This study used an explanatory sequential mixed methods design consisting of two phases [25]. Phase I (survey phase) was a cross-sectional online survey designed to collect quantitative data on existing OT practices and barriers in community-based OT services for Thai patients with stroke living in the community. Phase II (interview phase) used a generic qualitative design to build upon the initial findings. Through semistructured interviews, this phase gathered qualitative insights regarding service experiences, barriers to practices, and occupational therapists’ perspective on developing effective OT services in community stroke rehabilitation. The explanatory sequential mixed methods design enhanced the comprehensiveness of the findings and allowed qualitative data from the descriptive qualitative design to clarify and expand upon the quantitative results [26].

Given the contextual characteristics of community OT practice in Thailand and the lack of a validated instrument specific to this topic, the authors developed the research instruments. Instrument development was informed by a review of the relevant literature on community rehabilitation, stroke recovery, and OT practice.

In the survey phase, a questionnaire consisting of two sections was used. The first section of the questionnaire consisted of 13 items designed to collect demographic and practice-related information. These items included personal demographics (sex, education level, and employment status) and clinical practice characteristics (eg, primary practice setting, years of experience in community-based stroke rehabilitation, average number of stroke patients per week, frequency and duration of services, intervention formats, and the recovery stages of stroke patients served, categorized by Brunnstrom stages). The second section focused on perceived barriers to rehabilitation services for community-dwelling patients with stroke. This section also included open-ended questions to gather participants’ views on the characteristics of an effective community-based rehabilitation program. A combination of dichotomous, multiple-response, and open-ended questions was used to gather both quantitative trends and qualitative insights.

For the interview phase, a semistructured interview guide was developed to explore therapists’ experiences in service delivery, practical challenges encountered in community settings, and perspectives on future development of OT services. The interview questions are presented in Textbox 1.

The developed instruments were evaluated for content validity and clarity by three experienced occupational therapists, each with more than 5 years of experience in stroke rehabilitation. They independently reviewed all surveys and interview guide questions. The Index of Item-Objective Congruence (IOC) was used to assess the alignment of each item with the study objectives. Items with IOC scores between 0.50 and 1.00 were retained, while items scoring below 0.50 were revised or removed [28]. In addition, a pilot test was conducted with five occupational therapists. Their feedback was used to refine the wording, clarity, and practicality of the instruments.

Ethical approval was obtained from the Ethical Review Committee for Human Research, Faculty of Associated Medical Sciences (approval #161/2562). All procedures complied with national ethical guidelines for research involving human participants [29].

In the survey phase, eligible participants received detailed information about the study and the informed consent process. The online survey in this study was reported in accordance with the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) checklist [30].

In the interview phase, participants’ consent was obtained to audio-record interviews and take field notes to capture contextual details. Written informed consent was obtained prior to the interviews.

In the survey phase, eligible participants were provided with the study objectives and procedures, together with a link to the online survey distributed via OT social media networks. Reminder messages were sent to eligible participants 1 week and 3 days before survey closure to increase response rates and reduce nonresponse bias [31]. In the interview phase, in-depth interviews were conducted either face to face or via online videoconferencing, depending on participant preferences and logistical considerations. Each interview lasted approximately 30-45 minutes.

The data collection was divided into two distinct periods:

This study used credibility, transferability, dependability, and confirmability as strategies to ensure trustworthiness and rigor. The credibility triangulation strategy used both quantitative and qualitative data obtained from participants among various contexts to ensure accuracy of the findings. The transferability strategy of thick descriptions was used by providing detailed background information, including participants’ experiences, main practice settings, and the procedures for data collection and analysis. The confirmability strategy of peer debriefing was used by researchers to interpret results and reduce data bias [34,35].

The online survey was successfully completed by 59 occupational therapists, yielding a response rate of 78.67%. Table 1 shows the demographic and professional characteristics of the participants. The majority were female (35/59, 59.32%) and held a bachelor’s degree (50/59, 84.75%) in OT, while the remaining participants had postgraduate qualifications. Almost all participants (58/59, 98.30%) reported full-time employment. A substantial proportion worked in district hospitals (25/59, 42.37%), suggesting that occupational therapists in these settings are actively involved in providing community-based stroke rehabilitation services.

In terms of professional experience, nearly half of the participants (27/59, 46%) reported more than 10 years of experience working with community-dwelling patients with stroke. Most patients served by these therapists were classified as Brunnstrom Stage 3 (20/59, 34%), followed by stages 4 (14/59, 24%) and 2 (12/59, 20%), reflecting a population with moderate motor impairment. Individual therapy (40/59, 68%) was the most common mode of intervention. Many participants (27/59, 46%) reported managing more than 10 stroke cases per week. The most common service frequency per case was once per week (29/59, 49%), and the average duration of each session ranged from 30 to 60 minutes (49/59, 83%). These findings suggest a relatively high workload with limited service frequency per individual client. Nearly half of the participants had over 10 years of practice experience and managed a high weekly caseload of patients with stroke, indicating a significant depth of clinical experience of participants.

