Barriers to Caregiver Empowerment and Health Literacy in Low-Resource Pediatric Rehabilitation: A Case Study from Bolivia

Highlights

What are the main findings?

• Severe systemic saturation limits 100% of families to a single weekly session, while 68% face travel times exceeding one hour and spatial overcrowding.
• A critical functional health literacy gap was identified: despite 95% declaring initial comprehension, 68% revealed an urgent need for visual training resources to replicate therapy safely at home.

What are the implications of the main findings?

• Spatial overcrowding and “visual barriers” in low-resource centers exclude caregivers from direct observation, disrupting learning through imitation.
• Decentralizing technical competencies through structured health literacy tools is an ethical imperative to enable community co-therapy and sustain neurodevelopmental outcomes.

Abstract

Background/Objectives: In Latin American pediatric neurorehabilitation, clinic-centric models frequently reduce primary caregivers to passive bystanders. This study analyzes technical communication barriers, logistical constraints, and health literacy demands among caregivers at a university rehabilitation center in Bolivia to support a paradigm shift toward community co-therapy. Methods: A sequential mixed-methods design was employed. Qualitative semi-structured interviews were conducted with 19 primary caregivers (89.5% mothers, 10.5% fathers) of children with neuromotor conditions (aged 6 months to 6 years, mean age = 3.2 ± 1.4 years), integrated with descriptive frequency analyses to categorize structural bottlenecks. Results: Substantial logistical barriers were identified: 100% of families were restricted to a single weekly session due to center saturation, 89.5% relied on public transit, and 68.4% commuted over one hour. Additionally, spatial overcrowding (84.2%) and noise pollution (73.7%) created environmental interference. A marked health literacy gap emerged: While 94.7% reported general treatment understanding, 68.4% demonstrated an unmet technical competence gap, requesting structured visual tools to safely perform maneuvers at home. Intercultural language barriers further alienated indigenous caregivers. Conclusions: Isolated weekly sessions, within the framework of existing neurodevelopmental literature, may be clinically insufficient to sustain optimal progression unless complemented by home-based care. Decentralizing technical competencies through tailored health literacy strategies is an important avenue to explore for empowering caregivers as community co-therapists.

1. Introduction

The optimization of pediatric rehabilitation services focusing on neuromotor and neurodevelopmental conditions constitutes one of the most complex and necessary challenges within the current public health and social development agenda in Latin America [1,2]. Traditionally, clinical approaches in developing countries marked by deep structural access gaps, such as the Plurinational State of Bolivia, have been grounded in a heavily welfare-dependent and vertical biomedical model [3]. Within this classic paradigm of intervention, treatment success and efficacy are evaluated almost exclusively through quantitative indicators of physiological progression and anatomical-functional habilitation metrics of the infant [4]. This clinic-centric stance systematically relegates primary caregivers to a peripheral, instrumentalized, and undervalued role, limiting their operational participation to merely facilitating the mobility and physical transportation of the child to healthcare facilities [4].

However, scientific evidence and international consensus in the fields of early intervention and neurorehabilitation underline that the comprehensive development of a child with a disability does not depend solely on isolated temporary interventions received within a clinical setting [5]. On the contrary, the sustainability of biological milestones is directly contingent upon the quality, consistency, and frequency of the stimuli, adaptations, and specialized care provided within their daily natural environment, primarily at the core of the home and closest surroundings [6]. This reality forcibly shifts the focus of attention and therapeutic relevance from the classic therapist–patient dyad toward a markedly pedagogical relationship and technical communication interface among the healthcare professional, the child being treated, and the responsible primary caregiver [7]. Although the literature unanimously recognizes that treatment adherence, continuity, and success progress when a fluid channel of information exists, the operational reality of healthcare centers often reveals deep communication asymmetries that disrupt this synergy [8].

At a theoretical and conceptual level, this interface and scientific knowledge transfer phenomenon is situated at the intersection of the Health Literacy model and contemporary Caregiver Empowerment approaches centered on family capacity-building [9,10]. Within the scope of pediatric disability, health literacy does not merely imply the adult’s cognitive capacity to comprehend temporary verbal instructions given in a clinical setting [11]. On the contrary, it defines their complex functional competence to access, decode, process, evaluate, and autonomously, systematically, and safely apply physical maneuvers, postural transfers, and behavioral regulation guidelines within the home [10,11]. When a rehabilitation service operates under dynamics that produce methodological opacity regarding treatment design, the caregiver is pushed into a passive role of a driver, fragmenting the rehabilitation process and perpetuating an absolute dependence of the user on the center [12].

