This is a qualitative, single exploratory case study design using focus group discussions. In addition to the benefits of qualitative exploration of reality, the small number of education physiotherapists in the South African special needs schools makes focus group discussion a suitable approach to exploring subject of this study.

The study was conducted in the Limpopo province, which is one of South Africa’s rural provinces. Limpopo province is the fifth largest province out of nine provinces in South Africa in terms of population size (South African Institute of Race Relations 2020). The population is predominantly black African (96.7%), and highly varied in terms of languages spoken. The majority speaks Sepedi (52.9%), followed by Xitsonga (17%) and Tshivenda (16.7%) (Limpopo Department of Education 2020). As a result of the province being rural, there are constraints pertaining to resource allocation. For instance, the number of public special schools and healthcare facilities differs significantly from those in Gauteng province, which is urban. Limpopo province only has 35 special schools accommodating learners with intellectual and physical disabilities including visual and hearing impairments whereas there are 120 special schools in Gauteng province (Gauteng Department of Education 2023). Of the 35 special schools, only three are designated for learners with physical disabilities and with only one admitting learners from Grade R to Grade 12.

During the study period, the Limpopo Department of Education employed eight education physiotherapists, including researchers. Consequently, a sample of seven education physiotherapists (n = 7) working for the Limpopo Department of Education were purposefully sampled (Palinkas et al. 2015) to participate in the study. The purposive sampling approach enabled the first author to select participants who had experience and knowledge related to the research question and the objective of the study. Participants who are knowledgeable could provide in-depth information to deepen the understanding pertaining to challenges experienced with supporting learners with physical disabilities. Of the seven, only one physiotherapist was based at a special school, while six were appointed on an itinerant basis, rendering services to various education districts.

Physiotherapists working in the school setting were eligible to participate in the study, irrespective of their years of experience.

Following ethical approval from the provincial Department of Education, prospective participants were emailed detailed information letters and informed consent forms individually to invite them to participate in the focus group discussion for the study. The recruitment process started on the 19th of April 2021 and continued till the 06th of May 2021. Subsequently, after reminders all education physiotherapists expressed their interest and provided written informed consent forms via emails. Table 1 shows the demographic characteristics of the seven participants. The median age and years of experience were > 40 years and 11–15 years, respectively.

Considering the geographical dispersion of participants, a virtual session was adopted to facilitate convenient engagement (Keen, Lomeli-Rodriguez & Joffe 2022). Data collection followed a respondent-moderated synchronous virtual format for focus group discussion conducted via Microsoft Teams® platform (Keemink et al. 2022). This approach involved participants choosing a moderator to facilitate the discussions using the interview guide while the first author (Makwena M. Sibuyi) was the moderator’s assistant during the discussion. In addition, the moderator ensured maximum participation from all participants.

This approach is thought to increase wide-ranging responses that are truthful from participants (Kamberelis & Dimitriadis 2005; Onwuegbuzie & Frels 2015). The moderator was taken through the literature that provided guidance and tips on how to conduct focus group discussions. These included being able to listen to participants, probe during discussions, and contain the discussions (Fusch, Fusch & Ness 2022). The moderator was also an employee in the provincial Department of Education and tasked with advancing inclusive education policies such as the SIAS policy. The provincial Department of Education in Limpopo provided a formal in-service training to education physiotherapists in which the moderator and other participants were involved. Although not all education physiotherapists received this formal training, they were involved in executing their responsibilities to conduct in-service training to educators in special schools about the SIAS policy.

In addition to the formal training and training the educators, the first author (Makwena M. Sibuyi) provided a mock interview session with the moderator (chosen by participants) and offered feedback on areas for improvement, such as making use of prompts to break the ice or starting the conversation, probing to allow the participant to elaborate on statements uttered, maintaining focus of the interview guide, constructive engagement instead of veering off the topic and managing time effectively.

The interview guide (Jamshed 2024) was shared with participants to familiarise themselves with the questions in preparation for responses and for participants to make changes with the questions where necessary. There was no indication from the participants that questions needed to be added or changed. Participants were asked about challenges experienced in implementing the SIAS policy. To ensure confidentiality, each participant opted for a pseudonym to safeguard their identity (Kaiser 2009). Participants chose these names: Montsho, Celine, Sbakuza, Funky, R.S., Valentine, and Milkshake. Before a Focus Group Discussion (FGD), all participants agreed upon the rules governing FGD. One FGD was conducted in English, audio recorded and lasted for 90 min.

Inductive thematic analysis on ATLAS.ti version 9 was used to explore challenges experienced by education physiotherapists with the SIAS policy. Audio records were transcribed verbatim. Data were coded following a six-stage approach to inductive thematic analysis process (Dawadi 2021) by authors Makwena M. Sibuyi and Muziwakhe D. Tshabalala. Data saturation was reached when new data became redundant and participants did not have differing views (Francis et al. 2010). The six-steps began with the authors familiarising themselves with the data through repeated readings and note-taking. Initial codes were generated from quotations, which were then grouped into categories and refined into themes following consensus. The criteria for selecting quotations to be used for reporting were based on inclusive and ethical considerations involving a mix of quotations from different participants per theme where possible. Selected quotes that represented participants’ intentions were chosen to ensure that their meanings were not distorted. Personal identifiable information was removed to safeguard participant confidentiality (Brennan 2022).

Using a co-coder was aimed at maintaining coding consistency and validating the accuracy of the coding process. A consensus agreement was used as a strategy to determine themes (Prieto-González et al. 2021). This strategy allowed back-and-forth and in-depth discussions of themes among the authors yielding credible results. Finally, the two themes formed the basis of the study’s results and discussion.

