RESEARCH ARTICLE


Predictors of Physical Educators' Attitudes toward including Students with Disabilities in Inclusive Classes



Majed M. Alhumaid1, *
1 Department of Physical Education, College of Education, King Faisal University, Al-Ahsa 31982, Saudi Arabia


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Creative Commons License
© 2022 Majed M. Alhumaid.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Physical Education, College of Education, King Faisal University, Al-Ahsa 31982, Saudi Arabia; E-mail: malhumaid@kfu.edu.sa


Abstract

Background:

In recent years, inclusion has become an educational system implemented in many countries of the world, and teachers' attitudes towards this system are considered one of the most important factors to ensure its success.

Objective:

The purpose of this study was to examine Saudi Arabian physical educators’ attitudes toward teaching students with disabilities in inclusive physical education settings, and to examine the factors that affect such attitudes.

Methods:

Physical educators’ attitudes (N = 1,303; Mage = 40.07; SD = 9.30) were measured using the Arabic version of the Sentiments, Attitudes and Concerns about Inclusive Education-Revised Scale (SACIE-R).

Results:

Despite the moderately positive attitudes developed by physical educators, females reported more positive attitudes toward inclusion than males (2.51± 0.39 vs. 2.345 ± 0.36; Z = -8.545; p = 0.001). Regression analysis indicated that three personal factors (i.e., gender, previous participation in training courses to teach students with disabilities, and knowledge of the Saudi educational legislation or policy) were significant predictors of physical educators’ attitudes toward such inclusion.

Conclusion:

The findings provide a database that Saudi Arabian educational decision-makers can refer to when designing teacher preparation programs in universities and educational institutions.

Keywords: Inclusive physical education, Students with disabilities, Physical education teachers, Inclusion, Disability, Children with disabilities.



1. INTRODUCTION

In the last two decades, considerable efforts have been made to develop educational systems and legislation in many countries around the world. One of the most important of these developments is the wide and great interest in sports and physical education (PE) for students with disabilities. According to Article 30 of the International Convention on Rights for Persons with Disabilities, students with disabilities have the full right to practice sports and PE with their peers without disabilities in inclusive settings [1]. This confirms the importance of having in place a well-prepared process for physical educators to implement inclusive practices in their regular classes [2]. Attitudes of physical educators towards these practices play a critical role in the extent of their successful application on the ground [3-5].

It has been argued that the attitudes of physical educators, whether positive or negative towards teaching students with disabilities, have a significant impact on the desire of these teachers and their willingness to include students with disabilities in their regular classes [6, 7]. In recent years, numerous studies in many countries have focused on evaluating the attitudes of physical educators towards the inclusion of students with disabilities to ensure the successful and effective application of such inclusive practices [8-11]. Although these studies have also made considerable efforts to explore the factors that may affect the attitudes of physical educators towards the inclusion of students with disabilities, more research is needed in this regard [12].

The literature indicates that the attitudes of physical educators toward inclusion can be influenced by several factors. Gender has been identified as one of the factors that most influence physical educators’ confidence and attitudes toward inclusion. For example, Alhumaid [13] found that male Saudi physical educators were more confident and willing to provide inclusive practices than female physical educators. In terms of age, Özer et al. [14] reported that, in comparison with older teachers, younger teachers are more likely to have more positive attitudes toward inclusive education; however, no significant differences were found between the two groups in the study by Hutzler and Daniel-Shama [15] and more recently Ginevra et al. [11]. In terms of the effect of cultural differences on teachers’ attitudes toward students with disabilities, Loreman et al. [16] reported that such differences were found between teachers’ perspectives from Eastern and Western cultures. Therefore, cultural differences may play a critical role in this regard [7]. Furthermore, a study of education teachers in Greece [17] and a more recent study of physical educators in Italy [11] found that secondary school teachers developed negative attitudes towards students with disabilities more than primary school teachers. Meegan and MacPhail [18] suggested that physical educators felt they did not receive enough training on teaching students with disabilities in PE classes during their undergraduate studies, and expressed concerns about their ability in doing such tasks [19]. Hutzler et al. [7] in their narrative review study suggested that more research was needed to better establish the impact of instructional training or interventions on the attitudes of physical educators toward including students with disabilities. Gibbs and Bozaid [20] argued that receiving specialized training enabled education teachers to build their knowledge and understanding of inclusive education. Forlin et al. [21] found that Hong Kong teachers’ confidence in inclusive practices is more likely to be improved when their knowledge of local legislation and policy is increased. This was consistent with a recent local Saudi study by [22], which suggested that knowledge of policies and laws relating to persons with disabilities should be provided to teachers to improve their self-efficacy toward providing inclusive practices.

