Wheelchair Provision for Children with Disabilities in Rural Thailand: The Roles of Family Support and Environmental Barriers in Daily Participation

Abstract

Wheelchair provision remains an essential component of rehabilitation and participation support for children with disabilities, yet there is limited evidence on how wheelchairs are incorporated into daily activities and schooling decisions in rural low-resource contexts where environmental, social, and service constraints are substantial. This study employed a strictly exploratory multiple case study design involving two children with disabilities. Two home visits were conducted for each case, and a qualitative, descriptive cross-case analysis was conducted by integrating semi-structured interview data with WeeFIM scores and ICF Environmental Factors ratings. Wheelchair provision supported short-distance mobility and engagement in household and community activities and reduced some caregiving demands. Positive experiences during outdoor mobility and community interactions contributed to enjoyment and confidence. However, inaccessible housing, limited transportation, and family concerns about safety and readiness continued to inhibit broader independence and school enrollment. Both children remained outside formal schooling, while activities offered by Special Education Centers provided meaningful but limited opportunities for social interaction and development. The findings highlight not only practical implications but also the conceptual importance of environmental constraints and the ambivalent role of family support in shaping participation in rural settings.

1. Introduction

1.1. Background

Children with disabilities in rural settings often depend heavily on family-based support. Local resources and public services remain limited, and caregiving is largely provided by women, particularly mothers and grandmothers [1]. This heavy reliance increases both physical and psychological strain on caregivers, making sustainable community-level support essential, especially since children with disabilities may outlive their primary caregivers.

International reports similarly highlight that children with disabilities face heightened risks of exclusion when support systems are weak, particularly in under-resourced contexts [2,3].

Beyond family caregiving, environmental and systemic barriers such as limited transportation and insufficient health services further restrict children’s mobility and social participation. These constraints reduce access to schooling and later employment opportunities. As previous studies have shown, poverty among persons with disabilities is often reinforced more by limited educational opportunities than by impairment itself [4].

In rural Thailand, additional systemic and cultural factors further exclude children with severe disabilities. Children with severe disabilities face exclusion from education because Thailand’s special education system favors those who can manage Activities of Daily Living (ADL) [5]. In some communities, qualitative studies have reported Buddhist-influenced interpretations that suggest disability may be connected to past deeds. These interpretations can shape family and community attitudes toward disability in specific contexts [6].

This exclusion is compounded by structural imbalances within the national education system. The sharp imbalance between mainstream and special schools limits educational opportunities for children with disabilities. There are more than 20,000 mainstream schools across 77 provinces, but only 53 special schools exist. Most of them are residential and require independence in ADL for admission [7].

Special Education Centers (SECs), operated by the Ministry of Education as part of the public education system, provide early intervention, basic education, and home-visit services. However, SECs do not grant graduation qualifications, and their services usually end at age 18. This structure creates barriers to secondary education and vocational training [5]. Policies that prohibit dual enrollment in schools and SECs interrupt the continuity between academic learning and functional training. Families often choose SEC services alone because transportation is difficult and their understanding of the system is limited.

1.2. Prior Research and Rationale

Community-Based Rehabilitation (CBR), promoted by the World Health Organization (WHO), offers a comprehensive framework that covers health, education, livelihood, social participation, and empowerment [8]. This approach has been implemented in Thailand to support persons with disabilities in community settings. Within this framework, mobility is recognized as a foundational element for participation.

The WHO Wheelchair Provision Guidelines reinforce this approach by emphasizing collaborative dialogue between professionals, users, and families, and by positioning wheelchairs as a foundation for daily life, education, and social participation [9,10]. They frame wheelchair provision as a structured service process consisting of Select, Fit, Train, and Follow-up.

Nevertheless, prior research on the long-term and comprehensive impacts of wheelchair provision and follow-up in rural contexts remains limited. In particular, there is insufficient qualitative research examining how wheelchair provision interacts with environmental barriers, educational structures, and family caregiving practices in shaping participation trajectories. Even within the WHO Wheelchair Provision Guidelines, evidence from rural contexts is scarce, especially concerning how mobility gains are translated into meaningful educational and social participation [9,10].

This gap is both conceptual and contextual. Conceptually, participation is often discussed within the frameworks of the International Classification of Functioning, Disability and Health (ICF) [11] and CBR, yet the mechanisms through which environmental constraints and family decision-making jointly influence participation remain underexplored. Contextually, rural low-resource settings present unique structural barriers, including inaccessible housing, limited transportation, and fragmented educational pathways, which may prevent functional improvements from being converted into sustained participation.

A recurring debate in the field concerns whether participation is constrained primarily by environmental barriers or by caregiving patterns and family expectations, particularly in contexts where formal services are limited [11,12,13,14].