Strategies such as credibility, reflexivity, dependability, confirmability, and transferability ensured study rigour (Johnson, Adkins & Chauvin 2020).

Credibility was upheld through member checks where participants received transcripts to validate their accuracy (McKim 2023). In demonstrating reflexivity, the first author (Makwena M. Sibuyi) has a good understanding of the education sector, having worked for 4 years within the Inclusive Education sub-directorate of the provincial Department of Education and thus able to interpret participants’ responses accurately within the context. Prior collaboration with other physiotherapists and having trained educators in the province on SIAS policy makes the first author acknowledge her potential influence on the interpretation of data.

In interpreting the study’s findings, the first author considered the possible variability in participants’ experiences; only one directly working within the special school. It is possible that participants may have possessed a sense of compulsion to participate in this study, despite being informed of their right to withdraw from the study without consequences. Nonetheless, participants were contacted through their personal emails to receive information letters. It was hoped that communication through their personal emails would remove the sense of compulsion to participate in the study. However, in the first author’s reflection on the attitude and composures of the participants, throughout the study period, there was nothing to suggest that the participants were under any form of compulsion.

At the end of the focus group discussion, Makwena M. Sibuyi and the moderator allowed participants to reflect on questions and responses provided. Participants realised that they (School-based physiotherapist and those at district-based) had similar challenges in the education sector. It was then resolved that ongoing meetings were needed to find solutions collaboratively to the identified challenges. These meetings would take place for the first time since the appointment of educational physiotherapists at the district level. This showed a discussion like this was needed pointing to this study having relevance.

The researcher’s (Makwena M. Sibuyi) role entailed collaborative efforts with physiotherapists across various education districts, collectively working towards enhancing inclusive education. The first author was integral in educating educators from both special and full-service schools and training caregivers and Special Care Centres’ managers on inclusive education policies, with a particular focus on SIAS policy.

To ensure transferability, descriptions of the province name, the district names, participants’ demographics, data collection procedures, and duration were provided (Johnson et al. 2020). The findings are dependable, should the same interview guide, participants and similar context be used for another study. Lastly, confirmability was upheld through collaborative efforts with a co-coder, ensuring consensus and resolving any coding discrepancies that arose during the process (Nowell et al. 2017).

Approval to conduct the study was granted by both the University Health Sciences Ethics Committee (Ref: 668/2020) and the provincial Department of Education to ensure ethical considerations were met. The research adhered to the ethical principles of conducting studies involving human participants, following the guidelines in the Helsinki Declaration 2013 version (General Assembly of the World Medical Association 2014). All participants signed informed consent forms, thus agreeing to participate in the study and to have their voices recorded for the interviews.

There was a strong consensus among all the participants that poor knowledge of the SIAS policy on the part of both the educators and physiotherapists was a major challenge to the implementation of the SIAS policy. There were two factors that contributed to the poor knowledge of the SIAS policy. They included lack of in-service training and fear of transfers through the R&R policy.

There was a consensus among the participants that there was no collaboration between the educators and the physiotherapists at the special schools. The lack of collaboration was attributed to educators not being clear on the roles and responsibilities of physiotherapist in the SIAS process and hence, they were not involved in most instances. In addition, there was lack of support structures at the level of the school, circuit and the district.

As a result of poor knowledge, educators were unable to implement the initial stage of the SIAS process of assessment. Learner Profiles were not available to screen and identify learners who may have barriers to learning. Many school educators who received their qualifications before 2014 (when the SIAS policy was launched) were not exposed to inclusive education principles and practices during their initial training (Majoko & Phasha 2018). The SIAS policy is new for them and they require support. Similarly, studies conducted among South African educators also reported similar challenges pertaining to inadequate knowledge that led to failure to complete the SIAS toolkits (Maree, Condy & Meda 2023; Pillay & Tlale 2024). It has been commonly reported that limited knowledge is attributable to policy failure (Calvano 2013; Dembe & Partridge 2011). There is growing recognition that policies rarely fail because of their design alone but rather on their implementation (Hudson, Hunter & Peckham 2019). Factors contributing to poor knowledge of SIAS policy are discussed next.

Physiotherapists indicated that there was no working relationship between them and educators at schools. Physiotherapists were not involved in the assessment of learners with the SBST and referrals were delayed. These findings concur with those from Wiklund et al. (2024) in a study exploring facilitators and barriers in interprofessional collaboration pertaining to physical activity on prescription among Swedish schools. School physiotherapists in the above-mentioned study reported being isolated and often perceived as outsiders in the schools. Similarly, the study by Skrypnyk et al. (2020) investigated collaboration of teachers with specialists and parents in supporting Children with Special Needs. The specialists included school physiotherapists and reported a lack of collaboration between them and teachers. It was reported that teachers preferred to work independently. This highlights the need for improved interprofessional collaboration between physiotherapists and teachers in school settings. Contributing factors for a lack of interprofessional collaboration are discussed next.

While there were 35 special schools in Limpopo province, the study focused on only three that only admitted learners with physical disabilities because of the availability of education physiotherapists based at the district level and at the school level. Thus, the province itself is limited to the number of physiotherapists in the education setting. The authors used a consensus agreement approach to arrive at the conclusion of the two themes that emerged from the data. The fact that we conducted a single FGD constitutes a limitation. This is because of the low number of education physiotherapists within Limpopo province. There is the risk of social desirability bias because of group dynamics as individuals may have felt pressure to conform to dominant opinions and avoid disagreements. In addition, field observations may have influenced by the author’s viewpoint and may not have reflected participants’ behaviour.