Despite the efforts made by many of the above studies, there is still a significant lack of studies examining the attitudes of physical educators towards including students with disabilities and the factors that may affect those attitudes in non-Western countries, especially Arab countries [23]. For this reason, the current study examines the attitudes of physical educators in Saudi Arabia towards inclusion and explores the most important factors (e.g., gender, grade of teaching, region of teaching, previous participation in training courses to teach students with disabilities, and knowledge of the Saudi educational legislation or policy) that may affect such attitudes. This study is important as it will contribute to understanding the current reality of physical educators towards inclusion and the factors that affect them, which will determine if there is a need for revised curriculum offerings and additional teacher training in the area of disabilities. Based on the previous literature, it is hypothesized that: (a) female physical educators have lower attitudes toward inclusive practices than male physical educators, (b) younger physical educators have more positive attitudes toward inclusion than older physical educators, (c) cultural differences had a significant impact on physical educators' attitudes towards inclusion, (d) primary school physical educators had more positive attitudes than secondary school physical educators, (e) physical educators who reported prior training in teaching students with disabilities had more positive attitudes towards inclusion than those who did not report such experiences, (f) knowledge of disability-related education legislation or policies would positively impact the attitudes of physical educators attitudes towards inclusion.

2. MATERIALS AND METHODS

2.1. Participants

A random geographic cluster sampling technique was used for data collection. Public school physical educators in Saudi Arabia (Central Region, Western Region, Northern Region, Southern Region, and Eastern Region) were invited to participate in this study. All participants were asked to complete an electronic questionnaire aimed at assessing their demographic characteristics and level of attitudes towards including students with disabilities in their classrooms. The collected positive results were reviewed, the answers were checked, the incomplete questionnaires were discarded and 1,303 were retained and analyzed.

2.2. Instrument

In this study, the data was collected using an electronic questionnaire. Participants answered several questions related to their demographic characteristics and background information such as their gender, age, grade of teaching, region of teaching, previous attendance on courses related to students with disabilities, and knowledge of the Saudi educational legislation or policy. The Sentiments, Attitudes and Concerns about Inclusive Education-Revised Scale (SACIE-R) [24] were used in this study. The SACIE-R instrument consists of 15 statements to examine three psychometric constructs of inclusion: sentiments (e.g. ‘I find it difficult to overcome my initial shock when meeting people with severe physical disabilities’), attitudes (e.g. ‘Students who need an individualized academic program should be in regular classes’) and concerns (e.g. ‘I am concerned that students with disabilities will not be accepted by the rest of the class’). The instrument used a four-point Likert scale, from 1 (strongly disagree) to 4 (strongly agree) to measure participants’ attitudes. A higher score indicates a more positive attitude towards inclusion. The Arabic version of the SACIE-R instrument was translated and tested by Alhumaid et al. [25], which indicated that the instrument was found to be reliable and valid to investigate Saudi physical educators’ attitudes toward inclusion.

2.3. Procedures

Saudi physical educators were invited to participate in this study voluntarily. An online questionnaire platform (Google Forms) was sent to the targeted participants by email and through their educational departments in the five Saudi geographical regions. The email included a link and barcode for the questionnaire so the participants had the option of choosing either way to complete the questionnaire. Clicking on the link or scanning the barcode would display the information sheet so the participants could see and read the details of the study including its aims, and by continuing to the next page, the participants agreed to participate in this study. Completing the questionnaire was not obligatory, so the participants had the right to stop and leave the questionnaire at any time. A total of 1,350 questionnaires was received; however, only 1,303 of them (96.51%) were completed so this number of questionnaires was confirmed in the data analysis stage. The protocol of this study was approved by the Research Ethics Committee at King Faisal University, Saudi Arabia (KFU-REC-2022-MAR-EA000478).

