research study about inclusive education

Advertisement

Understanding the value of inclusive education and its implementation: A review of the literature

• Published: 07 September 2020
• Volume 49 , pages 135–152, ( 2020 )

Cite this article

• Anthoula Kefallinou 1 ,
• Simoni Symeonidou 1 , 2 &
• Cor J. W. Meijer 1  

8580 Accesses

38 Citations

11 Altmetric

Explore all metrics

European countries are increasingly committed to human rights and inclusive education. However, persistent educational and social inequalities indicate uneven implementation of inclusive education. This article reviews scholarly evidence on inclusion and its implementation, to show how inclusive education helps ensure both quality education and later social inclusion. Structurally, the article first establishes a conceptual framework for inclusive education, next evaluates previous research methodologies, and then reviews the academic and social benefits of inclusion. The fourth section identifies successful implementation strategies. The article concludes with suggestions on bridging the gap between inclusive education research, policy, and practice.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Inclusive Education in Lebanon: An Overview of the Concept and Its Implementation

Inclusive education: Developments and challenges in South Africa

Inclusion and equity in education: Making sense of global challenges

Ainscow, M. (1999). Understanding the development of inclusive schools . London: Falmer.

Google Scholar  

Ainscow, M. (2020). Promoting inclusion and equity in education: Lessons from international experiences. Nordic Journal of Studies in Educational Policy, 6 (1), 7–16.

Ainscow, M., Booth, T., & Dyson, A. (2004). Understanding and developing inclusive practices in schools: A collaborative action research network. International Journal of Inclusive Education, 8 (2), 125–139.

Ainscow, M., Dyson, A., Goldrick, S., & West, M. (2012). Making schools effective for all: Rethinking the task. School Leadership & Management, 32 (3), 197–213.

Ainscow, M., & Sandill, A. (2010). Developing inclusive education systems: The role of organisational cultures and leadership. International Journal of Inclusive Education, 14 (4), 401–416.

Allan, J. (2014). Inclusive education and the arts. Cambridge Journal of Education, 44 (4), 511–523.

Baer, R. M., Daviso, A. W., Flexer, R. W., McMahan Queen, R., & Meindl, R. S. (2011). Students with intellectual disabilities: Predictors of transition outcomes. Career Development and Transition for Exceptional Individuals, 34 (3), 132–141.

Baker, E. T., Wang, M. C., & Walberg, H. J. (1994/95). The effects of inclusion on learning. Educational Leadership, 52 (4), 33–35.

Båtevik, F. O., & Myklebust, J. O. (2006). The road to work for former students with special educational needs: Different paths for young men and young women? Scandinavian Journal of Disability Research, 8 (1), 38–52.

Bele, I. V., & Kvalsund, R. (2015). On your own within a network? Vulnerable youths’ social networks in transition from school to adult life. Scandinavian Journal of Disability Research, 17 (3), 195–220.

Bele, I. V., & Kvalsund, R. (2016). A longitudinal study of social relationships and networks in the transition to and within adulthood for vulnerable young adults at ages 24, 29 and 34 years: Compensation, reinforcement or cumulative disadvantages? European Journal of Special Needs Education, 31 (3), 314–329.

Benz, M., Lindstrom, L., & Yovanoff, P. (2000). Improving graduation and employment outcomes of students with disabilities: Predictive factors and student perspectives. Exceptional Children, 66 (4), 509–529.

Blatchford, P., Russell, A., & Webster, R. (2012). Reassessing the impact of teaching assistants: How research challenges practice and policy . Abingdon, OX: Routledge.

Blatchford, P., Russell, A., & Webster, R. (2016). Maximising the impact of teaching assistants: Guidance for school leaders and teachers (2nd ed.). Abingdon, OX: Routledge.

Booth, T. (2009). Keeping the future alive: Maintaining inclusive values in education and society. In M. Alur & V. Timmons (Eds.), Inclusive education across cultures: Crossing boundaries, sharing ideas (pp. 121–134). Los Angeles, CA: Sage.

Campbell, C. (2011). How to involve hard-to-reach parents: Encouraging meaningful parental involvement with schools . Nottingham: National College for School Leadership.

Carlberg, C., & Kavale, K. (1980). The efficacy of special versus regular class placement for exceptional children: A meta-analysis. The Journal of Special Education, 14 (3), 295–309.