In Global South environments, where specialized access is severely limited by saturation, bureaucracy, and distance from the public system, university-led social action centers emerge as essential elements of equity, distributive justice, and health democratization [9]. However, these spaces of training and intervention often face an organizational paradox: despite offering highly valued humane treatment, unconscious physical, spatial, architectural, and informational barriers persist, restricting parental participation and nullifying the principles of learning through modeling and imitation [9,13].

In the Bolivian context, the literature concerning the operational experiences and technical–pedagogical interfaces of caregivers within university physical therapy and occupational therapy environments is virtually non-existent [14]. The few exceptions within the scope of parental perception have been limited to evaluating specific psychomotor stimulation programs in southern departments of the country [15]. Beyond this line of work, most of the previous research in this regional field has focused exclusively on documenting socio-emotional burnout, chronic stress, or the intrinsic psychological experiences of the family system in response to the impact of the diagnosis.

There is, therefore, a manifest need to audit university social action services from a pedagogical, organizational, and technical communication interface perspective [15]. It is essential to understand how parents perceive the technical training received, what critical bottlenecks they identify in the infrastructure and time management, and financial constraints—such as indirect transportation costs and lost daily income from informal labor—and how their demands for empowerment emerge using stable didactic tools for reproduction in the domestic environment [16,17]. Grounded in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) framework, child rehabilitation must address the continuous interplay between Environmental Factors (such as healthcare communication and physical accessibility) and the child’s Activity and Participation dimensions. When physical and literacy barriers disconnect primary caregivers from active therapeutic participation, the child’s functional gains, motor autonomy, and daily well-being within their family and community environment are directly compromised. The general objective of this research is to analyze the technical communication barriers, logistical factors of material participation, and explicit demands for formalized training of primary caregivers linked to the rehabilitation center of the Universidad Andina in Bolivia in order to propose and substantiate a paradigmatic transition that guides the care center from a traditional closed welfare-based scheme toward a formative model of community therapy and co-therapy.

2. Materials and Methods

2.1. Study Design

To audit user experience and structural barriers in this setting, a qualitative-driven mixed-methods design was employed, incorporating a formal quantitizing procedure. In this framework, qualitative narrative data collected through semi-structured interviews serve as the primary analytical foundation, while descriptive frequency and percentage counts derived from thematic coding are integrated to systematically quantify the recurrence and organizational priority of specific operational bottlenecks.

The study was conducted in accordance with the Declaration of Helsinki and approved by the San Francisco Xavier University of Chuquisaca Faculty of Health Sciences and Technologies Research Ethics Committee (protocol code CEI-FCTS-2026-07-14; date of approval: 14 July 2026). While other derived publications focus strictly on psychosocial dynamics, marital erosion, and family systems, the present study operates independently. Its focus is uniquely restricted to evaluating the technical–pedagogical interface, health literacy barriers, spatial–environmental logistics, and explicit demands for formalized visual training materials to foster community co-therapy. To prevent redundant data duplication, the qualitative quotes and thematic coding matrix utilized in this manuscript are exclusive to clinical communication and accessibility metrics.

2.2. Participants

Participants were recruited via consecutive non-probabilistic purposive sampling at the Children’s Rehabilitation Center of the Universidad Andina during their scheduled weekly clinical appointments. Caregivers were approached in person by a research team member not involved in direct clinical treatment to minimize social desirability bias.

Sample size was determined by theoretical data saturation. Saturation was systematically monitored during data collection: code saturation (the point at which no new codes were identified) was reached after the 16th interview. Three additional interviews were conducted (reaching n = 19) to confirm meaning saturation and ensure that no novel operational themes or nuances emerged. Inclusion criteria were (a) being the primary legal and direct caregiver responsible for transportation and daily care, (b) active attendance at the center for at least three months, and (c) providing written informed consent.