2.4. Data Analysis

To achieve the first research objective, the mean and standard deviation for the items of the SACIE-R instrument was calculated. All distributions were checked for normality using the Shapiro-Wilk test. A Mann-Whitney nonparametric U test and a Kruskal-Wallis test were used for all comparisons. The linearity of the predictor variables was tested using scatterplots. The normality and homoscedasticity of the residuals were also checked, and the multicollinearity of the independent variables was checked using the variance inflation factor values, all of which were less than 5. Multiple linear regression was used to address the second research objective. Multiple linear regression scores were calculated to predict attitudes towards inclusion among physical educators based on the independent variables. The results are presented as standardized and non-standardized coefficients, partial R and R-squared. The Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics 26.lnk, Chicago, IL, USA) was used for statistical analysis. The significance level was set at p < 0.05.

3. RESULTS

3.1. Demographic Characteristics

The participant sample consisted of 1,303 physical educators aged between 24 and 57 years old (M = 40.07, SD = 9.30), randomly selected from the five Saudi geographical regions (Central Region [16.42%], Western Region [24.55%], Northern Region [9.20%], Southern Region [30.08%], and Eastern Region [19.72%]), teaching in Saudi primary, middle, and high schools (45.80%, 32.30% and 21.90%, respectively). Male physical educators represented over 57% of the total participants. Table 1 provides additional relevant information about participants' backgrounds and attitudes toward inclusion.

Table 1. Exploring the level of attitudes toward inclusion scores for independent variables (N = 1,303).
- All Participants Male Participants Female Participants Males vs. Females
N Mean SD N Mean SD N Mean SD Z P
Age (years) 25 and less 51 2.435 0.44 21 2.375 0.412 32 2.475 0.459 -1.39 0.165
26 – 35 207 2.437 0.416 123 2.388 0.406 89 2.506 0.424 -2.946 0.003
36 – 45 513 2.435 0.363 223 2.343 0.336 293 2.505 0.368 -5.186 0.001
46+ 532 2.385 0.386 385 2.331 0.361 148 2.525 0.413 -5.651 0.001
Between groups differences X2 = 6.355; P = 0.096 X2 = 1.749; P = 0.626 X2 = 1.218; P = 0.749 - -
Grade of Teaching Primary School 591 2.405 0.397 326 2.360 0.374 276 2.456 0.417 -3.731 0.000
Middle School 424 2.427 0.372 252 2.348 0.349 172 2.544 0.376 -5.357 0.000
High School 288 2.419 0.379 174 2.312 0.361 114 2.581 0.346 -6.458 0.000
Between groups differences X2 = 0.198; P = 0.906 X2 = 3.563; P = 0.168 X2 = 7.402; P = 0.025 - -
Region of Teaching Central Region 214 2.421 0.353 160 2.383 0.346 56 2.532 0.351 -2.667 0.008
Western Region 320 2.406 0.389 227 2.324 0.374 95 2.604 0.352 -6.347 0.001
Northern Region 120 2.377 0.329 76 2.320 0.332 44 2.476 0.305 -2.812 0.005
Southern Region 392 2.405 0.405 173 2.328 0.369 222 2.464 0.423 -3.675 0.001
Eastern Region 257 2.452 0.396 116 2.375 0.373 145 2.514 0.405 -3.487 0.001
Between groups differences X2 = 5.353; P = 0.253 X2 = 4.351; P = 0.361 X2 = 11.135; P = 0.025 - -
Participation in a Training Course to Teach Students with a Disability Theoretical Course 201 2.331 0.422 157 2.296 0.366 45 2.455 0.563 -3.376 0.001
Practical Course 26 2.212 0.437 21 2.289 0.293 6 1.944 0.734 -0.789 0.430
Theoretical and Practical Course 135 2.204 0.407 116 2.183 0.392 22 2.312 0.477 -1.180 0.238
No 941 2.469 0.355 458 2.405 0.342 489 2.529 0.358 -5.518 0.001
Between groups differences X2 = 77.881; P = 0.001 X2 = 41.857; P = 0.001 X2 = 9.463; P = 0.024 - -
Knowledge of the Saudi Educational Legislation or Policy Very good 70 2.307 0.498 43 2.228 0.501 29 2.423 0.480 -1.875 0.061
Good 112 2.244 0.399 75 2.145 0.342 38 2.440 0.435 -3.399 0.001
Average 220 2.321 0.365 173 2.283 0.354 48 2.460 0.373 -3.233 0.001
Poor 281 2.403 0.310 197 2.373 0.298 87 2.471 0.329 -2.754 0.006
None 620 2.497 0.384 264 2.440 0.359 360 2.538 0.398 -3.688 0.001
Between groups differences X2 = 84.927; P = 0.001 X2 = 52.367; P = 0.001 X2 = 10.458; P = 0.033 - -
Table 2. Multiple linear regression analysis to predict physical educators’ attitude toward including students with disabilities.
- Unstandardized Coefficients Standardized Coefficients Partial R
β Std. Error β t Sig.
All
(N = 1,303)
(Constant) 2.045 0.085 24.115 0.000
Age 0.011 0.015 0.024 0.706 0.480 0.020
Gender 0.083 0.029 0.107 2.865 0.004 ** 0.079
Teaching Grade 0.008 0.013 0.016 0.593 0.553 0.016
Region of Teaching -0.009 0.007 -0.035 -1.260 0.208 -0.035
Training Course 0.031 0.010 0.087 3.149 0.002 ** 0.087
Knowledge of educational policy 0.050 0.009 0.159 5.753 0.001 *** 0.157
Males
(N = 752)
(Constant) 2.131 0.094 22.585 0.000
Age -.001 .026 -.002 -.027 .979 -.001
Teaching Grade -.029 .016 -.062 -1.754 .080 -.064
Region of Teaching .001 .009 .004 .115 .909 .004
Training Course .026 .011 .085 2.345 .019 * .086
Knowledge of educational policy .070 .011 .230 6.319 .000 *** .226
Females (N = 551) (Constant) 2.274 .126 18.072 .000
Age .007 .021 .014 .327 .744 .014
Teaching Grade .061 .021 .121 2.880 .004 ** .121
Region of Teaching -.021 .013 -.070 -1.671 .095 -.071
Training Course .030 .020 .064 1.503 .133 .064
Knowledge of educational policy .025 .014 .076 1.795 .073 .076

