Living Conditions of Children with Disabilities in Rural Thailand: Factors Leading to Life Change through Interventions

Abstract

This study aimed to identify the characteristics and challenges faced by children with disabilities and their families living in rural Thailand, and understand the factors that bring changes in their lives through intervention. In a 2021 online survey on the quality of life of school-aged children with disabilities, approximately half of the respondents indicated that they were not enrolled in school. However, the factors responsible were not identified. Therefore, in 2023, we interviewed three children with disabilities in one of the target areas for the abovementioned survey to explore the correlation between the level of independence in the activities of daily living (ADL) and educational and rehabilitation opportunities. This study did not identify a clear correlation between the two factors. Furthermore, a hypothesis emerged that the changes in their lives are influenced more by environmental factors, especially personal factors such as social group awareness and attitudes, caregivers’ understanding and support, and individual relationships within the community. Further research is needed to develop environmental factor assessment tools for problem-solving in accordance with the regional characteristics of rural areas, assess the degree of functional independence of children with disabilities in daily life, and build regional support models.

1. Introduction

The right to education and social participation of children with and without disabilities is one of the fundamental human rights. The World Health Organization (WHO) estimates that approximately 700 million people with disabilities live in the Asia–Pacific region, many of whom lack access to necessary medical and social services and have limited opportunities for education, employment, and other social participation due to prejudice and poverty (World Food Programme 2023). To ensure the human rights and fundamental freedom of individuals with disabilities and promote their inherent dignity, the United Nations adopted the Convention on the Rights of Persons with Disabilities in 2006, which stipulates measures to realize the rights of persons with disabilities and calls for action in various areas, including civil and political rights; rights to education, health, labor, and employment; social security; and access to leisure activities.

The Kingdom of Thailand (hereinafter referred to as “Thailand”) signed the Convention on the Rights of Persons with Disabilities in 2007 and in the same year enacted the Persons with Disabilities Empowerment Act 2007 (B.E. 2550), which is the basic law for the legislation of persons with disabilities in Thailand. Furthermore, the Persons with Disabilities Education Act 2008 (B.E. 2551) recognizes the rights of children with disabilities to receive free education from the time they are born or diagnosed with disabilities (Nishizawa 2015). However, according to the results of a questionnaire survey on quality of life (QOL) conducted in the rural areas of Thailand in 2021 among 71 school-aged children with lower limbs and multiple disabilities who received assistance with mobility aids, such as wheelchairs, more than half (52%) of the participants indicated that they were unable to study much or at all, even after receiving wheelchair assistance (Kumazawa and Terada 2022, 2023). However, the results of the questionnaire survey alone did not reveal the factors and processes that led to this result, and did not provide a thorough understanding of the actual situation or uncover problems that needed improvement.

To clarify this issue, it is necessary to further investigate the environment surrounding disabled children, their families, local communities, and schools to understand their actual living conditions in detail. Therefore, in 2023, the authors visited the homes of children with disabilities living in Nong Khai Province in Northeastern Thailand, which was one of the target areas of the abovementioned questionnaire survey, and conducted semi-structured interviews on their living conditions to conduct a qualitative evaluation (Terada et al. 2023; Wachi et al. 2024). In Nong Khai Province, nine children with disabilities were targeted for a questionnaire survey in 2021, of whom seven were interviewed face-to-face during the first survey in March 2023. During the second visit, three of the seven participants were interviewed again. Through these interviews, we aimed to identify the regional characteristics and common challenges in this area and gain a better understanding of the factors that may lead to changes in the daily lives of disabled children through interventions. The study defined “intervention” as additional resources, training, and support to enable access to the resources available in the community, such as access to schools. In addition, this study examines the nature of community support for children with disabilities living in the rural areas of Thailand and their families by interpreting educational and rehabilitation opportunities in a broader sense in relation to the social context surrounding these children and their families.

2. Methods

2.1. Participants of the Survey

The participants in this study were three children with disabilities as shown in

Table 1. Participants of the survey.

