**4. Discussion**

In this study, which was based on the assumption that the experience, opinion, or ideas of parents may influence the use of TKM by their children, the participants were divided into groups based on whether their children had experienced using TKM or not; comparisons were made to evaluate whether these groups showed any differences in terms of the characteristics, awareness, or satisfaction of the parents. This analysis was done for the purpose of developing policies and identifying the ideal time for intervention by understanding the differences in satisfaction and awareness between the two groups.

The initial analysis regarding the participant's children showed that, out of the 5000 participants, 17.4% (*n* = 872) had a child under the age of 19. Of these, 24% (*n* = 209) answered that their children experienced the use of TKM. In previous studies, it was reported that 55.3% of the target population had a child with TKM use experience [26], and in another, 81% [25]. However, caution should be practiced when interpreting these results as the target populations were from a daycare center within a self-governing district or the outpatients of a TKM clinic who were familiar with TKM pediatric practices. Especially, the value of 81% provided in Choi [25] was in contrast with the result of this study, where the proportion of the children who experienced TKM was 17.4%. It is believed to be because of the bias in the selection of the participants, who were selected from the patients who used the TKM clinic of the researcher. In this study, certified national statistics were used and thus based on a representative, standard sample of Korea's general public; therefore, it is believed that the result can be generalized. Also, this study supports the findings in some preceding studies [25,26] that TKM clinics are used to treat the respiratory disease and skin disease in children. However, the said study could not cover the analysis on the purpose for the parents to use TKM clinics due to the limitations of the questions in the questionnaire, making it necessary to use caution in interpreting these findings, as it was assumed using the perception of treatment effect by parents based on the children's TKM use reported by parents.

The reason why the children in Chungcheong and Gyeongsang regions are more likely to use TKM compared to those in the Capital area is attributed to the shortage of mainstream medical institutions (e.g., CM institutions and TKM institutions) and the demographics of these areas. These two regions are some of the most representative examples of a combination of urban and rural areas in the same region [27]. Also, the demographics of these areas are heavily leaning toward the older population compared to children [27].

The results of the analysis were used to observe whether there was a difference in the characteristics of the parents depending on the experience of their children with TKM showed that 8.1% more females (mothers) answered that their children had experienced using TKM. Also, as the participants grew older, being in their 50 s or older, the rate of answering that their children had experienced using TKM, tended to be higher. This supports the existing study result, where females were more likely to use TKM, and 61.8% of the users of TKM were at least 45 or older [28]. However, this study does not clarify the factors and correlations. Therefore, care is needed as one attempts to interpret it. Future studies are needed to investigate what is the true tendency of female and people in their 50 s or older in their use of TKM and what are the factors that contribute to such a result. Based on such findings, it would be possible to employ a more detailed approach to the use of TKM by the children.

On the other hand, the fact that those in their 30 s or 40 s were less likely to use TKM, compared to those in their 50 s or older, can be attributed to the fact that the younger group corresponds with the prime age of workers, namely those aged 25 to 49 [29], a time when individuals are the most active in terms of economic activities. In addition, if both parents of the children are working, it would be more likely that they would experience time or money obstacles, when trying to seek out using TKM. The findings of this study suggest that if the accessibility to TKM is improved for individuals in their 50 s, the younger parents in their 30 s to 40 s, and females, it would be possible to improve accessibility for their children. Also, in the group where the children had experienced TKM, the proportion of those with a higher level of education was higher among those who gave positive answers concerning the experience of the parents, intent to use in the future, and willingness to recommend. This can be interpreted to be because of the financial resources, desire to be healthy, and interest among these higher-education groups. However, further study is needed in order to clarify this correlation.

About 60% of the participants answered that TKM treatments were more expensive, which is related to the reimbursement ratio of the health care insurance of Korea. As of 2019, the reimbursement coverage rate by the health care insurance over the entirety of medical institutions in Korea was 64.2%, while the rate for TKM clinics was 54% and TKM hospitals was 28.7% [30]. This is based on the national policy that the health care insurance coverage is to be provided for the treatments with a clear scientific basis to treat severe diseases. While CM treatments have accumulated scientific evidence all over the world, CAM treatments and traditional treatments differ between countries, making it difficult to build up scientific evidence. Therefore, it is necessary to accumulate scientific evidence for the treatment effectiveness and safety by means of exchange and harmonization of traditional medicine and CAM with international organizations such as the World Health Organization taking the leading role. If such a worldwide basis of evidence is built, it could be possible to integrate traditional medicine and CAM treatments into the healthcare coverage, eventually contributing to the improvement of the health of the public.