3.2. Physical Educators' Attitudes toward Inclusion

Table 1 presents the data regarding Saudi physical educators' attitudes toward the inclusion of students with disabilities in PE classes. The results indicate that participants’ attitudes were moderately positive overall (M = 2.415; SD = 0.385). Female physical educators reported more favorable attitudes towards inclusion than male physical educators (2.51 ± 0.39 vs. 2.345 ± 0.36; Z = -8.545; p = 0.001). Furthermore, in relation to their attitudes toward the inclusion of students with disabilities in PE classes, 6.62% of participants had a very low score (scores ≤ 1.8), 58.447% had a low score (between 1.8 and less than 2.6), 32.724% had a medium score (between 2.6 and less than 3.2) and only 2.21% had a high score (between 3.2 and less than 4). Significant differences between research groups were found for three independent variables: gender, previous participation in a training course to teach students with disabilities, and knowledge of Saudi educational legislation or policy (p < 0.001 for all). Educators who have never attended a PE training course for students with disabilities and those who are unaware of Saudi education laws or policies have the highest attitudes towards inclusion. However, significant differences were noted for grade and teaching region only in female physical educators (p < .05 for all). Table 1 provides additional relevant comparisons between groups by gender and independent variables regarding Saudi physical educators' attitudes toward including students with disabilities in PE classes.

3.3. Predictors of Physical Educators’ Attitude toward Inclusion

Multiple linear regression analysis showed that a significant regression pattern was identified among all participants (F = 18.064; p < .001; R2 = .088), males (F = 9.957; p < .001; R2 = .074), and females (F = 4.573; p < .001; R2 = .047). Therefore, the results of the regression analysis indicate that the independent variables explained 8.8% of the variation in attitude toward inclusion among all participants, 7.4% among males and 4.7% among females. Regression analysis indicates that there is no collinearity in the results, suggesting that the results have adequate statistical significance. Table 2 illustrates the significance, direction, and strength of the relationships between individual predictors and participants' level of attitudes towards including students with disabilities in PE classes. Gender (β = .083; p = .001), as the first predictor with a positive standardized beta value, suggests that female physical educators are more likely to develop more positive attitudes towards the inclusion of students with disabilities than male physical educators. Participation in a training course to teach students with disabilities and knowledge of Saudi educational legislation or policy also negatively contributed to participants' attitudes towards the inclusion of students with disabilities (β = 0.031 and 0.050, respectively). Furthermore, among male physical educators, participation in a training course to teach students with disabilities and knowledge of Saudi educational legislation or policy were significant predictors of their attitudes toward inclusion (β = 0.026 and 0.070, respectively); however, among female physical educators, only grade teaching (β = 0.061) was identified as a positive predictor suggesting that female physical educators teaching in primary schools are more likely to develop lower attitudes toward the inclusion of students with disabilities than those who are teaching in higher schools (i.e., middle and high schools).

