Two themes were identified regarding participants' experience of applying the parent-administered pediatric tuina intervention and participating in the study: (1) facilitators to the intervention implementation, (2) barriers to the intervention implementation. Under each theme, the specific sub-themes are described. Figure 2 presents the code structure.
3.2.1 Theme 1: Facilitators to the intervention implementation
This theme consists of four sub-themes: (a) Perceived benefits on children and parents; (b) Acceptability of parents and children; (c) Professional guidance and auxiliary supports; (d) Parents’ expectations on long-term use of the intervention.
Sub-theme 1: Perceived benefits on children and parents
All participants generally thought that their children had better health status. They described observable changes in physical well-being on their children during the intervention. The most prominent changes as perceived by the majority of participants were improved sleep quality and increased appetite. For example, a mother described the improvements of her child such changes:
“The main role of Tuina is reflected in the improvement of sleeping of our child. He had not even slept at eleven and twelve in the evening, but now he can even sleep in seconds in a quiet environment when he is left in bed alone. Now he is able to sleep at nine in the evening, which was previously no case at all...He received Tuina for about more than a month, when I noticed that his sleep was getting better and better...Actually, the Concerta which he received affected his appetite and sleep greatly. However, his appetite is also gradually getting better after his receiving Tuina for a period of time. He eats even more than ever before, which is a big surprise to me.”(PTA-FG-14)
Many participants also mentioned the changes in children’s moods. According to their narratives, their children could control their tempers and showed more patience when communicating with others. For example, a participant described, “He used to take unnecessary pains to study an insoluble problem. He kept saying one thing repeatedly, but there are less similar things for him now.” (PTA-FG-06). Another mother mentioned: “I used to ask him several times before he answered my question, but now he will tell me a lot of words. When he is angry, he will not lose his temper immediately but tell me: ‘Mom, please help me to see this and forgive me. I won’t do this again. Only for this once.’ His heart would melt and say good words to me. I think the child let me understand his psychological activities, and it is very good.” (PTA-FG-01).
Furthermore, some participants were impressed by improvements in academic performance and interpersonal communication at school. One participant shared: “My biggest feeling now is that the child is making progress in his learning. He had a problem with addition and subtraction within ten in math, but now he does this slowly, and he can figure it out. Then, that writing was not much for him before, but now he writes.... Then he learned some words from his peers. For example, he would say: ‘Mom, you were fierce to me,’ which he wouldn't say before…Also, he knew fewer children before, but now he basically knows the names of his peers. He now plays games with his peers in school, but he didn't play much before... Additionally, he began to like painting and improved very much.” (PTA-FG-02).
In addition to patient changes after the intervention, over half of the participants described their improvements in mood and mental status, citing “feeling good”, “much relaxed”, “reduced anxiousness”, and “much calmer”. “When I didn’t been exposed to this Attention-Deficit Hyperactivity Disorder (ADHD) before, I didn't understand my boy. I feel that other children are very good, why he is always so. I am angrier. But now, I feel that I understand him more, and he is very happy to be massaged at night. Now, when he has made a mistake, I feel that I can’t get angry because I want to know him. Therefore, my mood can also be adjusted even better.” (PTA-FG-05)
Some of them also mentioned that the relationships with children were closer. “He can feel that it is really communicating with him in the process of massage. He probably could not feel the care and love on him from adults before. When you really go into the process, he will give you back. This kind of feedback moved me very much. He slowly understood his mother’s difficulties, so now he will also say: ‘Mom, let me hug you and give you a kiss.’ I am really very moved, and it is also a process of growth for myself.” (PTA-FG-12)
Sub-theme 2: Acceptability of parents and children
Based on the participants’ descriptions, they were in support of using pediatric tuina for their children due to their perceived advantages. The primary advantage as felt by almost all participants was that pediatric tuina was safe and with no or minimal side effects. Besides, it is an economic intervention that would not bring financial pressure to ADHD families. A mother said:“About ADHD, there are many treatments, but I feel that this pediatric Tuina is the best kind. Only a little time is used, and it is not necessary to waste money. It won’t be bad for the body as medication, and it is particularly reassuring, so I think it is particularly good.” (PTA-FG-05)
Some participants also mentioned the additional advantage of the convenience and accessibility of this intervention as they were able to learn and deliver at home, which kept them away from hospital under the existing Covid-19 pandemic and was a more economical way compared with receiving the treatment in hospital. A parent mentioned that :“I used to go a long distance to take my child to the Children’s Hospital for Pediatric Tuina, and only on weekends. I also did not understand how to use the technique of Tuina. Every time I spent 200 yuan to receive Tuina only for 20 minutes, and then I was suddenly enlightened after having listened to the Tuina class, so I was just so happy. Now, you have created this condition for me to do Tuina by myself without going this so far distance.” (PTA-FG-01)
Additionally, a few participants described that pediatric tuina as a parent-administered intervention was more acceptable for children too, which provides them a sense of security and enjoyment. “When he came back from the outside, if he encountered any problems, in fact, I would have helped him for doing Tuina. He would say: ‘Mom, you please help me to do Tuina again, and have a rub and have a press’. He felt that his mother’s rubbing and pressing was a kind of love, and then he would feel that he likes it very much...” (PTA-FG-13)
Sub-theme 3: Professional guidance and auxiliary supports
Participants expressed that the intervention was satisfactory or even far met their expectations. They were very impressed by the professional guidance and auxiliary supports from the research team helps them a lot for persisting in practicing pediatric tuina.