The final sample consisted of 19 primary caregivers (89.47% mothers, n = 17; 10.53% fathers, n = 2), aged 25 to 50 years, caring for children with neuromotor conditions aged 6 months to 6 years (mean age = 3.2 ± 1.4 years). Additionally, all participants demonstrated functional conversational Spanish, although 58% identified as belonging to Aymara or Quechua indigenous communities.

Their children had diagnoses of Infantile Cerebral Palsy (ICP), global developmental delay, or genetic syndromes associated with motor disability. The infants and young children receiving care were aged between 6 months and 6 years (mean age = 3.2 ± 1.4 years).

Additionally, all participants demonstrated functional conversational Spanish, although 58% identified as belonging to Aymara or Quechua indigenous communities. This cultural background introduced unique sociocultural dynamics and traditional perceptions regarding child development and community-based caregiving, which often diverged from the formal biomedical model.

2.3. Data Collection Techniques and Instruments

Data collection was carried out through individual semi-structured interviews. The interview guide was developed based on the Health Literacy framework [18] and family capacity-building models [19]. The guide was organized around four operational dimensions: (1) architectural and physical environment barriers (perceptions regarding therapy rooms, overcrowding, noise, space for observation, and “closed-door” dynamics); (2) technical communication interface (comprehension of verbal instructions from therapists, information asymmetries, and clarity of therapeutic goals); (3) organizational/logistical management (factors associated with the frequency and duration of sessions and the compatibility of schedules with daily life); and (4) didactic training demands (specific requirements for stable support materials—printed guides, audiovisual resources, and practical workshops—for the reproduction of maneuvers at home).

Prior to formal data collection, the interview guide was pilot tested with two caregivers (not included in the final sample) to evaluate item clarity, narrative flow, and cultural appropriateness. Interviews had an average duration of 45 min and were digitally audio-recorded and verbatim transcribed.

2.4. Data Processing and Analysis

Qualitative data were analyzed using reflexive thematic analysis integrated with quantitative descriptive transformation (quantitizing):

−

Phase 1 (open coding and codebook development): Transcripts were examined line-by-line by two independent researchers (S.P.D. and I.R.) to identify initial codes linked to communication, infrastructure, and training needs. A structured codebook with explicit operational definitions was established.

−

Phase 2 (independent coding and reliability check): Double-blind coding was performed on 30% of the transcript corpus. Inter-coder agreement was calculated using Cohen’s Kappa (κ = 0.86), demonstrating high inter-rater reliability. Discrepancies were resolved through consensus.

−

Phase 3 (quantitizing and categorization): Discursive statements were assigned to mutually exclusive categories. Absolute frequencies (n) and percentages (%) were calculated to establish the relative prevalence and organizational priority of each barrier.

−

Phase 4 (trustworthiness criteria): Methodological rigor was ensured through investigator triangulation, member-checking (presenting preliminary thematic summaries to 5 participants to confirm interpretive accuracy), and maintaining a detailed audit trail of analytical decisions.

2.5. Trustworthiness Criteria and Ethical Considerations

To ensure methodological rigor and the transferability of the descriptive findings, investigator triangulation was employed during the coding process, along with participant validation (member-checking) of the identified critical bottlenecks, following established trustworthiness criteria in qualitative research [19].

From an ethical perspective, the initial macro-project from which this analysis originates was evaluated and approved by the Ethics Committee of the Universidad Andina (Ref: CEI-FCTS-2026-07). All procedures were conducted in accordance with the principles of the Declaration of Helsinki. Absolute anonymity of the participants was guaranteed through the assignment of alphanumeric codes (e.g., P1, P2, …, P19), and the confidential storage of transcripts was ensured, using them strictly for scientific research purposes and the improvement of community health management.

3. Results

3.1. Block I: Geographic Accessibility, Transport Logistics, and Adherence to the Therapeutic Itinerary

The analysis of the logistical dimension determined that the continuity of pediatric rehabilitation is directly conditioned by geographic, transport, and family-related time constraints. Upon quantifying the recurrence of these critical aspects, it was evidenced that the investment of economic and time resources to access the Universidad Andina center represents a vulnerability factor for treatment adherence (Table 1).

Table 1. Distribution of logistical and accessibility barriers perceived by caregivers.