Almost all participants (36/59, 61%) allocated the majority of their time (51%-75%) to intervention rather than assessment, referral, or documentation, as shown in Table 2. Physicians (49/59, 83%) were the most frequent source of referrals, followed by nurses (20/59, 34%) and self-referrals (19/59, 32%), indicating that referral pathways remain largely a hospital-based (Table 3).

Table 4 illustrates assessment tools used in community OT services according to standardized, nonstandardized, or both standardized and nonstandardized assessments. All participants (59/59, 100%) reported assessing basic activities of daily living (BADLs) and cognitive function. Sensorimotor (58/59, 98.30%), and physical (57/59, 96.61%) components were also commonly evaluated. Nonstandardized assessments were widely used across most occupational performance domains. Standardized assessments were used more frequently in the evaluation of BADLs (42/59, 71.19%) compared to other domains, suggesting greater accessibility or familiarity with formal measurement tools in this area.

As shown in Table 5, the most frequently implemented interventions were BADL training (49/59, 83.05%), cognitive training (44/59, 74.58%), and sensorimotor training (40/59, 67.80%). These patterns correspond closely with the reported assessment priorities and reflect a significant focus on restoring BADL function and physical and cognitive functional recovery.

Perceived barriers identified from survey responses were grouped into three categories: client related, occupational therapist related, and organizational/leadership related (Multimedia Appendix 1). The most frequently reported client-related barriers were inaccessibility to rehabilitation services (45/59, 76.27%) and limited public awareness of OT (45/59, 76.27%). Among therapist-related barriers, time constraints (42/59, 71.19%) were most frequently reported, indicating perceived workload pressures. Interestingly, the shortage of occupational therapists (6/59, 10.17%) was reported less frequently than other barriers. Organizational and leadership-related barriers were most commonly associated with resource shortages (50/59, 84.75%), including limited equipment, funding, and transportation.

Seven occupational therapists with diverse backgrounds in community rehabilitation participated in the semistructured interviews. Their experience in working with community-dwelling patients with stroke ranged from 10 to 18 years (Table 6). All participants were involved in community rehabilitation services, including the IMC program. Thematic analysis generated several key themes, which are presented next with illustrative quotations.

This study examined current OT practices among community-dwelling patients with stroke in Thailand and explored the contextual factors shaping service delivery. The findings suggest that community-based OT services are largely individualized, functionally oriented, and delivered within practical constraints that influence frequency, assessment approaches, and intervention planning.

The quantitative findings indicate that most therapists manage relatively high caseloads, while providing services at a limited frequency per client. Sessions are predominantly focused on BADL, cognitive interventions, and sensorimotor interventions, which correspond to the clinical presentation of patients with stroke commonly classified within moderate motor impairment stages. The interviews revealed that these are delivered through task-oriented training adapted to the client’s home environment. This synergy demonstrates that Thai community occupational therapists maintain occupation-based practice by embedding therapeutic goals within the practical functional needs of patients with stroke. These patterns reflect pragmatic prioritization of functional independence within available time and resource limitations. Similar trends toward function-focused, time-limited community rehabilitation have been reported in other low-, middle-, and high-income countries, where service intensity is often shaped by workforce capacity and infrastructure constraints rather than ideal clinical dosing [36-38]. The relatively frequent use of nonstandardized assessments, alongside routine administration of the BI for IMC reporting purposes, suggests that therapists balance clinical judgment with policy requirements. Rather than indicating inconsistency in practice, this pattern may represent contextual adaptation to administrative and system-level expectations.