Children of parents with an experience of using TKM were more likely to use TKM, compared with children whose parents had no experience with using TKM. Of the children whose parents experienced using TKM, 91.4% used TKM (*n* = 191) themselves, while 71.9% of the children whose parents never used TKM used it (*n* = 477) (*p* < 0.001). This indicates that the parents' experience with using TKM had a significant impact (20%) on the use of TKM by their children. The Ministry of Health and Welfare developed the TKM health promotion program for toddlers and infants in 2016 [31], which has gradually been implemented through community health centers [32]. As such, in order for the State to maximize the effectiveness of childhood health management, mainly via TKM, a policybased approach is needed such that the parents of these children may be provided with health management programs through TKM, as well.

In the group of parents whose children experienced using TKM, the rate of answering that they were willing to revisit a TKM clinic was higher by 9.5%, while the rate of answering that they were willing to recommend to others was higher by 20.8% (*p* = 0.003). This indicates that the perception of the parents impacted the use of TKM by their children, and the improvement of the perception of these parents may have an impact on the use of TKM by their children. It is necessary to conduct further studies in order to clarify these correlations.

The limitations of this study were as follows: first, due to the limitations in the data gathered for this study, it was not possible to clarify the correlations between the parents' experience, awareness, and satisfaction with the use of TKM or the use of TKM by their children. Additional studies are needed in order to clarify which variables among the parents' awareness, the purpose of visit, sex, or age, etc., had an impact on the use of TKM by their children. Second, the data obtained through the survey was based on the memories of parents, who were the participants of the survey. Therefore, it is still possible that they answered incorrectly when asked about their children's experience with TKM. Third, the age group of the children of the participants could have had an impact on the experience of using a TKM clinic. However, it was not possible to obtain information on the age of the children. That is, younger children were more likely to have not experienced TKM, which could have contributed to the outcome. Lastly, due to the limitations in the questionnaires, it was not possible to identify the type of treatment the participating patients received. Among the CAM treatments [5,33], vitamins and minerals, probiotics, yoga, qigong, meditation, tai chi, relation techniques, and hypnotherapy are rarely used in TKM clinics, and health insurance coverage of TKM treatment [11] includes acupuncture, electro-acupuncture, pharmacopuncture, herbal medicine, chuna, cupping, and moxibustion. Therefore, it is difficult to compare the usage status and perception of TKM and CAM at the same level and generalize the results of this study.

The strength of this study is that it was conducted using data that is representative of the general Korean population, making the study more generalizable so that the study results can be used as a resource for the government to develop relevant policies. Also, it would be necessary to conduct an in-depth analysis on the decision-makers who decide which medical services to be used, as it is likely that the selection of the medical services used by a child is influenced by parental decisions.

In the future, the following strategies will be needed for the popularization of TKM. First, it is necessary to obtain precise statistical data on the factors and usage of TKM by improving the questionnaire items for the national survey in the future. Based on this study, it was possible to understand that the awareness of the family members on TKM could have an impact on the use of TKM by other members. However, due to the limitations in the question items in the questionnaire, we had difficulties in the analysis of correlations and factors. During the subsequent round of the national survey, the following supplementations are believed to be necessary: (1) Add questions regarding the experience of talking with a family physician or the experience of actually using the TKM for a disease or symptoms; (2) add more question items to ask whether the parents' jobs were related to health care or they were actually healthcare professional, and if so, what type of healthcare professionals; (3) add more question items regarding awareness, the intent of use in the future, intent of the recommendation, and an item regarding the preference toward TKM; (4) more survey items for the children, regarding their age, education, and treated interventions and diseases; and (5) if questions are asked about the use of TKM by the children, conduct a face-to-face interview of the parents and the children at the same time. If the above-mentioned items are supplemented, it would be possible to clarify the point of intervention through policies by means of statistical analyses. Second, government-level standardization is required for the Clinical Practice Guideline (CPG) and the Clinical Pathway (CP) centered around the diseases for which TKM has an

advantage over CM. Choose the diseases for which TKM has an advantage in different stages of the life cycle and develop corresponding CPGs and CPs (e.g., children; atopic dermatitis, females; dysmenorrhea, adults; back pain, seniors; osteoarthritis). With the policies to include these into the coverage of health care, it would have an impact on the family members of TKM users, contributing to popularization. In particular, the use and awareness of TKM by a female parent is likely to have an impact on her child. Therefore, it is necessary to survey the diseases in more details when it comes to female participants (e.g., menstruation, sub-fertility, post-natal management, climacterium, and menopause).