Operational Accessibility Indicator	Frequency (n)	Percentage (%)
Commuting via mass public transportation (Minibús/Trufi)	17	89.47%
Long-distance travel times (exceeding 60 min per trip)	13	68.42%
Schedule conflicts with work activity or domestic dynamics	16	84.21%
Restriction of service frequency (attendance only once per week)	19	100.0%

Quantitative data reveal that 89.47% (n = 17) of caregivers rely on multiple transfers within public transit to transport the children. This dependency, combined with the children’s motor sequelae, transforms daily commuting into a material barrier to access. Participants’ narratives highlight how the deficiencies of urban transport in the metropolitan region impose significant mechanical and physical challenges:

“I travel every day by minibus with him, and since he is bigger and heavier now, it becomes very difficult for me to climb the steps of the vehicle with the child in my arms. Sometimes the drivers do not want to stop or they get angry because we take too long to get on. It is a daily battle just to reach the center”.

(P04)

Likewise, the temporal factor emerges as a critical variable. Concurrently, 68.42% (n = 13) of the participants confirm commuting itineraries that exceed one hour of travel per trip, forcing a drastic restructuring of household economies and informal subsistence workdays (informal commerce or casual employment). When therapy appointments coincide with the hours of highest family economic activity, the caregiver is forced to choose between daily income and the infant’s health:

“Getting to the center requires taking two different minibuses from the outer district. The main problem is the physical accessibility of public transport: carrying my child, who has no postural control, while climbing the steep steps of the vehicle creates a severe physical risk for both of us. Drivers rarely grant sufficient time for safe boarding, which turns every weekly commute into an exhausting physical struggle long before the therapeutic session even begins”.

(P08)

Finally, the most severe logistical finding lies in the discontinuity of institutional service. The entirety of the sample (100%, n = 19) indicates that the center can only assign them one therapy session per week due to demand saturation and the limitations of the university space’s physical infrastructure. From a healthcare management perspective, receiving a therapeutic stimulus with such a reduced frequency considerably diminishes the actual long-term clinical impact, unless the caregiver is trained to replicate the maneuvers at home. This temporal limitation of the institution is identified by the mothers as the primary argument to demand a model shift toward formative co-therapy:

“Coming only once a week for 45 min is very little for what my son needs; it has almost no effect on him. The rest of the six days of the week, the child is just at home doing nothing. That is why it is vital that they teach us well, because if the center has no more space to give us appointments, we have to be his therapists at home”.

(P15)

3.2. Block II: The “Visual Barrier” and the Demand for Health Literacy

The second block examines the technical–pedagogical communication component and the phenomenon of learning through modeling and imitation within the clinical setting. When tabulating the participants’ responses, the descriptive data yield an asymmetry between declared conceptual understanding and procedural training demands. When questioned about their overall level of understanding regarding the interventions (mutually exclusive categories), 89.47% (n = 17) of the caregivers preliminarily stated that they ‘understand the treatment,’ while 10.53% (n = 2) admitted to understanding it only ‘partially or insufficiently.’

However, when inquiring about specific operational competencies for the daily physical management of disability at home, caregivers expressed a strong request for structured educational support. Expressing a desire for training materials does not inherently imply low health literacy; rather, it highlights a proactive demand to bridge the gap between perceived theoretical comprehension and safe procedural execution at home. An explicit demand for formalized visual training tools reached 68.42% (n = 13) of the total sample (Table 2).

Table 2. Perception of general understanding versus functional health literacy demands.

Communicative and Formative Interface Variable	Frequency (n)	Percentage (%)
Declared level of understanding
- General/macroscopic understanding (“Understands the treatment”)	17	89.47%
- Partial or insufficient understanding (“More or less”)	2	10.53%
Explicit demands for technical support
- Prioritized need for formalized technical training	10	52.63%
- Need for greater information flow and communication channels	3	15.78%
- Unsatisfied technical competence gap (Subtotal)	13	68.42%

This marked discrepancy between the generic understanding of the purpose of therapy (conceptual knowledge) and the skill to execute postural control or transfer maneuvers at home (procedural knowledge) is conditioned by the “visual barrier”. The architectural dynamics and organizational policies of the center impose a segregation of the primary caregiver, who is relegated to a passive role as the child’s transporter. By remaining outside the rooms or being limited to distant observation, the basic principle of learning through imitation and direct behavioral modeling is disrupted.