Cimera, R. E. (2010). Can community-based high school transition programs improve the cost-efficiency of supported employment? Career Development and Transition for Exceptional Individuals, 33 (1), 4–12.

Cimera, R. E. (2011). Does being in sheltered workshops improve the employment outcomes of supported employees with intellectual disabilities? Journal of Vocational Rehabilitation, 35, 21–27.

Cobb, R. B., Lipscomb, S., Wolgemuth, J., Schulte, T., Veliquette, A., Alwell, M., et al. (2013). Improving post-high school outcomes for transition-age students with disabilities: An evidence review (NCEE 201 3–4011) . Washington, DC: National Center for Education Evaluation and Regional Assistance, Institute of Education Sciences.

Cobigo, V., Ouelette-Kuntz, H., Lysaght, R., & Martin, L. (2012). Shifting our conceptualization of social inclusion. Stigma Research and Action, 2 (2), 74–84.

Council of Europe Commissioner for Human Rights (2017). Fighting school segregation in Europe through inclusive education: A position paper . rm.coe.int/fighting-school-segregationin-europe-throughinclusive-education-a-posi/168073fb65.

Council of the European Union (2018a). Council recommendation on promoting common values, inclusive education and the European dimension of teaching . https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32018H0607(01)&from=EN .

Council of the European Union (2018b). Council conclusions on moving towards a vision of a European Education Area . https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52018XG0607(01)&rid=5 .

CRPD [United Nations Committee on the Rights of Persons with Disabilities] (2016). General comment no. 4 (2016), Article 24: Right to inclusive education . https://www.refworld.org/docid/57c977e34.html .

Day, C., Gu, Q., & Sammons, P. (2016). The impact of leadership on student outcomes: How successful school leaders use transformational and instructional strategies to make a difference. Educational Administration Quarterly, 52 (2), 221–258.

de Graaf, G., Van Hove, G., & Haveman, M. (2013). More academics in regular schools? The effect of regular versus special school placement on academic skills in Dutch primary school students with Down syndrome. Journal of Intellectual Disability Research, 57 (1), 21–38.

De Vroey, A., Struyf, E., & Petry, K. (2015). Secondary schools included: A literature review. International Journal of Inclusive Education, 20 (2), 109–135.

Dessemontet, R. S., Bless, G., & Morin, D. (2012). Effects of inclusion on the academic achievement and adaptive behaviour of children with intellectual disabilities. Journal of Intellectual Disability Research, 56 (6), 579–587.

Dweck, C. (2006). Mindset: The new psychology of success. How we can learn to fulfil our potential . New York, NY: Ballantine Books.

Dyson, A., Howes, A., & Roberts, B. (2002). A systematic review of the effectiveness of school-level actions for promoting participation by all students. In Research evidence in education library . London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=276 .

Dyson, D., Howes, A., Roberts, B., & Mitchell, D. (Eds.) (2005). What do we really know about inclusive schools? A systematic review of the research evidence. In Special educational needs and inclusive education: Major themes in education . London: Routledge.

Dyssegaard, C. B., & Larsen, M. S. (2013). Evidence on inclusion. Danish clearinghouse for educational research. Copenhagen: Department of Education, Aarhus University.

Erskine, H. E., Norman, R. E., Ferrari, A. J., Chan, G. C., Copeland, W. E., Whiteford, H. A., et al. (2016). Long-term outcomes of attention-deficit/hyperactivity disorder and conduct disorder: A systematic review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 55 (10), 841–850.

European Agency for Development in Special Needs Education (2003). Inclusive education and classroom practice: Summary report . Odense, Denmark. https://www.european-agency.org/sites/default/files/inclusive-education-and-classroom-practices_iecp-en.pdf .

European Agency for Development in Special Needs Education (2013). Organisation of provision to support inclusive education – Literature review . Odense, Denmark. https://www.european-agency.org/resources/publications/organisation-provision-support-inclusive-education-literature-review .

European Agency for Special Needs and Inclusive Education (2015). Agency position on inclusive education systems . https://www.european-agency.org/sites/default/files/PositionPaper-EN.pdf .