Barriers to service delivery were reported at multiple levels. Organizational and leadership-related barriers, particularly resource shortages and transportation limitations, were most frequently identified in quantitative data. These findings highlight the structural factors that shape community rehabilitation, beyond individual therapist effort. Client-related barriers, including limited public awareness of OT and restricted access to services, further affect continuity of care. These findings are supported by our qualitative data, which elucidate the practical reality that occupational therapists experience a discharge rehabilitation gap postdischarge were geographic, financial, or motivational barriers directly hinder continuity of care. Interestingly, although workforce shortages were reported less frequently, time constraints were commonly identified, suggesting that workload pressures and administrative responsibilities may reduce opportunities for sustained therapeutic engagement. Our findings are consistent with previous studies, which have identified infrastructure, workforce, and policy challenges in Thai community OT rehabilitation services [12,39]. The qualitative narratives explain this discrepancy, revealing that therapists’ time is not necessarily consumed by a lack of colleagues but by heavy administrative burdens linked to IMC reporting and the logistical challenges of traveling between community sites. This suggests that the perceived barrier is not a lack of clinicians per setting but a lack of clinical time within the current administrative framework. A related study conducted among Thai community-dwelling patients with stroke and their family caregivers revealed that a lack of knowledge and information related to rehabilitation contributes to a major barrier to the restoration of the functional abilities of patients with stroke [40]. For these participants, education from health care professionals and social support from local and central governments in accessing rehabilitation were perceived as crucial for well-being [40]. Together, these findings indicate that strengthening community rehabilitation requires attention not only to clinical training but also to system organization and resource allocation. Previous studies have suggested that strengthening community rehabilitation systems requires integrated service models, improved referral pathways, and policy-level investment in workforce and infrastructure [40-43]. These system-level strategies may complement the practice-level adaptations identified in this study, particularly in addressing structural barriers, such as resource limitations and service accessibility. The qualitative findings provide further insight into how therapists respond to these constraints. Participants described clinical reasoning that remains grounded in client-centered and occupation-based principles, even within policy-driven environments. The influence of IMC key performance indicators was evident in documentation and assessment procedures [11]; however, therapists continued to tailor interventions according to clients’ occupational roles and daily routines. Examples of task-oriented training adapted to specific work contexts illustrate how occupation-based practice is maintained in community settings [39].

Cultural context also emerged as an important factor shaping rehabilitation processes. Therapists described actively engaging family members as partners in care and framing caregiving within culturally meaningful values. In settings where service frequency is limited, caregiver involvement becomes central to continuity of rehabilitation. This finding is consistent with the literature emphasizing caregiver-mediated rehabilitation in community stroke recovery [24,40]. In the Thai context, strong family networks may serve as a practical resource that supports functional recovery when formal services are constrained. International studies have likewise emphasized the value of caregiver-mediated interventions in sustaining home-based stroke rehabilitation, particularly where professional contact time is limited [44,45].

The COVID-19 pandemic acted as a catalyst for home-based rehabilitation in Thailand [46]. As hospital resources were diverted to the pandemic response, OT services were forced to adapt quickly to community-dwelling environments. This temporal context may have influenced the patterns observed and should be considered when interpreting the findings. This context likely intensified the barriers identified in Multimedia Appendix 1, such as resource shortages and the need for caregiver-mediated interventions, as practitioners had to rely more heavily on family support when face-to-face clinical visits were restricted.

This cultural reliance, combined with identified resource shortages, directly informed the participants’ proposal of a stroke rehabilitation box set to support home-based intervention. Although conceptual at this stage, the idea reflects therapists’ efforts to extend rehabilitation beyond clinic visits through portable, low-cost tools combined with caregiver training. Although home-based technologies offer the advantages of flexibility in location and time for rehabilitation therapy, they also allow patients to receive feedback from therapists remotely as the use of rehabilitation technologies in the home environment requires technical training [47,48]. Rather than representing a technological innovation, this proposal suggests a practical strategy for improving continuity of care within existing resource limits. Future research should examine the feasibility, acceptability, and clinical outcomes of such home-based support models.

Although this study presents its strengths, certain limitations should be acknowledged. First, although the survey included participants from a range of practice settings, it may not fully represent the geographical diversity or variability of rehabilitation service structures across all regions of Thailand. Service organization and resource availability may differ in areas not captured within the sample. Second, the qualitative component included only occupational therapists. The perspectives of patients with stroke, their primary caregivers, and other rehabilitation professionals were not explored in this study. Including these stakeholders’ voices in future research would provide a more comprehensive understanding of community rehabilitation processes and challenges. Third, although the study identified practice-based ideas, such as the proposed home-based rehabilitation kit, these concepts remain exploratory and require further investigation regarding their feasibility, effectiveness, and scalability within community settings. Fourth, a notable limitation of this study is the extended 5-year data collection period, which spanned the pre- and post–COVID-19 eras. The global pandemic significantly disrupted health care systems in Thailand, potentially causing shifts in OT practice and practitioners’ perspectives over time. Although the sequential design allowed us to explore these transitions, the long duration may introduce historical bias, as participants’ responses might be influenced by systemic changes not present in 2020. This temporal context should be considered when interpreting the findings. However, a strength of this prolonged engagement is the ability to capture the resilience and evolution of OT services during one of the most challenging periods for the Thai health care system.

Overall, the findings illustrate that community-based OT in Thailand operates within identifiable structural constraints, while maintaining core occupation-centered principles. Therapists demonstrate flexibility in adapting assessment and intervention strategies to local realities. Efforts to strengthen community rehabilitation should therefore address both system-level factors, such as resource allocation, transportation, and administrative workload, and practice-level supports, such as caregiver training and context-specific intervention tools.

Taken together, these findings offer a contextually grounded understanding of community-based OT practice in stroke rehabilitation, which may help inform ongoing efforts to strengthen services in similar settings.