The analyzed discourses demonstrate that this exclusion from the intervention space generates methodological opacity and fragments treatment continuity. Mothers verbalize the need to overcome the scarce and non-specific transient oral instructions given in the hallways at the close of the session, demanding the incorporation of stable didactic supports:

“Because of space limitations inside the room, we are asked to remain in the outer corridor during the treatment. Watching through a small windowpane prevents me from learning the exact hand positioning or the direction of the mobilizations. At the end of the session, receiving quick verbal directions in the hallway is insufficient; I am afraid of causing an injury at home. We urgently need an illustrated physical manual or clear video guides to review the exact mechanical steps safely in our own household”.

(P11)

Furthermore, the qualitative analysis identified that the gap in health literacy is profoundly exacerbated by an unresolved intercultural dimension, which is particularly latent among the 58% of caregivers belonging to Aymara and Quechua communities. In addition to the high degree of technicality in the verbal instructions, there is an underlying linguistic friction; mothers often nod out of cultural deference or respect for the authority of the professional-in-training, thereby masking a real lack of comprehension regarding the clinical terms used. One of the mothers described this barrier as follows:

“Sometimes the young doctor talks to me with very difficult words, telling me things about muscles or nerves that I don’t understand in my head. I say yes to him with a nod of my head because I feel ashamed to interrupt him or have him think that I don’t know how to take care of my child. But when I get back to my community and want to do the exercises with my child, I no longer know what those words meant. We understand better if they show us with their hands or with a little drawing, not with so much technical talk”.

(P17)

This finding demonstrates that verbal instruction in saturated environments is not only ephemeral but also operates under an asymmetrical bias that culturally alienates the caregiver, transforming the clinical dialogue into an institutional monologue.

The analysis of this testimony exposes the ineffectiveness of purely verbal transmission in saturated healthcare environments. The so-called “hallway instruction” produces an illusion of information that dissolves upon reaching the domestic environment, limiting the mother’s actions due to the absence of visual or audiovisual clinical support guides. The demand for pedagogical transparency does not constitute a questioning of the therapist’s praxis but rather a formal request for didactic tools for operational survival at home.

This paradigm shift from the role of passive spectator toward that of an active technical agent or co-therapist is consolidated in the participants’ discourse, who link direct training with the effectiveness of motor skills and the child’s long-term future. The caregiver abandons a purely affective conception to claim a qualified technical role:

“I don’t want to come here my whole life just to sit and wait for the hour to finish and take my son back home. I need them to teach me directly, for the professionals to take at least ten minutes of the session to train me, to tell me: ‘Look mom, put your hand here, press like this.’ I want them to evaluate whether I am doing it right or wrong, so that I can also do exactly what the child needs at home safely. I don’t want to just be the person who brings him and takes him; I want to know how to heal him. Because […] if I don’t learn how to rehabilitate him at home now, nobody else is going to do it for him”.

(P19)

The narrative of this caregiver is paradigmatic and synthesizes the objective of health literacy in its advanced functional dimension.

3.3. Block III: Structural, Material, and Time Limitations in Service Management

The third and final block of results examines the material, physical infrastructure, and time management barriers identified by users as critical factors that limit the global success of the university social action program. Through a descriptive analysis of the service optimization demands verbalized by the participants, operational bottlenecks that restrict the performance of the intervention are confirmed. These limitations are concentrated across three priority axes: the urgent need to expand the physical space due to overcrowding, schedule flexibility for caregivers tied to the subsistence labor market, and an increase in the net duration of individual sessions.

In addition to these infrastructure challenges, there is a widespread grievance concerning the low weekly frequency of the treatment. For 100% of the evaluated families (n = 19), access to in-person sessions is strictly restricted to only once a week due to the high demographic demand of the population and the limited number of available staff (students in training and supervising therapists) (Table 3).

Table 3. Distribution of structural, architectural, and environmental barriers within the clinical setting.