	Participant A	Participant B	Participant C
Age	11 years old	10 years old	8 years old
Gender	Female	Male	Male
Diagnosis	Spina Bifida Syndrome	Cerebral Palsy (GMFSC: V)	Cerebral Palsy (GMFSC: IV)
Disability	Hemiplegia	Spastic Athetosis Quadriplegia	Spastic Quadriplegia Intellectual Disability Hearing Loss (Left)

and their families living in Nong Khai Province, one of the 20 rural provinces in Northeastern Thailand. All of them are registered with the Special Education Center (hereinafter referred to as “SEC”) of Nong Khai Province under the Ministry of Education and receive home visit services about once a week from the center’s staff. In addition, they also receive individually tailored wheelchair services from the Wheelchairs and Friendship Center of Asia, Thailand (hereinafter referred to as “WAFCAT”), a non-profit organization in Bangkok. The SEC and WAFCAT collaborate to provide continuous support for children with disabilities in the region.

2.2. Survey Period

In-person interviews were conducted over two days, on March 20 and 21, 2023, by visiting the homes of the seven families and the SEC district learning centers. SEC and WAFCAT staff members participated in the survey. The interviews were conducted through an interpreter for approximately one hour each. Nine months later, on 11 December 2023, three of the seven families were revisited in their homes and interviewed in the same format as the first interview.

2.3. Survey Items and Rating Scale

This survey was conducted in a semi-structured interview format by following the Functional Independence Measure for Children (WeeFIM) assessment items (

Table 2. Functional Independence Measure for Children (WeeFIM) items and rating scale (Riu 2000).

Items  Self-Care   (1) Eating   (2) Grooming   (3) Bathing   (4) Dressing (Upper body)   (5) Dressing (Lower body)   (6) Toileting  Bladder and Bowel Management   (7) Bladder Management   (8) Bowel Management  Mobility (Transfer)   (9) Bed, Chair, Wheelchair   (10) Toilet   (11) Bathing, Showering  Mobility (Locomotion)   (12) Walking, Wheelchair, Crawling   (13) Stairs  Communication   (14) Comprehension   (15) Expression  Social Cognition   (16) Social Interactions   (17) Problem-Solving   (18) Memory

Eating movements including chewing and swallowing Oral care, hairdressing, hand washing, and face washing Taking a bath, washing from the neck down (except the back) in the shower Dressing and wearing prostheses and orthotics above the waist Dressing and wearing prostheses and orthotics below the waist Undressing and dressing, and cleaning after excretion   Bladder control, including the use of devices and medications Bowel control, including the use of devices and medications   Transferring or crawling between bed, chair, and wheelchair, or crawling Transferring to/from the toilet Transferring to/from the bathtub and shower room   Walking indoors, moving around in a wheelchair, or crawling 12 to 14 steps up and down   Comprehension of daily conversations and multiple instructions Expression of basic needs and ideas (phonetic and non-phonetic)   Participating in play, and understanding rules Solve everyday life problems Memorize how to play with toys, holidays and birthdays, poems and songs, names, and ages

Rating Scale  Independence        Assistance   Partial Assistance     Total Assistance

7 Complete Independence (no assistive devices, and safely within usual time) 6 Modified Independence (use of assistive devices, longer time, and safety concerns) 5 Supervision or Setup (need to be watched, directed, and prepared) 4 Minimal Assistance (child performs at least 75% of activities) 3 Moderate Assistance (child performs 50% or more of activities) 2 Maximal Assistance (child performs 25% or more of the activities) 1 Total Assistance (child performs less than 25% of activities)

). WeeFIM is an evaluation scale for the activities of daily living (ADL) that was developed based on the Functional Independence Measure (FIM) as a minimum scale to assess the abilities of children, mainly those aged 6 months to 7 years. Like the FIM, the WeeFIM consists of 18 items, including 13 motor and 5 cognitive items, and is rated on a 7-point scale according to the degree of assistance needed (Jang et al. 2022). Although several pediatric ADL assessment instruments have been found to be reliable and valid (Maruyama and Takahashi 2021), the WeeFIM was selected for two reasons. First, it was able to ask questions that covered the entire range of motor and cognitive ADL abilities. Second, it was able to provide a numerical rating as a guide on a 7-point scale. These reasons were considered the most effective for visiting rural areas in a limited number of days and asking questions as similar as possible in each home with different environmental settings.

While asking broad questions following WeeFIM items, in-depth questions were also asked in response to the interviewees’ responses. Specifically, questions about daily wheelchair usage, school attendance, rehabilitation, and physical activities were asked, and the responses were carefully observed. With their consent, the participants were also asked to demonstrate wheelchair self-propulsion, transfers, and turning over, which could not be determined by verbal communication alone. The physical therapists in the research group determined their WeeFIM level.

