic disease risk, shown passed humans (Wu As being context, issues legality, disease, effect behaviour. work conducted understand Southeast (Crudge 2020; Davis, Glikman, 2019), main produces far bile. Additionally, presence illegal, affect consumed. We large-scale surveys public interviews investigate perceptions China. estimate prevalence 2012, 23% (n = 81) students 30% 204) sample Beijing reported having consumed at point 22-year period (Liu 2017). nationwide survey 2010 fewer 20% respondents either knew somebody who although could estimated two questions combined, time frame defined (Dutton Furthermore, published sale Therefore, aimed (a) what extent, situations, China; (b) drivers (c) alternative promoted reduce perceived plant-based medicines; Moorhouse Studies outside underreport asked directly, desirability biases related illegality employed Unmatched Count Technique (UCT) established method improve anonymity honesty responses our consumption. findings draw conclusions value combining markets, containing From March June 2018, carried out face-to-face (hereafter referred ‘public surveys’), key-informant workers perception ‘practitioner interviews’). collected provincial capital cities Nanning (Guangxi), Guangzhou (Guangdong), Changchun (Jilin) Chengdu (Sichuan). chosen represent combinations proximity to: international borders (Jilin [Russia], Guangxi [Vietnam]: Garshelis 2016); (Sichuan, Jilin: Gong Harris, 2006); Sichuan: advice Association [CATCM]); Guangxi: Zhang 2008). criteria, tried country, meaning Northeast was over southern province Yunnan) similar characteristics, Guangdong south, Sichuan Southwest. designed all interview English, translated piloted January 2018 (226 surveys, interviews). then refined questions, back-translated English. No further made after stage tested half day each province, ensure appropriate contexts consistently (See 1 2 final questions). All research University Oxford's Central Research Ethics Committee Ref:R54657/RE002, collaborators Sun Yat Sen University, Academy Inventory Planning National Forestry Grassland Administration (NFGA), CATCM. Surveys started if informed consent given, assured personal details would collected, answers linked back individual withdraw any time. Formal permits permissions obtained prior start collection areas hospitals. assistants received one full training conduct interviews, sections importance ethics. They given daily morning lunchtime briefings reinforce during accompanied lead assistants, hand answer help problems arose. divided city's districts relative population density (very high, medium low), randomly sampled category. district size calculate proportional sizes needed reach approximately 1,000 per city. directly indirectly. UCT’s high statistical error, 4,000 total yield power >0.8 least 8%, samples reaching 16% (Ulrich 2012). values below available (23%–30%: 2017), recent estimates Vietnam (18%–45%: suggesting adequate. Data continued until reached. approached (including parks, shopping areas, residential streets), tablet computers Open Kit software (Hartung 2010). Assistants possible, aim achieve broad groups. did reveal avoid priming name potential treatments infections (chosen key TCM-sanctioned uses bile). UCT purchase 3 years before ‘recent consumption’). downside very large standard errors, difficult way Other specialised questioning techniques available, improvements analytical combine decided another simple administer, protect anonymity, works aiming well-suited behaviours rare preserves asking say list engaged in, specify ones assigned control group, showed non-sensitive statements group (‘Visited pharmacy’; ‘Bought pianzaihuang’ [a medicine]; flu medicine’; ‘Made my own medicine’) same plus sensitive statement (‘Bought products’) group. Ideally, lists should low prevalence, likelihood inadvertently selecting none identified suitable items pilot read long select recently in. ‘bought ‘made list. second question proxy (therefore illegal) products. note forms offered cases, prove authenticity (although mislead consumers). discovered that, character ambiguous (see 3). instead Following UCT, bought lifetime occurred (‘>3 ago’, ‘<3 ‘would so future’). Self-reporting (DQ) resulted follow-up (source form used, purchase, reason use). users, status intended future Respondents reporting DQ (purported ‘non-consumers’) heard Those solely non-consumers answered questions. Once finished, feedback respondent's survey. descriptive statistics variables, use. ran model-averaged logistic regressions look relationships behavioural variables (Table 1) awareness r (R Core Team, package Mumin (v 1.43.6), averaging models ΔAIC < 4 (Barton, Awareness lifetime, answering yes ‘have you bile?’