This debate is particularly relevant in Thailand, where rural areas face persistent barriers to the education and social participation of children with disabilities. Under such conditions, research approaches that capture real-life experiences are required, especially qualitative and exploratory designs that can illuminate complex interactions among mobility, family factors, and environmental barriers.

In addition, prior studies have not sufficiently examined how family caregiving functions simultaneously as both a facilitator and a constraint on participation within the ICF and CBR frameworks. In rural low-resource settings, where formal services are limited, this ambivalent role of the family may constitute a key mechanism shaping children’s opportunities for mobility, education, and social participation. Clarifying this mechanism represents an important theoretical gap that the present study seeks to address.

1.3. Research Objectives

This study aims to explore how wheelchair provision is experienced by children with disabilities and their families in rural northeastern Thailand through an exploratory multiple case study approach. The focus is to describe changes observed in daily activities, family caregiving, and opportunities for educational and social participation following wheelchair provision provided by a local non-governmental organization in collaboration with SECs, in alignment with the WHO wheelchair provision framework.

The study also applies the ICF and the CBR framework to examine how environmental factors function as facilitators and barriers in children’s daily lives. The ultimate objective is to generate preliminary insights that may support the development of sustainable wheelchair provision and related services in rural settings, contributing to broader discussions on participation, equity, and access for children with disabilities. Therefore, the study focuses on how mobility, environmental barriers, and family decision-making intersect in shaping children’s participation trajectories in rural Thailand.

In addition to describing children’s daily experiences, the study aims to illuminate the ambivalent role of the family—as both a source of support and a potential constraint—within the ICF conceptualization of environmental factors. By examining how family decision-making interacts with environmental barriers, the study aims to clarify how participation trajectories unfold in rural low-resource settings.

2. Materials and Methods

2.1. Basic Characteristics of Participants

This study included two children with disabilities living in Maha Sarakham Province, northeastern Thailand. Their basic characteristics are presented in

Table 1. Basic characteristics of the participants.

Item	Case 1	Case 2
Residence	Maha Sarakham Province, Northeastern Thailand	Maha Sarakham Province, Northeastern Thailand
Age	First survey: 9 years (August 2024); Second survey: 10 years (March 2025)	First survey: 14 years (August 2024); Second survey: 15 years (March 2025)
Sex	Male	Female
Diagnosis	Cerebral palsy (spastic diplegia, GMFCS III); Paralysis in both lower limbs (more severe on the left); upper limb strength preserved	Cerebral palsy (spastic diplegia, GMFCS III); Paralysis in both lower limbs; no major limitation in upper limb strength
Height and Weight	Age 9: 120 cm/20 kg; Age 10: 123 cm/20 kg	Age 14: 129 cm (weight not measured); Age 15: 28.5 kg (height not measured)
Family Composition	Father, mother, 14-year-old brother (junior high school), participant	Father, mother, older sister (vocational school student, living separately), participant
Schooling Status	Not enrolled in school; Attended SEC 2–3 days/week; home visits twice/month by SEC staff	Not enrolled in school; Attended SEC since around age 3, 2–3 days/week; home visits twice/month by SEC staff
Wheelchair Services	Assessment: August 2024; Provision (manual wheelchair): October 2024; Follow-up: Mar 2025	Assessment: August 2024; Provision (manual wheelchair): October 2024; Follow-up: March 2025

GMFCS = Gross Motor Function Classification System, SEC = Special Education Centers.

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2.1.1. Case 1

Case 1 was a boy living in rural Maha Sarakham Province, northeastern Thailand.

He was 9 years old at the first survey (August 2024) and 10 years old at the second survey (March 2025). He was diagnosed with cerebral palsy (spastic diplegia, GMFCS level III). Paralysis was observed in both lower limbs and was more severe on the left side, although his upper limb strength was preserved. His family included his father, mother, and a 14-year-old brother. Although he was of compulsory school age, he was not enrolled in school. He attended the provincial SEC in Maha Sarakham two to three times per week, and the SEC staff visited his home twice a month. Wheelchair services included assessment in August 2024, provision in October 2024, and follow-up in March 2025.

The family’s primary income came from small-scale agriculture, resulting in unstable earnings, and they also received a disability allowance. They lived in a traditional wooden stilt house with several steps, which created significant barriers for wheelchair use and daily mobility. The surrounding roads were unpaved and extremely rough, becoming particularly difficult to access during the rainy season. Transportation relied mainly on a tractor or a motorcycle with a side platform. The father had built the house in an area where no other residents lived, leaving the family socially and geographically isolated. As a result, they had limited contact with neighbors and almost no access to community support.

2.1.2. Case 2

Case 2 was a girl living in rural Maha Sarakham Province, northeastern Thailand.