Evaluated Infrastructure and Healthcare Management Dimension	Frequency (n)	Percentage (%)
Limitations of healthcare time
- Insufficiency of weekly frequency (fixed frequency of 1 time per week)	19	100.0%
- Demand for scheduling flexibility and extended shifts	15	78.94%
Infrastructure and environmental barriers
- Perception of critical spatial overcrowding in therapy rooms	16	84.21%
- Interference from noise pollution/environmental noise	14	73.68%
- Physical exclusion from the treatment table due to lack of walkable space	12	63.15%

This limited availability in the flow of clinical care generates concern among caregivers, who perceive that the physiological progress achieved during the 45 min in-person session tends to stall or regress during the remaining six days of the week, especially if the home remains in a state of technical inaction due to a lack of training. The narratives reflect a constant tension between the high valuation of the free socio-assistance resource and the material insufficiency of the therapeutic time allocated by the management system:

“The center is a blessing because we don’t pay anything and the university kids are very dedicated. But once a week seems very little to me for my girl’s condition. She has severe stiffness in her little legs, and if they only move her for one hour a week, it’s not enough. I need her to come at least three days in a row so we can see progress. The problem is that when I ask if there are more slots available, they tell me that the rooms are full, that there are many children on the waiting list, and that the space is too small to put in more treatment tables. […] The center simply has no more capacity to give us more time”.

(P06)

From a public health and healthcare planning perspective, this saturation of the university care environment justifies the imperative need to transform the traditional operational model. If the institution is materially unable to increase session frequency due to budgetary and physical space constraints, the only scientifically and ethically viable alternative to multiply the patient’s functional stimulus hours is to execute an efficient community-based decentralization, turning the home into a guided extension of the physical therapy room. However, for this transfer of competencies to occur safely, it is necessary to first bridge the technical health literacy gap described in the previous block.

Likewise, the narratives deepen our understanding of the direct consequences of spatial overcrowding within the treatment rooms, demonstrating how the limitations of the architectural infrastructure negatively interfere with the therapeutic ecosystem and the child’s behavior:

“The therapy room is severely overcrowded, with four treatment tables placed right next to each other in a small room. The high noise level and simultaneous crying of other children overstimulate my son, causing intense muscle stiffness and distress. Furthermore, because there is no walkable floor space left for parents, we are forced to step outside, eliminating any possibility of observing the therapist’s modeling techniques”.

(P14)

In synthesis, the overall landscape of the qualitative service evaluation reveals an environment characterized by high emotional loyalty and trust in the technical staff, which nevertheless coexists problematically with spatial, architectural, and information flow barriers that limit the transfer of scientific knowledge toward the primary caregiver. The data demonstrate that families are not satisfied with a passive, welfare-based role limited to transportation; on the contrary, they emerge from the analysis urgently demanding clear informative channels, stable didactic tools for replicability, and spaces for formalized in-person training. This collective demand seeks to subvert the structural limitations of time and space within the university clinical center in order to assume, in an autonomous, technically proficient, and safe manner, an active role as co-therapists within their own community environment.

4. Discussion

The primary objective of this study was to comprehensively analyze the technical communication barriers, logistical factors of material participation, and explicit demands for formative training among primary caregivers linked to a socio-university rehabilitation center in Bolivia. The empirical findings revealed a complex phenomenon of formative asymmetry, bureaucratic–spatial barriers, and a consequent technical vulnerability that limits and fragments the continuity of neurorehabilitation treatment within the domestic environment. This landscape of vulnerability does not present itself in isolation; rather, it is directly conditioned by severe restrictions in the center’s architectural infrastructure—analytically coined here as the “visual barrier”—and by an alarmingly low frequency in the allocation and time management of individual intervention sessions [14,20]. When subjecting these results to rigorous theoretical scrutiny, the findings acquire robust consistency and scientific relevance when contrasted with contemporary postulates of the Health Literacy model and global approaches to early intervention strictly centered on family capacity-building [9,10].

A finding of notable interest in this research lies in the contrast between the high level of general conceptual understanding initially declared by caregivers (where 89.47% stated that they ‘understand the treatment’) and their high demand for structured visual training materials for home care (68.42%). In interpreting this dynamic, it is essential to clarify that an expressed request for educational resources or visual guides does not necessarily indicate a baseline deficit in health literacy. Rather, in line with Demont et al. [21], it reflects the operational nuance of functional health literacy: caregivers may grasp the theoretical purpose of a clinical intervention (conceptual knowledge) while simultaneously recognizing their need for structured procedural supports to execute complex physical transfers, joint mobilizations, and postural controls safely and confidently within the domestic environment [22,23].