. For difference-in-means assumed proportion selected confidence interval crossing zero suggest difference lists. DQ, number indicated last years. R (Blair Imai, produce estimates, significantly (at 95%) DQ. development combines respondent sampling variability, ‘combinedListDirect’ function (Aronow 2015). example, Aronow (2015) assume three latent classes respondents, applied those (DQ no, no); hide yes, yes); try yes). differentiate ‘a’ ‘c’ aggregate level, required identify ‘b’. Combining groups determined, wider relies several holding true, combined check via ‘placebo’ tests compare person. test falsely confess no), item does respondents’ report 4). fitted covariates Table score. Multivariate analyses yet possible 2015), separately sub-samples residents province; male female aged 18–34, 35–54 55. Controlling pre-treatment increase efficiency, errors Although lists, controlling might increases results reflect assignment 20 pharmacy-worker visited pharmacies close location interviewed member duty. Where immediate area, third closest shops starting visited, skipping belonging chain already location. Pharmacy limit took hours, structured short (usually 10–20 min). told question, open came infection. Further followed structure doctor interviews. doctors, contacted hospitals city Medicine, management 10 referral generate biases, potentially reducing involvement against hospital policy. indication prescriptions among disciplines. limited length normal appointment slot 5–10 min) make audio recordings. points covered interviewee, easily assistants. Doctors aware background, patient requests views herbal alternatives. summaries closed practising medicine), coded remaining analysis. reviewed native speaker, into English checked original coder discussion speaker. Any inconsistencies coding discussed refined. Due nature interview, short, little debate coding. answers, following discussion, categories sub-divided detail stated patients ask re-coded ‘No’ ‘No advice’). summarised themes example quotes show theme. survey, 4,374 people, obtaining 3,646 completed responses, unless otherwise stated. Of 728 sample, 483 refused begin 22 agreed meet age residence criteria 119 began 104 removed completion confusion answers. ranged 860 (Guangdong) 942 49.5% (49% male, 0.1% other), largest 25–34 (25.2%), 11.4% 65. was, average, better educated (www.stats.gov.cn. See 5). Most past year (56.4% n 2,055), 56.1% 1,152) visiting Western practitioner, 15.2% 312) 28.8% 591) both. 38 Guangdong, Jilin, 8 Guangxi) 80 Guangdong; 18 Guangxi). 0.5–50 experience (mean 12.8) 1–30 6.8). Five fields commonly (liver disease: 4; ophthalmology: 1). Less (42.8%) Without prompting study, 19.2% infection 4.4% interviewers mentioned 15 named customer When for, three-quarters 66) diseases, ‘heatiness’ (a term general feeling unwell). 1,521 (these bile), 85.9% 1,306) thought 2.1% 32) (12.0% know). 57.0% 867) decreasing, 9.3% 142) increasing 1.8% 28) stable (31.8% said Interviewees mixed substitutability 2). More 47) one-third 14) effectiveness drugs, depended severity patients, much with. (of 38) five 80) generally Twelve one-quarter 11) alternatives, almost 17) best problem, regardless available. ‘Because expensive, effective’ (Ph28. JL); ‘For eyes’ maybe better’ (Ph27. JL) ‘The matched diseases. kind one’ (Ph55. GD); ‘It depends use’ (Ph13. GX); ‘There theoretically, reality…generally speaking, because natural environment farm, leading purity content’ (D25, Liver, gastrointestinal disease*, Internal TCM. GD) ‘Like buffalo horn replacing antelope horn, good wild.’ (D2. Liver dermatology. GX.) living better. things’ (Ph21. ‘It's hard reason. natural. food feed wild’ (Ph30. ‘They will sure. There difference, mainly level purity’ (Ph14. GX) Over 21) 31) believed farmed. 13) 14 real just wild. small best, this. Reasons purity, bears, poor quality One (D11, Jilin) addressed prescribing larger quantities farme