She was 14 years old at the first survey (August 2024) and 15 years old at the second survey (March 2025). She was diagnosed with cerebral palsy (spastic diplegia, GMFCS level III). Before wheelchair provision, she moved short distances indoors by crawling or using a walker. After receiving the wheelchair, she continued to use these methods for very short distances inside the house, but relied on the wheelchair for safe and comfortable mobility over longer distances and for all outdoor movement. Her family included her father, mother, and an older sister who lived separately while attending vocational school. She had already exceeded the age for compulsory school entry and had missed the opportunity for formal schooling. However, she had attended the provincial SEC in Maha Sarakham since around age 3. SEC staff visited her home twice a month. Wheelchair services included assessment in August 2024, provision in October 2024, and follow-up in March 2025.

The child lived in a household where the father worked as a farmer, and the mother was a homemaker, resulting in unstable income; the family also received a disability allowance. They lived in a traditional wooden stilt house with several steps, which created architectural barriers and made wheelchair use difficult both inside and outside the home. The surrounding roads were unpaved and extremely rough, further limiting her mobility and access to community activities, especially during the rainy season.

2.2. Study Design

This study used home visits conducted in August 2024 and March 2025. The research adopted a qualitative exploratory multiple case study design, which is suitable for understanding how wheelchair provision is experienced in real-life settings with small sample sizes and context-dependent factors. This design allows for an in-depth description of daily living, family caregiving, and environmental conditions rather than evaluating causal effects or generalizing findings.

2.3. Participant Recruitment

Participants were recruited through routine collaboration with the SEC in Maha Sarakham, which already provided home-visit services to the families. During scheduled visits, SEC staff introduced the study and explained that participation was voluntary and independent from regular services. Staff from the partnering non-governmental organization, which provided wheelchair services in the area, served as a liaison between the research team and the SEC by assisting with communication, confirming schedules, and supporting interactions with families when needed. Caregivers then received written and oral explanations about the purpose and procedures of the study. Written informed consent was obtained before data collection.

To ensure transparency and reproducibility, the following inclusion criteria were applied:

(1)

the child had received a wheelchair through the same NGO–SEC service pathway;

(2)

a follow-up home visit took place approximately 6–7 months after provision; and

(3)

the wheelchair was used in daily life at the time of the follow-up visit.

Cases were excluded if wheelchair services had been declined or if the provided wheelchair was not used, as comparable service trajectories could not be established.

This recruitment process reflects the realities of rural northeastern Thailand, where the number of eligible children is limited, and outreach is conducted primarily through community-based services. During the same period, the research team also visited five additional children; however, these cases were not included in the final analysis because families declined wheelchair services or because the wheelchairs were not used in daily life due to environmental or personal circumstances. Consequently, only two cases met the criteria of having received wheelchair provision and using the wheelchair in everyday settings. This small sample reflects the contextual difficulty of identifying comparable cases in rural northeastern Thailand, where the number of eligible wheelchair users is highly limited.

The two cases were selected because they represented comparable wheelchair service trajectories, including assessment, provision, and follow-up within the same time frame. At the same time, they differed in key characteristics—such as age, schooling opportunities, and family decision-making processes—allowing for a meaningful descriptive comparison. Other children visited during field activities were excluded because wheelchair services had been declined or the provided wheelchair was not used, making it impossible to systematically compare wheelchair-related changes across cases.

2.4. Data Collection

At each visit, a one-hour semi-structured interview was conducted. Information was collected on living conditions before and after wheelchair provision, changes in ADL, family support and attitudes, and participation in education and community life. All interviews were conducted with interpreter support, and detailed field notes were taken during the interview and expanded immediately after each visit. Because interviews involved a mix of Thai and Isan languages, the notes were translated into English by the research team with assistance from SEC staff familiar with the local dialect to ensure accuracy and cultural appropriateness.

A descriptive qualitative approach was applied to organize the field notes. The notes were manually coded without software, and emerging themes related to mobility, environmental barriers, family support, and educational decision-making were identified through iterative team discussions.

ADL was assessed using the Functional Independence Measure for Children (WeeFIM) [15]. WeeFIM consists of 18 items, each rated on a 7-point scale from 1 (Total Assistance) to 7 (Complete Independence). WeeFIM was selected because it is simple, feasible in rural settings, and well-suited for interviews conducted within a limited survey time. Its reliability and validity have also been confirmed internationally [16,17]. The assessments were based on direct observation and caregiver reports. Two physiotherapists independently scored each case, after which the research team reviewed the interview data and reached a consensus on the final scores. Because the study involved only two cases, formal inter-rater statistics were not calculated; however, consensus-based scoring was used to ensure inter-rater reliability.