4. DISCUSSION

The purpose of this study is to examine the attitudes of Saudi physical educators towards including students with disabilities in their PE classes. It also aims to explore the factors that may influence physical educators’ attitudes toward such inclusion. In general, Saudi physical educators reported moderately positive attitudes toward including students with disabilities.

As regards participants’ personal factors (i.e., gender, age, grade of teaching, region of teaching, previous participation in training courses to teach students with disabilities, and knowledge of the Saudi educational legislation or policy), the analysis illustrated that significant differences were obtained between the research groups only in terms of their gender, previous participation in training courses to teach students with disabilities, and knowledge of the Saudi educational legislation or policy. In particular, in terms of gender, female physical educators reported more positive attitudes toward inclusion than male physical educators. This finding is inconsistent with a Saudi study by Alhumaid [13] that concluded that male physical educators reported higher levels of confidence and self-efficacy toward including students with disabilities than female physical educators. Based on these results, the first hypothesis of this study has to be rejected. These differences in the above findings partially reflect those reported by Tsakiridou and Polyzopoulou [17] and add to the evidence base indicating that female teachers reported more positive attitudes toward inclusion than male teachers; however, the opposite was reported in terms of their self-efficacy toward inclusion. Tsakiridou and Polyzopoulou [17] explained that these contradictions may be a result of the higher level of stress female teachers may face in their classroom settings with students with disabilities. Therefore, this may be reflected in their feelings and confidence toward the inclusion of students with disabilities even if they show positive attitudes. The school environment could be also a reason for the differences between male and female physical educators’ attitudes toward inclusion in Saudi Arabia. As Saudi Arabia’s schools are separated by gender, it would be important and worthwhile to explore the impact of the school environment on physical educators’ attitudes toward inclusion.

The age of the participants did not influence the attitude of Saudi physical educators towards the inclusion of students with disabilities in their PE classes, so the second hypothesis must be rejected. On the contrary, grade and teaching region only significantly influenced the attitude of female physical educators. Those with the highest levels of education and those working in the central, western, and eastern regions had the highest levels of attitudes towards inclusion. These findings were confirmed by the results of Hutzler et al. [26] that girls were more accepting of the norm of doing PE under different conditions, which is embedded in the inclusion approach. However, boys still meet the standard of performing the designated task, such as learning a specific skill, when a child with a disability may pose a threat. Socio-economic differences between regions may also influence educators' attitudes towards inclusion.

In terms of previous participation in training courses to teach students with disabilities, although a significant difference was found between the research groups, those participants who reported not having such previous training showed more positive attitudes towards inclusion than those who reported having such previous training, regardless of whether the training was theoretical, practical or both theoretical and practical. Therefore, this led us to conclude that the fifth hypothesis could not be supported. Despite the fact that participation in training in inclusive practices may affect physical educators’ attitudes toward such inclusion [27], the current study’s findings may reflect the type and quality of training courses that the participants had received. It has been argued that the quality of training received by in-service or pre-service physical educators to improve their attitudes towards and preparation for the inclusion of students with disabilities is very important to achieve the desired goal of the such training. In support, Granell et al. [28] suggested that the quality of the training provided for teachers of students with disabilities has the most significant impact on these teachers’ subjective opinions of their own professional and scientific abilities to manage the respective special educational needs and disabilities of such students. Granell et al. [28] further pointed out that there is an urgent need to ensure the continuation of the move to improve teacher training for those who teach students with special educational needs and disabilities; such training must facilitate a greater degree of inclusiveness in lesson content both theoretically and practically. This recommendation concurs with that mentioned in an up-to-date study [20] carried out in Saudi Arabia; the researchers proposed that teachers in general education contexts should be provided with tailored tuition on how to provide education for those with special needs that combines the theoretical aspects with their respective practical ones; it was also highlighted that the paucity of classroom resources negatively affects students’ subjective perceptions of the quality of their education-related experiences. The findings of the above studies confirm the need for more efforts to be made by educational decision makers to provide high-quality training for general and physical educators to ensure its positive impact on such teachers’ attitudes and preparation in order to guarantee that it effectively prepares teachers of students with disabilities to effectively and successfully deliver inclusive education [22].