In the field of pediatric neuromotor disability, where critical maneuvers such as postural transfers, joint mobilizations, and tone control demand rigorous mechanical precision [24], Cano de la Cuerda et al. [25] strongly point out that perpetuating this training gap through mere oral instructions outside the intervention environment at the close of sessions is not only ineffective but also constitutes a latent risk factor for the infant’s musculoskeletal integrity and conditions the stagnation of their neurodevelopment [26]. In the Andean context, this phenomenon is structurally compounded by an implicit ethno-linguistic friction. The technical vocabulary deployed by therapists-in-training creates an informational barrier for Indigenous Quechua and Aymara caregivers, who, despite nodding in a sign of cultural respect or conversational conformity, cannot decode the professional jargon. This linguistic mismatch, combined with traditional maternal care beliefs that favor intuitive bonding over highly specialized mechanical interventions, exacerbates the technical gap. Consequently, the lack of tailored visual resources forces these families into a double marginalization: they are restricted by both physical exclusion from the clinical space and cultural alienation from the healthcare dialogue.

This technical–pedagogical disconnection is structurally and institutionally aggravated by the presence of the “visual barrier.” In agreement with the observations of Alghamdi et al. [27] regarding the physical organization of rehabilitation services, the operational dynamics of community centers often impose a spatial segregation of the primary caregiver, confining them to waiting rooms or external hallways due to internal control policies or the prioritization of space for clinical teaching [27]. From the theoretical frameworks of situated learning and family empowerment, this physical exclusion fundamentally interrupts the behavioral modeling process through direct imitation [9]. The caregiver, deprived of access to the live clinical act, is instrumentalized by the medical system under a peripheral role of simple logistical transporter or passive companion—a dynamic severely criticized by Novak et al. [28] in their studies on family-centered interventions [28]. To transform this deeply entrenched, clinic-centric, and vertical model, it is imperative for university social action centers to reconfigure their protocols and implement an “open-door” training scheme, where sessions involve guided training and an in-person audit of the skills that the mother must perform on the treatment table under the direct supervision of the student-in-training.

Complementarily, the ergonomic and environmental limitations documented in the care rooms—specifically critical overcrowding (84.21%) and the consequent noise pollution (73.68%)—act as a two-way clinical interference factor that compromises service quality. On one hand, research by Almasri et al. [29] solidly demonstrates that sensory overstimulation and high ambient noise within pediatric physical therapy rooms negatively affect self-regulation mechanisms and exacerbate anomalous neuromotor responses (such as spasticity and tactile reactivity) in users with severe neurological compromises or autism spectrum disorders, thereby reducing the net clinical effectiveness of individual interventions [9]. The absence of this formalized and institutionalized training perpetuates a technical vulnerability that severely restricts the actual impact and cost-effectiveness of the therapy hours invested at the university social center [30].

On the other hand, this saturated spatial ecosystem operates as the logistical pretext that justifies the exclusion of the adult from the room to clear the transit pathways for technical staff. When the physical infrastructure of a community institution is overwhelmed in its capacity, literature in health services administration and planning dictates that the only scientifically and ethically viable strategy to safeguard the right to health and multiply functional stimulus hours is to execute a structured community decentralization toward the domestic environment [31]. For all these reasons, it is clearly revealed that overcrowding does not constitute a mere logistical inconvenience for the user but rather a critical environmental barrier that harms the direct clinical efficacy of neurorehabilitation [6]. Sensory overstimulation involuntarily interferes with the infant’s nervous system, increasing patterns of spasticity or reactivity, limiting their capacity for cooperation, and reducing the technical performance of the therapist-in-training.

Likewise, this spatial arrangement consolidates the physical exclusion of the mother. By being forced to leave the room to clear clinical transit pathways, the institution loses a valuable opportunity to exploit behavioral modeling and the regulation strategies applied by the professional—an irreplaceable educational input for the subsequent home management of the condition [7].

This need for decentralization and technology transfer becomes unquestionable given the logistical finding that 100% of the evaluated sample is restricted to receiving institutional care only once a week due to demographic saturation. While a single weekly session is also standard practice in high-income healthcare systems (such as the UK), its clinical efficacy relies on strong practitioner–parent communication, active parental presence during therapy, and continuous home guidance. In contrast, within the studied setting, an isolated weekly stimulus is compounded by spatial segregation and informational barriers, which may potentially hinder continuous therapeutic progress without structured family training [32]. From the perspective of contemporary neurodevelopmental literature, a rehabilitation scheme based on an isolated weekly stimulus of 45 min is theoretically considered insufficient to optimize processes of neuronal plasticity or maintain long-term functional gains in complex neurodevelopmental pathologies [32]. Although the present study did not directly measure the children’s clinical or functional outcomes, caregiver narratives suggest that long intervals between sessions create operational uncertainty at home.