European Agency for Special Needs and Inclusive Education (2016a). Raising the achievement of all learners in inclusive education—Literature review (A. Kefallinou, Ed.). Odense, Denmark. https://www.european-agency.org/resources/publications/raising-achievement-all-learners-inclusive-education-literature-review .

European Agency for Special Needs and Inclusive Education (2016b). Early school leaving and learners with disabilities and/or special educational needs: A review of the research evidence focusing on Europe (A. Dyson & G. Squires, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/early-school-leaving-and-learners-disabilities-andor-special-educational-0 .

European Agency for Special Needs and Inclusive Education (2017a). Early school leaving and learners with disabilities and/or special educational needs: To what extent is research reflected in European Union policies? (G. Squires & A. Dyson, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/early-school-leaving-and-learners-disabilities-andor-special-educational .

European Agency for Special Needs and Inclusive Education (2017b). Raising the achievement of all learners in inclusive education: Lessons from European policy and practice (A. Kefallinou & V. J. Donnelly, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/raising-achievement-all-learners-project-overview .

European Agency for Special Needs and Inclusive Education (2018a). Evidence of the link between inclusive education and social inclusion: A review of the literature (S. Symeonidou, Ed.). Odense, Denmark. https://www.european-agency.org/resources/publications/evidence-literature-review .

European Agency for Special Needs and Inclusive Education (2018b). Key actions for raising achievement: Guidance for teachers and leaders (V. Donnelly & A. Kefallinou, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/key-actions-raising-achievement-guidance-teachers-and-leaders .

European Agency for Special Needs and Inclusive Education (2018c). Supporting inclusive school leadership: Literature review (E. Óskarsdóttir, V. J. Donnelly and M. Turner-Cmuchal, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/supporting-inclusive-school-leadership-literature-review .

European Agency for Special Needs and Inclusive Education (2019a). Preventing school failure: A review of the literature (G. Squires & A. Kefallinou, Eds.). Odense, Denmark. https://www.european-agency.org/resources/publications/preventing-school-failure-literature-review .

European Agency for Special Needs and Inclusive Education (2019b). Preventing school failure: Examining the potential of inclusive education policies at system and individual levels (A. Kefallinou, Ed.). Odense, Denmark. https://www.european-agency.org/resources/publications/preventing-school-failure-synthesis-report .

European Union Agency for Fundamental Rights (2020). Fundamental rights report —2020. https://fra.europa.eu/sites/default/files/fra_uploads/fra-2020-fundamental-rights-report-2020_en.pdf .

Farrell, P., Alborz, A., Howes, A., & Pearson, D. (2010). The impact of teaching assistants on improving pupils’ academic achievement in mainstream schools: A review of the literature. Educational Review, 62 (4), 435–448.

Farrell, P., Dyson, A., Polat, F., Hutcheson, G., & Gallannaugh, F. (2007). Inclusion and achievement in mainstream schools. European Journal of Special Needs Education, 22 (2), 131–145. https://doi.org/10.1080/08856250701267808 .

Article   Google Scholar  

Faubert, B. (2012). A literature review of school practices to overcome school failure. OECD Education Working Paper no. 68. Paris: OECD. http://dx.doi.org/10.1787/5k9flcwwv9tk-en .

Flecha, R. (2015). Successful educational actions for inclusion and social cohesion in Europe . Cham: Springer.

Flexer, R. W., Daviso, A. W., Baer, R. M., McMahan Queen, R., & Meindl, R. S. (2011). An epidemiological model of transition and postschool outcomes. Career Development and Transition for Exceptional Individuals, 34 (2), 83–94.

Florian, L., & Black-Hawkins, K. (2011). Exploring inclusive pedagogy. British Educational Research Journal, 37 (5), 813–828.

Francis, B., Archer, L., Hodgen, J., Pepper, D., Taylor, B., & Travers, M. C. (2017). Exploring the relative lack of impact of research on ‘ability grouping’ in England: A discourse analytic account. Cambridge Journal of Education, 47 (1), 1–17.

Fullan, M. (2002). The change. Educational Leadership, 59 (8), 16–20.

Gill, M. (2005). The myth of transition: Contractualizing disability in the sheltered workshop. Disability & Society, 20 (6), 613–623.

Göransson, K., & Nilholm, C. (2014). Conceptual diversities and empirical shortcomings—A critical analysis of research on inclusive education. European Journal of Special Needs Education, 29 (3), 265–280.

