In this study, we developed a TKM-based health promotion program as a strategy for disadvantaged children's health problems and evaluated its effectiveness based on the medical use and health conditions of children in CCCs. We found that the program significantly reduced the frequency of outpatient visits. The number of absences, lateness / early leave, and infectious symptoms tended to decrease, but not at a significant level.
The significant decrease in the number of outpatient visits is consistent with that reported in the study by Park et al , which was conducted to evaluate a TKM-based healthcare program for preventing infectious diseases in infants. This result showed that providing TKM doctor’s visits to CCCs and necessary herbal medication over-the counter had the effect of replacing outpatient visits of disadvantaged children. If this program is extended to the local community at large, it would be more appropriate to use TKM doctors hired by local public health centers rather than those who run private clinics in consideration of cost-effectiveness.
Although the number of absences, lateness / early leave, and infectious symptoms in the intervention group tended to be lower than those in the control group, there was no significant difference between the groups. This result may be due to the following reasons. First, the intervention period of this study was from July to September, and in South Korea, August is the vacation period, so it is estimated that it was difficult to show a difference in attendance or lateness due to the small number of school days. In addition, in the case of infectious symptoms, it may have been difficult to detect a difference between the two groups because South Korea has a good sanitary environment with few digestive infections and respiratory infections generally occur frequently after October in South Korea's climate.
In analyzing the effectiveness, the individual effects of each part of the program were not analyzed separately. This complements the purpose of this study, which was to develop a comprehensive packaged service program rather than to prove the effects of a single intervention for health promotion.
The DIDs, used as the analysis model for this study, are popular in empirical research to estimate the causal effect of certain policy interventions or changes that cannot affect everybody at the same time and in the same way . This model not only controls the unmeasured time-varying factors (trend effect) but also offsets the heterogeneity between the intervention and control groups through differences on the assumption that they are time invariant. However, even in DID, when setting up a control group, the propensity score matching method is used, or multiple control groups are included in consideration of internal validity. In this study, children's demographic information was collected as bivariate, which limited the accuracy of propensity score matching. In addition, it was difficult to set up multiple control groups because local communities and CCCs had different opinions and circumstances regarding participation.
To compensate for these problems, we conducted a homogeneity test and referred the results to program effects. Homogeneity tests showed some heterogeneity among participating children. However, it is unlikely that this would have overestimated the effectiveness of the program. According to the homogeneity test, there was no significant difference in demographic characteristics between the two groups in the pre-survey. In the post-survey, the proportion of children with past medical history and present illness was significantly higher in the intervention group than in the control group. This indicates that the effectiveness of the program was judiciously measured because the intervention group of the post-survey included more children with poor underlying health conditions than the control group.
This TKM-based health promotion program presents a comprehensive and systemic health promotion strategy comprising medical examination and counselling, health education, daily management, and health monitoring. CCCs in Korea are usually small centers composed of a director and two or three childcare teachers and cannot have their own medical personnel and facilities. In this program, medical examinations and consultations by visiting TKM doctors can help determine children's current health and developmental levels. In addition, this program intended to increase children's health knowledge and interest in health through periodic health education and health monitoring using a self-reported health diary. To facilitate this multi-faceted program, not only visiting TKM doctors but also CCC teachers and caregivers were given cooperative roles. This is in line with the recent trend of emphasizing the partnership of diverse personnel in child health care .
Traditional and complementary and alternative medicine (T&CAM) has been used to treat children’s health problems in many Western countries. In the United States, the Integrative Therapies Team Program of Boston Children’s Hospital has been established to provide massage therapy, guided imagery, reiki, acupuncture, expressive arts, and yoga . This Team program is also available in Minnesota, Philadelphia, Colombia, Utah, and Orange County [38–42]. In Germany, the Integrative Pediatrics project (Integrative Pädiatrie Projekt) was operated from 2015 to 2017 [43, 44], and the Integrative Pediatrics Center (Center de pédiatrie intégrative) of Switzerland has been providing homeopathic medicine, herbal medicine, acupuncture, and cupping for pediatric diseases since 2015 [45, 46]. These cases have used T&CAM on children's diseases in hospital settings, so few have investigated the effects of T&CAM on health promotion in community settings, as in this study.
A potential limitation of this study is that TKM doctors were included according to their voluntary participation without restricting for their clinical careers or major medical fields. This was due to the fact that many childcare facilities in South Korea had difficulty securing medical professionals [47–49], and we not only wanted to secure a sufficient number of medical professionals in this study but also a realistic operational model that would be easier to introduce if the program is institutionalized in the future. To minimize variations caused by the difference in performance capabilities among TKM doctors, we prepared a program manual, standard consultation form, and educational materials and held a pre-workshop for TKM doctors. Another limitation was that the three months of intervention period was relatively short to determine the disease prevention effect through the health promotion program, and follow-up after the intervention period was not performed. Although it was possible to observe changes in some program outcomes despite these limitations, it is necessary to consider a longer period of intervention and follow-up observations when designing further studies.