Although a formally validated Thai version of WeeFIM is not available, all items were explained to caregivers and children with support from SEC staff familiar with the local dialect to ensure comprehension and cultural appropriateness.

At the second survey, an ICF Environmental Factors Checklist was also applied. Nine items were evaluated: e120 (Mobility Aids), e155 (Home Barrier-free), e310 (Family Support), e410 (Family Attitudes), e525 (Housing Service), e540 (Transportation), e580 (Health Services), e585 (Education), and e590 (Labor and Employment). Each factor was rated on a 9-point scale ranging from −4 (complete barrier) to +4 (complete facilitator). Initial scoring was performed by one investigator, and the final ratings were determined through team consensus. Given the small sample size, no formal inter-rater statistics were calculated; instead, agreement was ensured through discussion and consensus among the research team.

These nine codes were selected by the research team based on their direct relevance to the study objectives, environmental challenges repeatedly identified in rural fieldwork, and practical input from Special Education Center staff and local wheelchair providers. Together, these codes cover the environmental domains most likely to influence wheelchair use, daily activities, and participation in rural settings, including physical accessibility, family-related factors, and essential community services.

Finally, the qualitative field notes were integrated with the WeeFIM scores and ICF Environmental Factors ratings to support a descriptive cross-case comparison and to identify converging and diverging patterns across the two cases.

Because WeeFIM and the ICF Environmental Factors Checklist were not originally developed for rural Thai contexts, some items required cultural adaptation. These limitations may have influenced how functional abilities and environmental barriers were interpreted and should be considered when reading the results.

2.5. Ethical Considerations

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Bukkyo University Human Research Ethics Review Committee (Approval No. 2023-67-B, approved on 27 March 2024). All surveys were conducted in participants’ homes to ensure comfort and safety during data collection.

To support ethical communication and safeguard participant welfare, staff from the SEC and the wheelchair provider organization accompanied the research team as needed for interpretation and coordination.

Before each survey, the purpose, methods, expected burdens and benefits, privacy protection, and the right to withdraw at any time were explained orally and in writing to caregivers and children. Written informed consent was obtained from caregivers, and all data were anonymized to protect confidentiality.

3. Results

3.1. ADL Assessment

The WeeFIM results for both cases are presented in

Table 2. WeeFIM Scores at Baseline and Follow-up for Case 1 and Case 2.

Domain	Item	Case 1	Case 1	Case 2	Case 2
		Baseline	Follow-Up	Baseline	Follow-Up
Self-care	(1) Eating	7	7	7	7
	(2) Grooming	4	4	7	7
	(3) Bathing	4	4	7	7
	(4) Dressing upper body	4	4	4	4
	(5) Dressing lower body	4	4	4	4
	(6) Toileting	4	4	3	3
Bladder/Bowel	(7) Bladder management	7	7	7	7
	(8) Bowel management	7	7	7	7
Transfer	(9) Bed–chair–wheelchair	7	7	4	4
	(10) Toilet transfer	1	1	4	4
	(11) Bath/shower transfer	1	1	4	4
Locomotion	(12) Indoor/outdoor mobility	7	7	7	7
	(13) Stairs	1	1	1	1
Communication	(14) Comprehension	7	7	7	7
	(15) Expression	7	7	7	7
Social cognition	(16) Social interaction	7	7	7	7
	(17) Problem solving	7	7	7	7
Memory	(18) Memory	7	7	7	7

Scoring Scale: 7 = Complete independence; 6 = Modified independence; 5 = Supervision or setup; 4 = Minimal assistance (≥75%); 3 = Moderate assistance (≥50%); 2 = Maximal assistance (≥25%); 1 = Total assistance (<25%).

, and the following section summarizes the empirical observations from these assessments. Overall, Case 1 required more assistance for transfers and locomotion, whereas Case 2 demonstrated greater independence in self-care.

Case 1 showed complete independence in eating, bladder and bowel management, comprehension, expression, problem-solving, and memory. He required minimal assistance from his mother for grooming, bathing, and dressing. Transfers between the bed and chair were independent; however, toilet and shower transfers required total assistance. Stair climbing required total assistance. Family reports noted difficulties in emotional control, which occasionally interfered with his daily interactions. As his mother explained, “When he becomes frustrated, it’s very hard for him to calm down, and I stay beside him all day.”

Case 2 demonstrated complete independence in eating, grooming, and bathing. Dressing was partly independent: she could undress independently but needed minimal assistance for dressing. Toileting required moderate assistance. Bed-to-chair transfers required minimal assistance, whereas toilet and shower transfers required partial assistance. Indoor mobility was independent using crawling or a walker; however, stair climbing required total assistance. Social cognition and communication were independent, indicating well-preserved abilities despite her motor limitations.