A participant expressed her satisfaction with the course sessions, timely responses from TCM practitioners, and prescriptions with manipulation videos. “What I like is that the doctor could spend a long time to give us an explanation of each acupoint patiently, which is equivalent to a systematic pectination, more than I expected. The teacher I contacted was also very careful, and she responded to me every time I asked anything... I took some videos and photos during the diagnose through interrogation, and the doctor also watched the videos and photos and answered my questions.” (PTA-FG-02)
Corresponding textbooks and weekly auxiliary documents promotion meet the requirements of participants. One said that “Firstly, the textbooks of Tuina are particularly good, and in color, looking more clearly, which completely exceeded my expectations. Secondly, pushing message weekly let us constantly have learning and understanding of Tuina, which is also very good.” (PTA-FG-03)
Sub-theme 4: Parents’ expectations on long-term use of the intervention
All parents attended the interviews expressed their expectations to keep practicing pediatric tuina for the effects of chronic symptoms, such as inattention, adjusting constitution, and health preservation.
A mother described her hope to solve her child’s inattention problems before 12 years and improve other aspects. “I just hope to solve his attention problem before age of 12, so I am willing to make various attempts. Furthermore, Tuina can promote his spleen and stomach, and promote sleep, which I think are very good. Of course, you can’t see much effect in the short term, but it needs to be adhered to for a long term.” (PTA-FG-08)
Another mother was surprised by the additional effects of pediatric tuina and decided to persist on using it. “ I will keep sticking to it. Originally we did Tuina for attention, but we accidentally found that the spleen and stomach needed to be recuperated in the doctor’s dialectical process. After about two weeks of recuperating, then I felt that his face has changed very well, ruddy, so this is also an unexpected harvest. Later we will insist, will not stop.” (PTA-FG-08)
Parents also described their great needs and expectations of long-term professional supports on pediatric tuina. One expressed that persistent guidance is an important factor for her to use the intervention considering the safety issues on children “At present, I will continue to do Tuina. In the future, I may stop after doctor’s guidance is gone subsequently, because Tuina still needs the doctor to continuously give some guidance to do it...” (PTA-FG-15)
Another one mentioned her expectations of continue to learn knowledge in this area“As parents, we may still need to improve the accuracy and professionalism of the operation of Tuina; for the theoretical knowledge of dialectical thought of Tuina, we still hope to have an opportunity to learn further.” (PTA-FG-03)
3.2.2 Barriers to the intervention implementation
Barriers included the following three sub-themes: (a) Limited benefits of pediatric tuina on children’s inattention symptoms; (b) Manipulation difficulties of parents; (c) Limitation of online TCM pattern identification.
Sub-theme 1: Limited benefits of pediatric tuina on children’s inattention symptoms
Despite acknowledging physical and psychosocial benefits associated with pediatric tuina, more than half of participants expressed that little improvements were observed for their inattention symptoms. Two participants mentioned their children’s attention improves a little, but not that obvious. Such change was usually acceptable for parents because they believed that it took a longer time to observe improvements in ADHD symptoms. A mother mentioned: “For the moment, I don’t think that the improvement of attention is too obvious. After all, it is something on the neurological aspect, which may not be obvious in the short term. A long-term persistence is needed.” (PTA-FG-14)
Sub-theme 2: Manipulation difficulties of parents
The majority of participants spoke of different issues encountered in the 2-month daily implementation of pediatric tuina. The biggest issues as perceived by these participants were uncertainties about the acupoints selection and the strength of each manipulation. This was particularly for some participants who perceived the effects of pediatric tuina conducted by themselves was not efficient compared to that conducted by TCM practitioners, especially when their children were not cooperative. A participant expressed this issue as follows: “I don't know whether it is my problem of strength or other problems, and I feel that the effect will be a little slower than the doctor’s saying... sometimes he did a little more homework as if he did not have enough strength when lying on the sofa. There were more inner activities, and he did not look at me, and then it was more difficult and a little slower to communicate with him.” (PTA-FG-01)
However, other participants actively solved the acupoint problems by turning to manipulation videos and books, communicating with the TCM practitioner, or checking information on the internet. “The first problem is the accuracy of the acupoints; the second problem is whether the strength is appropriate. In response to these two problems, I basically solved these problems by taking a video of my own Tuina operation, and then taking one at each acupoint and sending it to the teacher for further consultation.” (PTA-FG-03)
Several parents were not sure whether the prescription should be adjusted in time according to the changes of several factors, such as season, children’s signs, and symptoms.
“I still have a problem, that is, the adjustment of the acupoints. For example, his coated tongue will change again through Tuina, or his liver-Qi is very prosperous, and we always want to relieve his liver-Qi. Now, do the acupoints need to be adjusted again? Do you need to replace it with the four seasons? Will the pressing of the same acupoints be useless for a long time, as if the drug has resistance for a long time?” (PTA-FG-13)
Sub-theme 3: Limitation of online TCM pattern identification
As an intervention that all implemented on parents by online methods, several problems were put forward by the participants, which mainly focused on the TCM pattern identification process.
A parent expressed her worried about the accuracy of online TCM pattern identification. “As far as I am concerned, does the TCM pattern identification need to be more detailed? Because if you do not see the child face to face, you may not be sure? The accuracy of TCM pattern identification is a little low, and I have nothing to worry about except this.” (PTA-FG-06)
Another parent doubted the comprehensiveness of the TCM pattern identification: “However, there may be a little difference in the TCM pattern identification of children, because traditional Chinese medicine still has four ways of diagnosis of looking, listening, questioning and feeling the pulse. Pulse feeling is needed for children, such as coated tongue face examination, etc. This may not be comprehensive when just examination of the coated tongue and faces are not examined. (PTA-FG-04)