In terms of knowledge of the Saudi educational legislation or policy, a significant difference was found between the research groups. However, such awareness of the Saudi educational legislation or policy about students with disabilities did not impact the attitudes of the participants in this study toward including students with disabilities. Therefore, the sixth hypothesis for this study might be rejected. This finding contradicted the findings of Tsakiridou and Polyzopoulou [17], which found that Greek teachers who were aware of policies and legislation regarding students with disabilities reported more positive attitudes than those who were not. A possible explanation of the current study’s findings might be that the participants were not aware of the most recent changes in the legislation or policy regarding the rights of people with disabilities. In fact, although since the end of the 20th century many countries around the world have begun to modify and change their educational systems in relation to the practices of inclusive education, Saudi Arabia has only recently been working on these modifications and changes [29]. Therefore, this reflects the current study’s findings that teachers, and in particular physical educators, were not really aware of the recent changes in the policies concerning teaching students with disabilities. It is critical to raise awareness of laws and policies regarding people with disabilities more effectively. Alnahdi [22] concluded that the educational decision makers in Saudi Arabia and other countries more broadly should work to raise awareness and knowledge among teachers, of the laws and legislations relating to this population and how to deal with them. This movement will undoubtedly be reflected positively in the attitudes and confidence of teachers toward inclusive practices, which will be reflected in the quality of education provided for students with disabilities.

Despite the strengths of this study, two limitations should be discussed. First, the data was collected through an online questionnaire platform; thus, the mood and psychological state of the participants when they were filling out the questionnaire may affect their assessment. However, this approach was applied because Saudi Arabia is a big country, so it was difficult to travel around the country for data collection. Second, because the current research project was based on participant self-reported data collected using the SACIE-R research instrument, this means that it did not collect empirically-based quantitative data on participant behavior gathered in their respective PE-teaching settings. Therefore, the findings of the current study are likely to be influenced by participant bias [30]: the participants are likely to have over-stated the positive aspects of their level of SE and over-estimated their ability to provide students with autism with an inclusive learning environment in their PE classes. Given this, the researcher suggests that those researching this topic in the future ought to use empirical research instruments such as structured class observations to collect quantitative data to provide a more comprehensive overview of the in-class behaviors of physical educators who teach students with disabilities.

CONCLUSION

Along with the increasing number of students with disabilities in general PE classes [31, 32] the current findings indicate that Saudi Arabia physical educators have developed moderately positive attitudes toward including such students in their PE classes. This suggests that Saudi educational institutions and government decision makers must exert more effort to guarantee the effective implementation of inclusive PE for students with disabilities by providing more high-quality, practical inclusive training for physical educators. Moreover, the current findings highlight that physical educators in Saudi Arabia should be made aware of the most recent changes in the legislation or policy regarding the rights of people with disabilities. This awareness of such recent changes relating to people (e.g., school students) with disabilities may play an important role in improving physical educators' attitudes toward providing inclusive practices for such populations. Finally, it is recommended that investigations about the influence of other variables (e.g., degree in PE) on physical educators’ attitudes toward inclusion are needed.

LIST OF ABBREVIATIONS

PE = Physical Education
SACIE-R = Sentiments, Attitudes and Concerns about Inclusive Education-Revised Scale
SPSS = Statistical Package for the Social Sciences

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was approved by the research ethics committee at King Faisal University, Saudi Arabia (KFU-REC-2022-MAR-EA000478).

HUMAN AND ANIMALS RIGHTS

No animals were used in this research. All human research procedures were followed per the ethical standards of the committee responsible for human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Written informed consent was obtained from the participants.

STANDARDS OF REPORTING

STROBE guideline were followed.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

This study was financially supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (Grant No. GRANT1378).

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or others.

ACKNOWLEDGEMENTS

The author acknowledges the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research at King Faisal University, Saudi Arabia for the financial support (Grant No. GRANT1378).

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