3.2. ICF Environmental Factors

Table 3. Results of the ICF Environmental Factors Checklist.

Code	Category	Case 1 (Score, Notes)	Case 2 (Score, Notes)
e120	Products and technology for personal indoor and outdoor mobility and transportation	+2: Independent mobility within 300 m using a manual wheelchair; reduced need to be carried	+2: Uses a manual wheelchair; able to go out using a motorcycle with a sidecar
e155	Design and construction of buildings for private use (housing barrier-free)	−4: Raised-floor house with many steps; difficult toilet/bathroom access	−4: Narrow toilet, unpaved paths, many steps; wheelchair mobility not feasible
e310	Immediate family (support and relationships)	+3: Care mainly by mother; subsistence lifestyle	+4: Care mainly by mother; father farming/day labor; whole family support
e410	Individual attitudes of immediate family members	−1: Parents hoped for schooling but avoided it due to tantrums and separation anxiety	−3: Parents hoped for schooling, but the mother’s anxiety led to avoidance of enrollment
e525	Housing services, systems, and policies	−4: No public support; house built by father alone	−4: No public support; dependent on support from private organizations or donations
e540	Transportation services, systems, and policies	−3: No public or school transport; poor access to medical/educational services	−3: Lack of public transport and school bus; severe restrictions
e580	Health services, systems, and policies	+1: No hospital visits; standing training at SEC; home training by mother	+1: Medical care free, but transport costs borne by family; annual ophthalmology visits
e585	Education and training services, systems, and policies	+2: Attended SEC 2–3 days/week; home visits twice/month	+3: Attended SEC since age 3; home visits; excursions and contests
e590	Labor and employment services, systems, and policies	Not applicable	+1: Internship at local factory being explored with SEC support

Scoring Scale: −0 = No barrier; −1 = Mild barrier; −2 = Moderate barrier; −3 = Severe barrier; −4 = Complete barrier; +0 = No facilitator; +1 = Mild facilitator; +2 = Moderate facilitator; +3 = Substantial facilitator; +4 = Complete facilitator. ICF = international classification of functioning; disability and health.

presents the ICF Environmental Factors ratings, and the narrative below describes the observed environmental facilitators and barriers for each case. Both cases experienced severe barriers in housing and transportation, while family support and SEC services acted as key facilitators.

3.2.1. Barriers

Both cases faced strong barriers related to housing design (e155), housing services and policies (e525), and transportation services (e540). The observations revealed that raised-floor houses, narrow toilets, and small bathrooms severely restricted mobility and transfers. In both cases, the absence of public housing support meant a reliance on self-construction or support from private organizations and donations, which was rated as a complete barrier (−4). In addition, a lack of public or school transportation limited access to health and educational resources.

Family attitudes (e410) also acted as barriers in both cases, but with differing severity. In Case 1, the barrier was mild (−1), as the parents wished for schooling but decided against it due to the child’s tantrums and anxiety about leaving home. In Case 2, the barrier was severe (−3), as the mother’s anxiety led to avoidance of school enrollment, resulting in lost educational opportunities. As the mother noted, “I worry she cannot stay far from home. I want her to be safe with us.”

3.2.2. Facilitators

Common facilitators in both cases included family support (e310), education services (e585), health services (e580), and personal mobility aids (e120). The provision of manual wheelchairs (e120) enabled mobility around the home and reduced caregiving demands.

Differences were also observed. Family support (e310) was rated +3 in Case 1, where care was primarily provided by the mother, and +4 in Case 2, where both parents and siblings were involved. Educational services (e585) were available through SEC attendance and home visits in both cases; however, Case 2 also participated in excursions and contests, resulting in a stronger facilitator score (+3). Health services (e580) were rated +1 in both cases. Case 1 mainly received home-based training, whereas Case 2 maintained annual ophthalmology visits.

Employment (e590) was not assessed for Case 1 owing to his age (10 years), but was rated +1 in Case 2. With the support of the SEC staff, internship opportunities at a nearby factory were being explored. This represented a potential facilitator for community participation but also highlighted its role as an alternative to formal schooling, reflecting the consequences of missed educational opportunities.

3.3. Education and Social Participation

This section describes empirically observed patterns in educational access and social participation, focusing on how each child and family navigated schooling opportunities and community interactions. In both cases, SEC staff arranged visits to a special school outside the province to explore potential enrollment. During these visits, families received explanations about boarding arrangements, classroom activities, and available supports. However, both families ultimately chose not to enroll their children because they were concerned about whether their children could live independently away from home.

Regarding educational participation, both children remained out of school after wheelchair provision, yet their situations diverged due to age and timing.