2.4. Ethical Considerations

The survey was conducted after requesting the WAFCAT Secretariat for cooperation, which in turn made a formal request to the SEC in Nong Khai Province. Both WAFCAT and SEC accepted our request for cooperation as they agreed with the goal of this study, which was to improve their wheelchair service and daily life support projects for children with disabilities in the region. The survey was conducted in the living room or semi-outdoor space of the home of the target disabled children and their families. It was considered more suitable for observing the real living conditions of the children than gathering them all in one place, such as a school or a community center. It was also assumed that the familiar environment would ease their tension, and they would be able to answer the interview questions as they normally would without anxiety.

Four members of the research group, including two physiotherapists, conducted the survey and were accompanied by approximately 10 SEC teachers and staff, including SEC staff who visited the homes of the target children with disabilities about once a week. WAFCAT staff members also accompanied during the survey and provided support through interpretation, coordination, and supplementary explanations. Prior to each interview, the WAFCAT and SEC explained to the interviewees that their participation in the survey was voluntary, they would not be disadvantaged whether they participated or not, and their personal information would be strictly protected; their written consent was obtained. Lastly, as part of the ethical considerations, we checked with the interpreter and SEC teachers in advance to ensure that none of the questions were inappropriate in the local culture, and repeatedly informed the interviewees that they did not have to respond to questions that they found difficult to answer.

3. Results

3.1. Physical Information and Wheelchair Use

When comparing the results observed in March 2023 with those observed in December 2023, the following differences were noted. As shown in

Table 3. Physical information and wheelchair use.

	Participant A		Participant B		Participant C
Survey Date	March 2023	December 2023	March 2023	December 2023	March 2023	December 2023
Height	133 cm	138.5 cm	128 cm	130 cm	111 cm	115.5 cm
Weight	36.75 kg	37.6 kg	21 kg	22.75 kg	15.1 kg	14.8 kg
BMI	20.78	19.6	12.82	13.46	12.26	11.09
Grip Strength	Unmeasurable	1.5/1.6 kg	Unmeasurable	Unmeasurable	Unmeasurable	Unmeasurable
Wheelchair Use	Using at home about 2 h a day	Using daily at school and home	Using only when going out, once a week	Using only when going out, 2–3 times a month	Using daily at home	Using daily at home
Daytime Activities	Watching TV and playing mobile games at home.	Attending elementary school from May 2023.	Watching TV and playing mobile games in lying position on a mattress in the living room at home.		Playing alone in a wheelchair at home. He can sit in a wheelchair for as long as half a day.
Sitting Ability	Able with hand support		Unable to sit		Unable to sit
Wheelchair Transfer Frequency	2–3 times a day	Twice a day	Once a day	2–3 times a month	2–3 times a day	2–3 times a day

, physical measurements were taken and interviews were conducted to obtain basic physical information. There was no deterioration in their physical condition owing to their disability, and they were all in good health. Meanwhile, there was some change in the frequency of wheelchair use: Participant A primarily used the wheelchair at home but was now able to use it to commute to school, too. As a result, the amount of time she spends using her wheelchair has increased. Although she still needs assistance to move her wheelchair, she now has more opportunities to go out and travel longer distances in her wheelchair. On the contrary, in the case of Participant B, the frequency of wheelchair usage and opportunities to go out, including walks in the neighborhood, has decreased because of damage to the wheelchair’s front wheels and worsening physical pain during use. Participant C showed no particular changes in ADL, lifestyle, or wheelchair use during the investigation period.

3.2. Level of ADL Independence and Living Conditions

Table 4. Results of WeeFIM for Participant A.