Gross, J. M. S., Haines, S. J., Hill, C., Francis, G. L., Blue-Banning, M., & Turnbull, A. P. (2015). Strong school–community partnerships in inclusive schools are “part of the fabric of the school… we count on them”. School Community Journal, 25 (2), 9–34.

Haines, S. J., Gross, J. M., Blue-Banning, M., Francis, G. L., & Turnbull, A. P. (2015). Fostering family–school and community–school partnerships in inclusive schools: Using practice as a guide. Research and Practice for Persons with Severe Disabilities, 40 (3), 227–239.

Harris, A. (2012). Leading system-wide improvement. International Journal of Leadership in Education, 15 (3), 395–401.

Hattie, J. A. C. (2009). Visible learning: A synthesis of 800+ meta-analyses on achievement . Abingdon, OX: Routledge.

Hehir, T., Grindal, T., Freeman, B., Lamoreau, R., Borquaye, Y., & Burke, S. (2016). A summary of the evidence on inclusive education . Cambridge: ABT Associates.

Hill, N. E., & Tyson, D. F. (2009). Parental involvement in middle school: A meta-analytic assessment of the strategies that promote achievement. Developmental Psychology, 45 (3), 740–763.

Jeynes, W. H. (2005). A meta-analysis of the relation of parental involvement to urban elementary school student academic achievement. Urban Education, 40 (3), 237–269.

Jeynes, W. H. (2007). The relationship between parental involvement and urban secondary school student academic achievement: A meta-analysis. Urban Education, 42 (1), 82–110.

Kalambouka, A., Farrell, P., Dyson, A., & Kaplan, I. (2007). The impact of placing pupils with special educational needs in mainstream schools on the achievement of their peers. Educational Research, 49 (4), 365–382.

Kinsella, W., & Senior, J. (2008). Developing inclusive schools: A systemic approach. International Journal of Inclusive Education, 12 (5–6), 651–665.

Kools, M., & Stoll, L. (2016). What makes a school a learning organisation? OECD Education Working Paper no. 137. Paris: OECD. https://doi.org/10.1787/5jlwm62b3bvh-en .

Kvalsund, R., & Bele, I. V. (2010a). Students with special educational needs—Social inclusion or marginalisation? Factors of risk and resilience in the transition between school and early adult life. Scandinavian Journal of Educational Research, 54 (1), 15–35.

Kvalsund, R., & Bele, I. V. (2010b). Adaptive situations and social marginalization in early adult life: Students with special educational needs. Scandinavian Journal of Disability Research, 12 (1), 59–76.

Lang, R., Kett, M., Groce, N., & Trani, J. F. (2011). Implementing the United Nations Convention on the rights of persons with disabilities: Principles, implications, practice and limitations. ALTER-European Journal of Disability Research/Revue Européenne de Recherche sur le Handicap, 5 (3), 206–220.

Lin-Siegler, X., Dweck, C. S., & Cohen, G. L. (2016). Instructional interventions that motivate classroom learning. Journal of Educational Psychology, 108 (3), 295.

Looney, J. W. (2011). Integrating formative and summative assessment: Progress toward a seamless system? OECD Education Working Paper no. 58. Paris: OECD.

Loreman, T., Forlin, C., & Sharma, U. (2014). Measuring indicators of inclusive education: A systematic review of the literature. Measuring Inclusive Education, 3, 165–187.

Lunt, N., & Thornton, P. (1994). Disability and employment: Towards an understanding of discourse and policy. Disability & Society, 9 (2), 223–238.

Mitchell, D. (2014). What really works in special and inclusive education: Using evidence-based teaching strategies . London: Routledge.

Muskin, J. A. (2015). Student learning assessment and the curriculum: Issues and implications for policy, design and implementation. In-Progress Reflection no. 1. Geneva: UNESCO International Bureau of Education (IBE).

Myklebust, J. O. (2006). Class placement and competence attainment among students with special educational needs. British Journal of Special Education, 33 (2), 76–81.

Myklebust, J. O. (2007). Diverging paths in upper secondary education: Competence attainment among students with special educational needs. International Journal of Inclusive Education, 11 (2), 215–231.

Myklebust, J. O., & Båtevik, F. O. (2005). Economic independence for adolescents with special educational needs. European Journal of Special Needs Education, 20 (3), 271–286.