Case 1, who was still of compulsory school age, continued to receive basic learning activities and standing training at the SEC, supplemented by educational support during home visits. Family reports indicated that although enrollment had previously been postponed, signs of a growing interest in schooling emerged after wheelchair provision. His mother explained, “I worry he might be teased at school because he gets upset easily,” reflecting ongoing concerns that contributed to delaying enrollment.

Case 2, who had already passed the age for compulsory school entry, had missed the opportunity for formal education. She continued to participate in learning and leisure activities at the SEC, although access to these services was only available until the age of 18. Despite school visits organized by SEC staff, family anxiety prevented further consideration of enrollment.

Regarding social participation, the two cases showed contrasting patterns.

Case 1 spent most of his daily life at home with limited opportunities for interaction. According to family reports, their relocation to a farmland area reduced informal contact with neighbors, resulting in few opportunities for play or social exchange. His main external engagement was attending the SEC two to three times per week. Despite limited environmental change after wheelchair provision, interviews revealed his desire to attend school, suggesting an emerging motivation toward broader participation.

Case 2, in contrast, engaged actively with community members during neighborhood walks. Friendly greetings and recognition from others were reported to enhance her confidence and self-esteem. She expressed enjoyment in going out in her wheelchair and interacting with people in the community, indicating an expansion of positive social experiences. During the interview, she said, “I’m happy when people talk to me on the way. I like going outside.” Meanwhile, her mother emphasized the wish for her daughter to “live happily at home,” even without formal schooling. While prioritizing higher education and employment opportunities for the older sister, the mother sought stability and local participation for Case 2. SEC staff also reported that simple internship opportunities at a nearby factory were being explored, which both the girl and her mother viewed as a realistic future pathway.

In summary, a descriptive cross-case comparison revealed several common patterns across the two cases. Children’s functional abilities alone did not determine participation; rather, participation was shaped by the interaction of individual functioning with environmental barriers such as inaccessible housing and limited transportation. Service availability, particularly SEC-based support, played a compensatory role, while family decision-making emerged as a decisive factor influencing school enrollment and community participation. These cross-case patterns highlight how individual, environmental, and family-level factors combine to shape participation trajectories in rural settings.

4. Discussion

This study adopts a qualitative epistemological positioning that focuses on understanding how wheelchair provision is experienced by children and families within their rural context. The aim is not to generate generalizable findings but to explore the contextual mechanisms that shape daily participation. The two cases, therefore, provide exploratory insights that help clarify how family and environmental factors interact in everyday life and how these insights relate to existing theoretical frameworks.

4.1. Daily Activities and the Influence of Environmental Constraints

Although the WeeFIM scores showed little numerical change, the case narratives indicate that standardized measures alone cannot fully capture meaningful functional and psychosocial changes experienced by children and families. In both cases, wheelchair provision supported short-distance mobility and reduced caregiving demands during indoor movement. Beyond these functional gains, qualitative observations revealed important shifts in children’s motivation, emotional responses, and willingness to engage with their surroundings. For example, one child expressed a renewed interest in attending school, and the other experienced increased enjoyment and social recognition during neighborhood outings. These subtle but meaningful changes highlight the value of qualitative exploration in understanding how children adapt to assistive devices within their everyday environments.

Environmental constraints emerged as a decisive influence on daily independence and often outweighed the children’s own motor capacities. Restricted toilet and bathroom spaces, raised-floor housing with steps, and narrow pathways frequently prevented safe transfers and limited the functional benefits of wheelchair use. These findings align with previous research suggesting that home environments can constrain mobility more than children’s physical abilities and that home modification plays a critical role in improving ADL performance and subjective well-being [12,18]. In rural settings where families themselves often complete home construction and public housing support is scarce, such architectural barriers can persist throughout childhood.

Transportation limitations further constrained participation and demonstrated how macro-level infrastructure interacts with individual-level assistive technology use. Despite improvements in short-distance mobility inside the home, both children continued to experience substantial difficulty accessing school, health services, and community activities because public transportation and school transport services were unavailable. From an implementation perspective, wheelchair provision represented an essential starting point but could not independently expand participation. These findings reinforce the CBR framework, which identifies transportation and environmental accessibility as fundamental components of community life [8]. Integrating wheelchair provision with broader community development, including housing, transportation, and public services, remains essential for supporting long-term independence and meaningful participation in rural contexts.

4.2. Family Support as Both Facilitator and Constraint

Family support demonstrated a dual function: it provided essential daily care while unintentionally limiting opportunities for participation. In both households, mothers carried most caregiving responsibilities, reflecting the broader pattern in rural Thailand where women provide the majority of daily support for children with disabilities. Such commitment ensures safety and stability; however, preferences to prioritize home-based care, avoid risks, or maintain familiar routines sometimes resulted in postponed school enrollment or reduced opportunities for community engagement.