Items	Results in March 2023		Results in December 2023
	Remark	Score	Remark	Score
Self-Care  (1) Eating  (2) Grooming  (3) Bathing  (4) Dressing (Upper body)  (5) Dressing (Lower body)  (6) Toileting	Complete independence Complete independence Bathing by herself Complete independence Complete independence Her mother carries her to the toilet and helps her to clean. She uses diapers when she goes out. She has a sense of urination.	7 7 7 7 7 1	Complete independence Complete independence Complete independence Complete independence Complete independence Use diapers when going out, including to school	7 7 7 7 7 1
Bladder and Bowel Management  (7) Bladder Management  (8) Bowel Management	Complete independence Complete independence	7 7	She feels the urge to urinate. She has defecation every day.	7 7
Transfer  (9) Bed, Chair, Wheelchair  (10) Toilet  (11) Bathing, Showering	Total assistance Total assistance Total assistance	1 1 1	Total assistance Total assistance Total assistance	1 1 1
Locomotion  (12) Walking, Wheelchair, Crawling    (13) Stairs	Able to crawl and move a wheelchair on her own but very slowly Total Assistance	5   1	Total assistance	5   1
Communication  (14) Comprehension  (15) Expression	Complete independence Complete independence	7 7	Complete independence Complete independence	7 7
Social Cognition  (16) Social Interactions    (17) Problem-Solving	She rarely hangs out with her friends. Not attending school Complete independence	5   7	She enrolled in school in May 2023.Complete independence	5   7
(18) Memory	Complete independence	7	Complete independence	7

, along with Figure 1 and Figure 2, presents the levels ADL and the living conditions for Participant A. Participant A lived with her parents and older brother, and her grandmother’s sister and other relatives lived next door. As of March 2023, she was not enrolled in school, so she spent most of her time at home during the day, either in a wheelchair or sitting on the floor, watching TV, playing mobile phone games, and drawing pictures. She could move her wheelchair by herself, but very slowly. She attended the SEC’s district learning center about once a week for rehabilitation, and another part of her daily routine was to self-propel her wheelchair, which she was granted in August 2020, to her next-door relative’s house. When she goes out to the local temple or shopping center, she rides the side car of a motorcycle driven by a family member while sitting in her wheelchair. When she had not started school, her mother taught her to read, write, and perform simple mathematics at home. She could sit in her wheelchair for approximately two hours at a time. Although she does not feel pain, her legs become edematous after sitting for long periods. The frequency of transfers was 2–3 times per day. She can sit up and relieve pressure on her own; however, her mother assists her in all the transfers and getting in and out of her wheelchair.

During the first survey, Participant A and her mother’s intentions to enroll in school were confirmed, and WAFCAT decided to support her with a scholarship. This led the SEC and her mother to apply for admission to an elementary school about 500 meters from their home. She was then approved by the school principal to enroll in the fifth grade appropriate for her age and was transferred from the SEC to the elementary school in May when the new school year began. As a result of this transfer, she was no longer eligible to receive SEC’s rehabilitation services. On admission, no academic tests or ADL assessments were conducted. Her mother pushes her wheelchair to and from her home to the elementary school. She arrives at school at 8:00 a.m. and attends classes in Thai, math, social studies, science, and art. At school, her teachers and classmates push her wheelchair and help her move around. Her mother picks her up at around 12:00 p.m. and takes her home, where she has lunch and spends the afternoon doing homework. The school has a special class for children with learning disabilities in the afternoons; however, because she does not have any learning disabilities, she can study at home by herself. The school’s toilets are not wheelchair accessible; therefore, she does not use them. Her mother commented on the changes before and after her daughter’s schooling, stating that when she comes home from school, she talks happily about what happened at school, and her facial expressions and behavior have become more cheerful than before. Her mother also mentioned that she was now able to go to work and perform errands while her daughter studied at school. She also added that she had always wanted to go to school and meet her friends but never had the chance, but now all her classmates are her friends, and she feels that she is able to study better than when she studied alone.

Table 5. Results of WeeFIM for Participant B.

Items	Results in March 2023		Results in December 2023
	Description	Score	Description	Score
Self-Care  (1) Eating        (2) Grooming  (3) Bathing  (4) Dressing (Upper body)  (5) Dressing (Lower body)  (6) Toileting	Needs to be assisted in the supine position or on the lap of a caregiver, can eat solid foods, but has likes and dislikes, likes eggs and fish Total assistance Total assistance Total assistance Total assistance Uses a potty	1       1 1 1 1 1	Total assistance       Total assistance Total assistance Total assistance Total assistance Total assistance	1       1 1 1 1 1
Bladder and Bowel Management  (7) Bladder Management  (8) Bowel Management	Can say he needs to go to the toilet Can say he needs to go to the toilet	1 1	Total assistance Total assistance	1 1
Transfer  (9) Bed, Chair, Wheelchair  (10) Toilet  (11) Bathing, Showering	Total assistance Total assistance Total assistance	1 1 1	Total assistance Total assistance Total assistance	1 1 1
Locomotion  (12) Walking, Wheelchair, Crawling  (13) Stairs	Able to turn over Total assistance	1 1	Total assistance Total assistance	1 1
Communication  (14) Comprehension  (15) Expression	Able to have conversations Complete independence	7 7	He has a lot of friends Complete independence	7 7
Social Cognition  (16) Social Interactions  (17) Problem-Solving	Can play with siblings and relatives Complete independence	7 7	Complete independence Complete independence	7 7
(18) Memory	Complete independence	7	Complete independence	7