Caregivers evaluate this limitation with notable operational lucidity and, far from assuming a posture of resignation or welfare-based passivity, they emerge from the qualitative data prioritarily demanding the design and delivery of stable didactic supports, such as printed manuals or specific audiovisual resources (68.42%). The introduction of telehealth tools and adapted physical training materials has proven to be a strategy of high cost-effectiveness and social equity in low-resource settings, according to Bright et al. [33], since it embeds procedural knowledge in the user’s memory, reduces the fear of technical error in the domestic environment, and actively democratizes access to scientific health knowledge [33].

4.1. Study Limitations

This study presents several methodological limitations that must be acknowledged when interpreting the findings. First, the study relied on a non-probabilistic purposive sample of 19 caregivers circumscribed to a single university social action center in Bolivia. While data saturation was empirically achieved within this cohort, the small sample size and single-center scope preclude statistical generalization of the exact quantitative frequencies and percentages to broader populations. Second, the reliance on self-reported narrative data may introduce recall or social desirability biases, although these were mitigated through participant anonymity and independent interviewer dynamics.

Despite these limitations, the descriptive depth of the qualitative narratives, combined with rigorous triangulation, provides strong analytical transferability. The identified operational bottlenecks, ‘visual barriers,’ and health literacy gaps reflect systemic structural conditions characteristic of public and university-led pediatric rehabilitation facilities across low-resource settings in the Andean region and the broader Global South.

4.2. Practical Implications and Feasibility in Low-Resource Settings

This study highlights that clinic-centric models in low-resource environments face significant operational challenges when system saturation restricts patient care to a single weekly session. While transforming caregivers into active co-therapists is conceptually desirable, its practical feasibility in resource-constrained clinics requires realistic, low-burden strategies.

In university social action settings, student-therapists under clinical supervision represent a valuable, underutilized educational resource. Integrating brief, structured 5-to-10-min ‘teach-back’ demonstrations at the end of each session allows students to practice communication competencies while empowering parents without extending session durations. Furthermore, to overcome time constraints among clinical staff, centers can deploy asynchronous, low-cost educational tools, such as illustrated physical booklets or mobile-accessible QR-code video demonstration libraries. These passive educational supports reduce the direct burden on healthcare providers while offering sustainable, repeatable guidance for families in household environments. Future studies should quantitatively evaluate the clinical effectiveness and cost-efficiency of these educational implementations on child functional outcomes.

5. Conclusions

This exploratory study indicates that the perceived quality and clinical impact of pediatric neuromotor rehabilitation in university social action settings are closely linked to communication and structural interfaces. Grounded in the WHO International Classification of Functioning, Disability and Health (ICF) framework, findings highlight a notable distinction between caregivers’ general conceptual understanding of therapy and their functional health literacy required to execute complex postural and movement maneuvers safely at home.

Institutional challenges, including spatial overcrowding, noise, and physical exclusion from treatment, create a ‘visual barrier’ that not only restricts opportunities for observational learning through direct modeling but also directly impacts child well-being during clinical sessions by triggering sensory overstimulation and muscle stiffness. In settings where high demographic demand restricts center appointments to an isolated session once a week, these physical and educational barriers directly threaten the child’s functional progression, motor independence, and active participation in daily home activities.

Consequently, caregivers often rely on quick verbal instructions at the end of sessions, which leaves them feeling uncertain when attempting home management. Far from assuming a passive role, families actively demand accessible didactic tools, clear informative channels, and structured training to safely assume their role as community co-therapists. Enhancing health literacy through tailored visual educational resources and guided instruction represents an essential approach not only to support family involvement but also to sustain direct gains in pediatric function, emotional well-being, and long-term community participation. Future longitudinal and interventional studies are needed to quantitatively evaluate whether integrating these educational tools can effectively improve caregiver competence, treatment adherence, and child neurodevelopmental outcomes in low-resource environments.