This dual nature corresponds with the ICF model, which conceptualizes environmental factors as either facilitators or barriers depending on context [11]. The present cases suggest that when care systems remain centered exclusively within the family, external service use may gradually decline, especially when unfamiliar environments are perceived as unsafe or overwhelming for the child [13].

A key issue relates to decision-making. Families often face the difficult task of balancing safety, convenience, cultural expectations, and the child’s long-term development. Decisions such as whether to enroll a child in school, encourage participation in community activities, or promote independence through training are rarely straightforward. The challenge is not to determine whether family-centered care is good or bad, but to consider whether decisions are made with a clear understanding of both the benefits and disadvantages, and whether the child’s own preferences are heard in this process.

Collaborative goal-setting and sustained dialogue between families and professionals are therefore essential [19]. Small, achievable experiences, such as short neighborhood outings or brief participation in local events, can help families recognize children’s emerging capacities and gradually shift expectations [14]. To interpret these dynamics, the capability approach provides a useful perspective. It distinguishes between actual functioning—what children currently do—and capabilities—what they could meaningfully choose to do if environmental and institutional constraints were reduced [20,21]. In rural low-resource settings, this distinction is critical because improved mobility does not automatically translate into participation when barriers such as inaccessible housing, transportation limitations, or schooling structures remain in place.

The insights from these cases align with the 2023 WHO Wheelchair Provision Guidelines, which highlight the importance of the Select, Fit, Train, Follow-up process and emphasize ongoing dialogue throughout service provision [10]. In rural contexts, SEC staff and NGO providers may serve as important intermediaries by facilitating communication, providing structured opportunities for participation, and supporting families as they navigate difficult decisions. Such involvement can help recalibrate family priorities, broaden participation possibilities, and ensure that choices reflect both family perspectives and the child’s developing sense of autonomy.

Taken together, these findings illustrate that family support operates as an ambivalent environmental factor that both enables and restricts children’s capabilities for participation. While the CBR framework highlights the importance of family- and community-based support, the present cases demonstrate that even when mobility improves, participation may remain limited if family decision-making is shaped by concerns about safety, readiness, or unfamiliar environments. Similar patterns have been reported in other low-resource contexts, where family expectations and decision-making processes can both enable and restrict participation despite improvements in mobility or assistive technology [22]. This ambivalent and dynamic role of the family represents a preliminary analytical pattern observed in these two cases, offering an exploratory insight that may inform future research.

4.3. Educational Access and Community Participation

The findings of this exploratory study illustrate how fragile educational pathways are for children with disabilities living in rural settings. Wheelchair provision did not lead to formal school enrollment in either case, and when entry at compulsory school age was missed, subsequent educational options narrowed quickly. This pattern reflects a broader gap between Thailand’s policy commitments to inclusive education and the challenges families encounter in navigating educational transitions. International analyses similarly report that children with disabilities are at heightened risk of educational exclusion when institutional support for transition is limited, particularly in rural areas where families must manage complex processes on their own [2,3].

Despite remaining outside formal schooling, both children engaged in social and learning activities through SEC programs and community interactions. These opportunities fostered confidence, social recognition, and a sense of belonging; however, they do not provide the structured curriculum or formal qualifications associated with school education. Community participation and formal schooling, therefore, serve complementary but not interchangeable roles in children’s development. Similar patterns have been reported in rural settings of other low- and middle-income countries, where improvements in mobility or access to assistive devices do not directly translate into sustained educational participation due to persistent environmental and infrastructural barriers [23].

A central issue arising from the two cases concerns the complexity of educational decision-making for families. SEC staff supported both families by arranging visits to a special school outside the province and providing detailed explanations about boarding arrangements, classroom routines, and available supports. Nevertheless, the families ultimately chose not to pursue enrollment due to concerns about whether their children could live independently away from home. For Case 2, who had already passed the age for compulsory school entry, opportunities for formal education were effectively closed. For Case 1, delayed enrollment remained possible, yet the decision required balancing potential benefits with emotional, logistical, and cultural considerations, including separation from family, transportation barriers, and unfamiliar school settings.

These situations illustrate that decisions about schooling are shaped not only by the child’s capacities but also by parental concerns, perceived risks, cultural expectations, and the limited availability of structured transition support. Studies from rural Southeast Asia similarly note that when families lack access to clear guidance and assistance in navigating the education system, children with disabilities are more likely to remain outside formal schooling [24]. In contexts where distance and transportation further amplify these challenges, families often face consequential decisions without sustained support.