Myklebust, J. O., & Båtevik, F. O. (2014). Economic independence among former students with special educational needs: Changes and continuities from their late twenties to their mid-thirties. European Journal of Special Needs Education, 29 (3), 387–401.

OECD (2012). Equity and quality in education: Supporting disadvantaged students and schools . Paris: OECD.

Oh-Young, C., & Filler, J. (2015). A meta-analysis of the effects of placement on academic and social skill outcome measures of students with disabilities. Research in Developmental Disabilities, 47, 80–92.

Pagán, R. (2009). Self-employment among people with disabilities: Evidence for Europe. Disability & Society, 24 (2), 217–229.

Pallisera, M., Vilà, M., & Fullana, J. (2012). Beyond school inclusion: Secondary school and preparing for labour market inclusion for young people with disabilities in Spain. International Journal of Inclusive Education, 16 (11), 1115–1129.

Priestley, M. (2000). Adults only: Disability, social policy and the life course. Journal of Social Policy, 29 (3), 421–439.

Rea, P., Mclaughlin, V., & Walther-Thomas, C. (2002). Outcomes for students with learning disabilities in inclusive and pullout programs. Exceptional Children, 68 (2), 203–223.

Rowe, N., Wilkin, A., & Wilson, R. (2012). Mapping of seminal reports on good teaching (NFER Research Programme: Developing the Education Workforce) . Slough: National Foundation for Educational Research.

Ruijs, N. M., & Peetsma, T. T. D. (2009). Effects of inclusion on students with and without special educational needs reviewed. Educational Research Review, 4 (2), 67–79. https://doi.org/10.1016/j.edurev.2009.02.002 .

Salend, S. J., & Garrick Duhaney, L. M. (1999). The impact of inclusion on students with and without disabilities and their educators. Remedial and Special Education, 20 (2), 114–126.

Sebba, J., Brown, N., Steward, S., Galton, M., & James, M. (2007). An investigation of personalised learning approaches used by schools . Nottingham: Department for Education and Skills Publications.

Shandra, C. L., & Hogan, D. (2008). School-to-work program participation and the post-high school employment of young adults with disabilities. Journal of Vocational Rehabilitation, 29 (2), 117–130.

Sharma, U., & Salend, S. J. (2016). Teaching assistants in inclusive classrooms: A systematic analysis of the international research. Australian Journal of Teacher Education, 41 (8), 118–134.

Simplican, S. C., Leader, G., Kosciulek, J., & Leahy, M. (2015). Defining social inclusion of people with intellectual and developmental disabilities: An ecological model of social networks and community participation. Research in Developmental Disabilities, 38 , 18–29.

Skjong, G., & Myklebust, J. O. (2016). Men in limbo: former students with special educational needs caught between economic independence and social security dependence. European Journal of Special Needs Education, 31 (3), 302–313.

Swann, M., Peacock, A., Hart, S., & Drummond, M. J. (2012). Creating learning without limits . Maidenhead: Open University Press.

SWIFT [Schoolwide Integrated Framework for Transformation] (2017). Equity as a basis for inclusive educational systems change, research to practice brief . Lawrence, KS: Sailor Wayne.

Symeonidou, S., & Mavrou, K. (2019). Problematising disabling discourses on the assessment and placement of learners with disabilities: Can interdependence inform an alternative narrative for inclusion? European Journal of Special Needs Education, 35 (1), 70–84.

Szumski, G., Smogorzewska, J., & Karwowski, M. (2017). Academic achievement of students without special educational needs in inclusive classrooms: A meta-analysis. Educational Research Review, 21, 33–54.

UNESCO (2009). Policy guidelines on inclusion in education . Paris: UNESCO. https://unesdoc.unesco.org/ark:/48223/pf0000177849 .

UNESCO (2017). A guide for ensuring inclusion and equity in education . Paris: UNESCO. https://unesdoc.unesco.org/ark:/48223/pf0000248254 .

UNICEF (2017). Inclusive education: Including children with disabilities in quality learning: What needs to be done? https://www.unicef.org/eca/sites/unicef.org.eca/files/IE_summary_accessible_220917_brief.pdf .

United Nations (2006). Convention on the rights of persons with disabilities . www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html .