, and Figure 3 and Figure 4 show the ADL levels and living conditions of Participant B. Participant B lived with his maternal grandparents, mother, stepfather (his mother’s second marriage partner), younger brother, younger sister (one month old), aunt, and cousin, making it a total of nine people. His mother had gone to work in another province, but at the time of the interview, she had returned home to give birth, and his grandmother was out working instead. As his grandmother was the primary caregiver, while his mother was away on a migrant job, Participant B was more accustomed to her care and seemed more relaxed. He leads his daily life by lying down all day on a thick mattress in the semi-outdoor living room of his house. He comes inside only after dinner and when he goes to bed at around 11 p.m. He does not commute to school or hospital. He is registered with the SEC and is visited by the SEC staff about once a week for checks. Regarding his wheelchair usage, during the first survey, when his grandmother used to come home from work every evening, she used to push his wheelchair and take a walk around the house, he used to visit his great-grandmother’s house in the neighborhood about once a week, and go to a shopping mall on a motorcycle with a sidecar two or three times a month. However, by the time of the second survey, the front wheel of his wheelchair had broken, and he had stopped his daily walks. He had strong muscle tension and could not control his posture with his trunk bent over, hence he used to have pain when his body parts touched the sideboard of his wheelchair. Now, he rarely uses his wheelchair at home because he gets tired after sitting for long periods. According to his family, sitting in a wheelchair restricts his freedom of movement. He likes going out; therefore, he perseveres and uses his wheelchair while doing so. At home, however, it is easier for him to watch TV or play games while lying on his mattress, as he can better move and manipulate his body parts on his own. A few relatives who are close to his age live and play with him, and he does not feel isolated.

Table 6. Results of WeeFIM for Participant C.

Items	March 2023		December 2023
	Description	Score	Description	Score
Self-Care  (1) Eating        (2) Grooming  (3) Bathing  (4) Dressing (Upper body)  (5) Dressing (Lower body)  (6) Toileting	Can grab and eat with hands, can drink packaged milk, but cannot use a spoon or fork Total assistance Total assistance Total assistance Total assistance Use diapers	5       1 1 1 1 1	Can eat with hands when handed     Total assistance Total assistance Total assistance Total assistance Use diapers	5       1 1 1 1 1
Bladder and Bowel Management  (7) Bladder Management  (8) Bowel Management	No signs of urination No signs of defecation	1 1	No signs of urination No signs of defecation	1 1
Mobility (Transfer)  (9) Bed, Chair, Wheelchair  (10) Toilet  (11) Bathing, Showering	Total assistance Total assistance Total assistance	1 1 1	Total assistance Total assistance Total assistance	1 1 1
Mobility (Locomotion)  (12) Walking, Wheelchair, Crawling        (13) Stairs	Able to move around by turning over   Total assistance	2       1	Unable to sit, unable to self-propel wheelchair, but able to turn over to move Total assistance	2       1
Communication  (14) Comprehension  (15) Expression	Able to identify others No speech, and voice comes out when not wanted	3 2	Can follow instructions, but does not understand everything	3 2
Social Cognition  (16) Social Interactions    (17) Problem-Solving	Not playing with children of the same age Can move his body in response to sound	Undeterminable Undeterminable		Undeterminable   Undeterminable
(18) Memory	Never played games before	Undeterminable	Can play sitting in a wheelchair	Undeterminable