From a policy and practice perspective, these findings underscore the importance of strengthening the connection between mobility services, SECs, and the formal education system. The current separation between SEC-based early support and pathways into school, together with restrictions on dual enrollment, can create discontinuities that hinder smooth transitions. International reports emphasize that gradual school-entry guidance, transportation support, and coordinated transition mechanisms are crucial for maintaining educational trajectories before they diverge irreversibly [2,3,24]. While the present analysis is based on two cases, the findings offer preliminary insights into how sustained and structured transition support may help ensure that educational opportunities remain open for children with disabilities living in rural areas.

Across the two cases, critical moments of educational transition emerged as decisive turning points. In Case 1, delayed entry during the compulsory school-age window narrowed future options, while in Case 2, age-related closure of school enrollment eliminated formal pathways altogether. These transitions were shaped not only by environmental barriers such as transportation and inaccessible school facilities but also by parental perceptions of independence, safety, and emotional readiness. Identifying these critical moments as decision points provides an exploratory observation based on these two cases, which may offer useful starting points for future investigation.

4.4. Limitations and Future Directions

This study involved only two cases, and the findings should therefore be interpreted as exploratory. The patterns identified in this study, particularly the dual role of family support and the influence of environmental barriers, may reflect characteristics specific to rural northeastern Thailand. Further research is needed to examine whether similar dynamics are observed in other settings.

Methodologically, the study relied primarily on WeeFIM and the ICF Environmental Factors Checklist. Although these tools captured functional and contextual aspects of daily life, they did not assess psychosocial dimensions such as children’s confidence, motivation, or caregiver well-being. Incorporating qualitative and subjective measures in future studies would provide a more comprehensive understanding of how wheelchair provision affects children and families.

In addition, the exclusion of non-use and declined cases constitutes a significant selection bias, as these cases often reflect the most substantial barriers to wheelchair use. This limitation restricts the transferability of the findings and should be considered when interpreting the results.

The follow-up period of six to seven months provided only an initial snapshot of changes after wheelchair provision. Longitudinal research will be important for clarifying how children’s participation evolves across developmental stages and educational transitions. The 2023 WHO Wheelchair Provision Guidelines emphasize the importance of sustained collaboration and follow-up, and examining how these elements can be adapted to rural service delivery systems remains a critical area of inquiry.

A key priority for future research is to clarify how families can be supported to make informed decisions about schooling and community participation, and to identify the most appropriate timing for providing such support. Decisions regarding school enrollment were strongly shaped by parental concerns, cultural expectations, and the absence of structured transition guidance. Understanding how information, counseling, coordinated services, and potentially technology-based options such as remote learning or tele-support can assist families will be essential for improving long-term educational and social outcomes for children with disabilities in rural contexts.

In addition, the presence of SEC and NGO staff during interviews may have encouraged socially desirable responses, potentially influencing how caregivers described their daily practices and challenges. This should be considered when interpreting the findings.

Finally, the cultural adaptation required for applying WeeFIM and the ICF Environmental Factors Checklist in rural northeastern Thailand may have shaped aspects of the findings. Certain items may not fully capture locally relevant practices or environmental conditions. Therefore, a cautious and context-sensitive interpretation is necessary.

Taken together, these methodological and contextual constraints indicate that the empirical base of this study remains highly limited.

Given the extremely limited empirical base, the transferability of the findings is inherently restricted. The patterns identified should not be interpreted as generalizable but rather as emergent insights specific to the socio-cultural and institutional context of rural northeastern Thailand.

5. Conclusions

This exploratory study examined how wheelchair provision was incorporated into the daily lives of two children with disabilities living in rural northeastern Thailand. Wheelchairs supported indoor mobility and created new opportunities for social engagement, yet decisions regarding school enrollment remained strongly shaped by family concerns, cultural expectations, and the limited availability of structured transition support between community-based services and formal schooling. These findings underscore the importance of viewing wheelchair provision not as a standalone intervention but as part of a broader ecosystem of environmental accessibility, family guidance, and educational pathways.

Although wheelchair provision alone was insufficient to expand participation, the positive changes observed in children’s motivation, social interactions, and daily mobility suggest that wheelchair services may serve as a practical entry point for connecting families with broader supports when accompanied by sustained guidance and coordination. Strengthening collaboration among service providers, schools, and families may help sustain participation and support the development of future opportunities for learning and autonomy for children with disabilities living in rural settings.

Conceptually, the study provides a preliminary and context-specific observation on the ambivalent role of the family within the ICF and CBR frameworks. The two cases suggest possible ways in which family decision-making may interact with environmental barriers at key moments in a child’s life. These insights should be interpreted as exploratory rather than generalizable. Overall, the findings offer an initial starting point for future research on participation among children with disabilities in rural low-resource contexts.