United Nations (2015). Transforming our world. The 2030 agenda for sustainable development . https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf .

Vescio, V., Ross, D., & Adams, A. (2008). A review of research on the impact of professional learning communities on teaching practice and student learning. Teaching and Teacher Education, 24 (1), 80–91.

Waldron, N. L., & McLeskey, J. (2010a). Inclusive school placements and surplus/deficit in performance for students with intellectual disabilities: Is there a connection? Life Span and Disability, 13 (1), 29–42.

Waldron, N. L., & McLeskey, J. (2010b). Establishing a collaborative school culture through comprehensive school reform. Journal of Educational and Psychological Consultation, 20 (1), 58–74.

Download references

Author information

Authors and affiliations.

European Agency for Special Needs and Inclusive Education, Østre Stationsvej 33, 5000, Odense C, Denmark

Anthoula Kefallinou, Simoni Symeonidou & Cor J. W. Meijer

Department of Education, University of Cyprus, P.O. Box 20537, 1678, Nicosia, Cyprus

Simoni Symeonidou

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Anthoula Kefallinou .

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The development of the article was supported by the European Agency for Special Needs and Inclusive Education.

About this article

Kefallinou, A., Symeonidou, S. & Meijer, C.J.W. Understanding the value of inclusive education and its implementation: A review of the literature. Prospects 49 , 135–152 (2020). https://doi.org/10.1007/s11125-020-09500-2

Download citation

Published : 07 September 2020

Issue Date : November 2020

DOI : https://doi.org/10.1007/s11125-020-09500-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Inclusive education
• Academic outcomes
• Social inclusion
• Inclusive practice
• Find a journal
• Publish with us
• Track your research

CONCEPTUAL ANALYSIS article

The dilemma of inclusive education: inclusion for some or inclusion for all.

• 1 Institute of Education, University of Tartu, Tartu, Estonia
• 2 Research Department, Haute Ecole Pédagogique BEJUNE, Biel/Bienne, Switzerland
• 3 Faculty of Philosophy, University of Belgrade, Belgrade, Serbia

In this paper, we intend to consider different understandings of inclusive education that frame current public and professional debates as well as policies and practices. We analyze two – somewhat opposing – discourses regarding inclusive education, namely, the “inclusion for some” – which represents the idea that children with special needs have a right to the highest quality education which can be delivered by specially trained staff, and the “inclusion for all” – which represents the idea that all children regarding their diverse needs should have the opportunity to learn together. To put the two discourses in a dialogical relation, we have reconstructed the inferential configurations of the arguments of each narrative to identify how the two definitions contribute to position children with and without special needs and their teachers. The results show the possibilities to bridge the two narratives, with respect to the voices they promote or silence, the power relations they constitute, and the values and practices they enact or prevent.

Introduction

Inspired by social justice ideas, the Convention on the Rights of the Child ( UN, 1989 ) and the Salamanca Statement ( UNESCO, 1994 ), many European countries have developed policies and implemented practices to promote inclusive education ( Arcidiacono and Baucal, 2020 ; Nelis and Pedaste, 2020 ). Consequently, more children with special education needs 1 are nowadays learning with their peers in mainstream schools and the number of special schools has decreased. Although this is a trend in different countries in Europe and in the Global North, there are several challenges. Most notably, there is still no clear understanding of inclusive education. Researchers, policy makers, and teacher educators have diverse understandings ( Haug, 2017 ; Van Mieghem et al., 2018 ; Kivirand et al., 2020 ), which range from the idea that special education is itself a form of inclusive education, to the observation that all children are, for the majority, learning together in an inclusive setting ( Ainscow and Miles, 2008 ; Hornby, 2015 ; Kivirand et al., 2020 ). Magnússon (2019) has concluded that the “implementations, interpretations and definitions of the concept vary greatly both in research and in practice, between countries and even within them” ( ibid , p. 678).

These different discourses are present in several societies, but the debates are more heated in contexts which more recently have started to implement inclusive education practices, such as Eastern Europe and former Soviet countries ( Florian and Becirevic, 2011 ; Stepaniuk, 2019 ). One of the reasons for so many challenges in the latter context is the past experience of a strongly segregated educational system. This historical context is illuminated in the views of teachers, parents, and the general public.