, and Figure 5 and Figure 6, illustrate the ADL scores and living conditions of Participant C. Participant C’s mother lost her parents when she was 10 years old, and a family adopted her along with her older sister. When she was 14 years old, she gave birth to her son (Participant C) six months early, and she still lives with him in her adoptive parents’ home. Her adoptive grandparents live next door and seven or eight people live together. All the family members except the mother work outside, and he is usually at home alone with his mother. He does not attend school or the SEC’s district learning center because his mother cannot drive a car or motorbike; therefore, she cannot take him to and from school. Instead, the SEC staff visits the home about once a week to check on him. He wakes up at 6:00 a.m. every morning and immediately sits in his wheelchair with his mother’s assistance to have breakfast and take a shower. The remaining family members go to work around 7:30 a.m. and return home in the evening. He goes to bed at around 8:30 p.m. During the day, when he is alone with his mother, he spends time playing alone in his wheelchair or on the floor. Sometimes, he responds to music or goes to a nearby shopping center when someone in the family who can drive has free time. However, because he spent most of his time at home and had little social interaction with others outside the family, it was not possible to determine his communication and social cognitive abilities.

3.3. Target Life Goals

Participant A and her family’s target life goal was to continue attending school and lead a more independent life in the future. However, the elementary school she currently attends does not have a secondary school attached to it; hence, after graduating, she will have to go to a middle school in another village far from her home. Since she will no longer be able to commute to school in a wheelchair, they will need to secure an alternative means of transportation. She will also need to further improve her ADL to lead an independent school life in a secondary school.

Participant B’s family and himself are satisfied with the regular visiting services provided by SEC staff and recognize that he is receiving an “appropriate education” without having to commute to a school or learning center. Thus, they do not wish to switch to commuting to school or learning center, as it would be inconvenient to drop him off and pick him up, increasing the burden on his family. His family hopes that he will continue to receive home visitation services once a week until he is 18 years old, the age at which he would be eligible for SEC, after which they hope that he will live a healthy life at home, both physically and mentally, with the family taking care of him.

According to Participant C’s mother, her target life is for her son to remain healthy and in a good mood every day at home. She does not wish for him to switch to commuting to a school or learning center, as it would be inconvenient to drop him off and pick him up. The family members who live together (her adoptive parents and siblings-in-law) support the mother and child by providing food, clothing, and shelter for them, and the mother takes care of her son at home instead of working outside during the day.

4. Discussion

In Thailand, the rights of persons with disabilities are protected across various sectors: education by the Ministry of Education, employment by the Ministry of Labor, healthcare by the Ministry of Public Health, and welfare services by the Ministry of Social Development and Human Security. Nonetheless, it has been observed that access to these services is challenging in rural areas (Japan International Cooperation Agency (JICA) 2021). The actual living conditions of children with disabilities and their families living in rural Thailand vary according to the type and degree of disability and individual family situations. In fact, there was one case in which the intervention resulted in life changes, and others in which it did not. The following discussion examines the level of ADL independence of children with disabilities, their actual living conditions, and the factors that contribute to their transformation, focusing on regional characteristics and common issues.

4.1. Challenges for Children with Disabilities in Rural Areas

The first two issues that need to be addressed for Participant A to live the life she is aiming for are “transferring” and “toileting”, which currently require full assistance. Since she has a sense of urination, improvement can be expected if the environment is prepared, and she can be trained in her daily life. For example, it would be effective to secure a flat space without steps from the living room to the toilet at her home, place a bed (mattress) at approximately the same height as the seat of the wheelchair, and transfer from the bed to the wheelchair using a transfer aid such as a sliding board. It is also possible to install a Western-style toilet bowl and use a sliding board for her to transfer from the wheelchair to the toilet seat. The next issue is enabling her to become self-propelled in her wheelchair. Currently, she can slowly move her wheelchair several meters on her own with supervision and instructions. Therefore, it is considered effective to train her as a part of her daily routine, for example, by making it a rule for her to ride her wheelchair as far as possible when moving from the living room to the toilet. To train her in transferring, toileting, and wheelchair self-propulsion, it is important to control her weight and improve her muscle strength as she enters her second growth spurt. She had undergone surgical treatment for knee flexion contracture three years ago, and her muscle strength had decreased due to her inability to move after the surgery for a while. As she stated, she never liked being physically active and rarely engages in physical activities in her daily life. Therefore, it is important to spontaneously increase physical activity within a reasonable range. Finally, regarding the “social interaction” of social cognition, which was evaluated as requiring monitoring and preparation, she had said before entering school that she did not play with her friends; however, about six months after she started going to school, she said with a smile, “I enjoy school and studying, and all my classmates are my friends”. Thus, it was apparent that her confidence had grown as a result of increased social interactions at school. However, because the opportunities and scope of interaction are still limited, appropriate monitoring and support are needed to help her become independent.

Participant B’s challenges in achieving their target life may include how to compensate for the short sitting time, lack of physical activity, and lack of learning support to further develop communication and social cognitive skills. The fact that he spends most of the day in a supine position instead of sitting in a wheelchair inside his home may be a threat to his health. In addition, the lack of opportunity for immediate repair when the wheelchair breaks and the lack of access to the services of a therapist to readjust the wheelchair’s seating position on a regular basis may also limit change. It was considered effective to create an environment in which he can sit and do activities, and study without pain or discomfort by using a sitting chair, large cushion, or learning tablet.

In the case of Participant C, the mother herself does not have much social interaction with people outside the family. This may explain why it was difficult for her to visualize their target life goals when asked about it. In other words, understanding and changing the mother’s (caregiver) mindset seems to be the priority challenge.

4.2. Factors Leading to Life Changes through Interventions

Participant A, whose lifestyle and self-awareness had changed as she was able to attend school, was rated as “fully independent (WeeFIM Level 7)” in self-care (eating, grooming, bathing, and dressing), communication, social cognition, and memory. She required full assistance in self-care (toileting), transferring, and locomotion; however, she was able to continue going to school using diapers or having family members assist her as needed. Most schools in rural Thailand do not provide transportation services, such as school buses, and in most cases, families do not own cars. Therefore, in this case, it was fortunate that their home was within walking distance from the school, with the caregiver pushing the wheelchair. Furthermore, in schools in rural Thailand, admission and the decision of which grade to enter are at the discretion of the school principal. The fact that the student was admitted immediately without having to take an academic achievement test or ADL check may be considered a characteristic of rural areas that are institutionally tolerant. As this case study demonstrates, in rural areas, it is reasonable and feasible to set a goal of enrollment in a general or special needs school if the student has a high degree of independence in self-care and communication. However, it is also true that there are some barriers for children with mobility disabilities to attend inclusive schools, especially in accessibility. Her school does not have a wheelchair-accessible toilet, so she must wear a diaper every day. It is also possible that she would still not have been able to attend school if she had not been fortunate enough to have a school close to her home (Vibulpatanavong 2017).

In contrast, in the case of Participant B, although he was rated as “fully independent (WeeFIM Level 7)” in terms of communication, social cognition, and memory, his self-care was assessed as “total assistance (WeeFIM Level 1)” and he was unable to sit up, making it difficult for him to attend a general school or special needs school. In addition, Participant C was rated as “total assistance (WeeFIM Level 1)” in all the items; moreover, since he remained at home and had few opportunities to interact with non-family members, the level of independence in communication and social cognition could not be determined. In cases of low ADL independence, it is difficult for the children to attend general or special needs schools; however, the educational system allows them to attend the SEC’s learning center for as little as one day a week if they and/or their families wish. However, this intervention did not result in a life transformation. At home, there were no changes, such as increased physical activity or sitting time, to improve daily functioning. Based on the responses and attitudes of the family members, it was inferred that in cases where there was a change in their lives, the participants were willing to change, whereas in cases where there was no change in their lives, the participants were generally satisfied with their current daily lives and did not want to change. Therefore, these results suggest that simply presenting them with a variety of options is not sufficient to immediately change their attitudes. Cultural factors in rural Thailand may have influenced their self-perception and self-actualization, limiting their potential for life change. This may be influenced by the “accept things as they are” and “be content with what they have” mentality that is unique to people living in the rural areas of Thailand, where resources are limited. Buddhist beliefs may also have influenced their own deep-rooted attitudes of accepting and trying to understand their own disabilities in a positive way, and helping one another (Yokoyama 2024). For example, the lack of transportation and other services is an issue that needs to be resolved; however, before addressing this issue, it would be effective to intervene in the development of the awareness and attitudes of children with disabilities and their families. In particular, when considering the lives of children with relatively severe disabilities who will remain in rural communities without going to school or finding employment, it is important for them and their families to have a correct understanding of their disabilities and acquire rehabilitation knowledge and skills from an early age based on appropriate goal setting to improve their life functions.

4.3. Future Direction for Supporting Children with Disabilities in Rural Areas

As mentioned earlier, in both the cases where the intervention led to life changes and those where it did not, there was little change in the level of independence in ADL in the short period of less than one year. However, despite the little change, there was a difference in life changes resulting from the intervention. A comparison of both cases showed that one of the factors that led to life changes was that the children had a certain degree of independence in self-care, such as eating and changing clothes. More importantly, however, children with disabilities and their family members had the will to “go to school and change their lives”, and the intervention was able to lead to life changes simply by confirming their own will. In contrast, in the cases with no life changes, the participants did not have the intention to do so and were unable to change their attitudes even after the intervention. This indicates that in the rural areas of Thailand, where medical care and educational services are inadequate, the assessment of individual disability and independence in daily functioning does not necessarily lead to appropriate educational and rehabilitation opportunities; that is, simply assessing ADL is not sufficient. In other words, the hypothesis emerged that in rural areas, people tend to be more influenced by the ICF, International Classification of Functioning, Disability, and Health (Kostanjsek 2011; World Health Organization 2001); contextual factors, especially personal factors such as social group awareness and attitudes; understanding and support by caregivers; and personal relationships in the community, rather than by health and physical function problems caused by disability (Tongsiri and Riewpaiboon 2012). Therefore, an environmental factor evaluation tool for individual cases should be developed, not only to evaluate functional independence using WeeFIM but also to solve problems according to the characteristics of the community, and a specific support model based on such an evaluation should be constructed.

In addition to the review of the evaluation tools, the survey revealed that even though the physical environment (buildings, wheelchairs, etc.) and social environment (services, institutions, etc.) were already available or accessible if motivated, they alone did not lead to drastic life transformations. This suggests that the need for a role (organization or system) that comprehensively brings together the human, material, and social support that already exists in the community may also be an issue. Especially when children with disabilities are younger and have severe disabilities, it is considered important to be attentive to the feelings of the family members who are the primary caregivers, explain the situation patiently and repeatedly, and provide interventions that encourage them to change their mindsets (Ploypetch et al. 2022). Even if wheelchairs and educational facilities are available, they are meaningless unless the people involved understand their advantages and disadvantages and are willing to utilize them. In this role, it is expected that more cooperation will be sought with NPOs/NGOs, such as WAFCAT, which can work across organizations, whether public or private, and be close to the families of children with disabilities. If such NPOs/NGOs that support the improvement of the quality of life of disabled children can continuously provide them with the necessary knowledge and skills, and if their parents and caregivers can realize their effectiveness, it may be possible to bring about a change in their awareness. In order to visualize the effects, it is also important to consider an evaluation system tailored to the actual conditions of disabled children in the rural areas of Thailand (Wachi et al. 2024). When developing such an evaluation system, it is important not only to provide knowledge and skills, but also to work with beneficiaries to clarify the problem and find solutions tailored to local characteristics and realities.

Furthermore, it is important to continuously improve the ADL of children with disabilities by introducing self-care functional training and exercise at home without difficulty, in parallel with school attendance support, to deal with cases where children cannot receive functional training at school even if they are able to attend general schools or remain at home after intervention because they are unable to attend school. For example, Individualized Educational Program (IEP) initiatives are being actively implemented in special needs schools, SECs, and other special needs education settings in Thailand (Nastiti and Azizah 2018). Similarly, it would be effective to develop practical guidelines and manuals for individualized rehabilitation plan (IRP) that can be implemented at home in accordance with the living environments of rural areas with few resources and characteristics of people’s lives. It is also important to periodically evaluate the results and revise the plans accordingly. However, the fact that the SEC staff members who regularly visit the homes of children with disabilities are not qualified rehabilitation professionals should be considered when developing evaluation tools and guidelines. To put this into practice, training is necessary to deepen service providers’ understanding.

4.4. Limitations of This Study and Suggestions for Further Research

This study involved interviews with three children with disabilities and their families to gather in-depth descriptions. However, the small sample size constrained the generalizability of the findings and conclusions. Additionally, the brief duration of the observations meant that the participants exhibited little change in their lifestyles or the activities of daily living (ADL) levels. Future research should extend the observation period to better understand the living conditions of a larger group of children with disabilities. Moreover, the study explored the link between ADL independence and educational and rehabilitative opportunities. It highlighted the necessity for subsequent research to concentrate on various aspects, including environmental accessibility in buildings and roads, medical rehabilitation services like physical and occupational therapy for wheelchair adjustments, the attitudes of teachers and parents, the support available to families and individuals, and the availability of tailored assistive technologies and devices.