In this paper, we will analyze two – somewhat opposing – discourses regarding inclusive education encapsulating two positions that are in the core of many current debates about inclusive education. The first one (“inclusion for some”) represents the idea that children with special needs have a right to highest quality education which can be best delivered by specially trained staff in a specialized and often segregated environment, while the second one (“inclusion for all”) represents the idea that all children regarding their diverse needs should have the equal opportunity to learn together in a regular education setting.

In this paper, we are going to put the two discourses in a dialogical relation. Through an argumentative analysis based on the reconstruction of the inferential configurations of arguments, we intend to identify how the two definitions contribute to position children (with and without special needs) and teachers, whose voices they promote and whose voices are silenced, what power relations they constitute, and what values and practices they enact or prevent. The possibility to map out the reasoning beyond these arguments is discussed as the starting point for bridging the existing conceptions about inclusive education. Prior to introducing the two narratives, we introduce briefly the background of inclusive education in Estonia which forms the context of the current study.

Inclusive Education in Estonia

Similarly to many Eastern European countries, Estonia has a long special education tradition, which is influencing acceptance of the principles and the actual practices of inclusive education. These principles have been established at the legislative level in Estonia since 2010, most notably the law states that students with special needs have the right for studying in their schools of residence with their peers ( Basic Schools and Upper Secondary Schools Act, 2010 , 2019 ). In accord with the changes in the legislative framework, the number of pupils with special educational needs in mainstream schools has increased; however, another phenomenon has appeared – the number of students enrolled in special classes in mainstream schools has also increased ( Räis et al., 2016 ). These special classes are often taught by teachers of special education and not by regular teachers. Although many school leaders understand the need for inclusive education, their main concern is a lack of availability of support specialists – including special needs teachers, speech therapists, and phycologists ( Räis and Sõmer, 2016 ). Although the expertise of support specialists is highly valued in Estonian schools and kindergartens, more and more teachers have recognized the importance of their own professional development related to supporting diverse learners. For example, the comparison of TALIS 2013 and TALIS 2018 survey data ( OECD, 2020 ) showed that teachers’ participation in professional development activities related to supporting diverse learners has significantly increased in Estonia and at the same time teachers indicated that training in this area is for them still the largest need for professional development. Consequently, diverse in-service training courses are available for teachers. An analysis of the course content at one of the major universities in Estonia providing teacher education showed that the core content of these courses has tended to focus on didactical methods of teaching students with special educational needs rather than on strategies of inclusive pedagogy. However, more recent in-service courses have emphasized social justice, possibilities for participation, and inclusive pedagogies as well (e.g., Kivirand et al., 2021 ). This brief overview illuminates that very different perspectives and practices are present in Estonia. We will explore these in more detail in the next sections.

Two Discourses of Inclusive Education

Inclusion for some.

There have been several articles published in 2020 in Estonian national newspapers arguing that inclusive education is a dream or ideology that does not take into account actual circumstances of reality. In one of such articles ( Ehala, 2020 ), a university professor, who regularly writes about education, cites a recent study conducted in Estonia on the added value of education on children’s cognitive abilities. The study showed that 80% of the children’s knowledge and skills can be explained by individual abilities and home background, and only 20% by the influence of school. The professor argued that children with physical disabilities could be included, but it is problematic to include children who have been raised according to very different principles or who have significant cognitive disabilities. He specified that inclusive education would only be possible in societies which are very homogeneous, most importantly regarding child raising practices and family values. This would result in a situation where there are few differences between children’s behaviors and are used for similar norms and regulations. He pointed out as: “Inclusive education is a mirage created by our sense of justice, but its implementation puts young people in a learning environment that is not in line with their home preparation and developmental needs. They are just too special and different so that everyone could learn together in a way that no one suffers.” He concluded that we simply need different kinds of environments for different children.

Many of these ideas are also pointed out by some teachers. In 2019, a new educational strategy was prepared for Estonia and in this process, several meetings were held in different places across the country. Many teachers were critical regarding the recent policy reform related to inclusive education. On the one hand, teachers are concerned about the learning process and outcomes of the regular children and, on the other hand, their own preparation to support students with special needs. Working with special needs students requires specialized knowledge and expert skills, which many teachers simply do not have. Similar to these views, a group of master students wrote an article in a national newspaper in June 2020 ( Kupper et al., 2020 ) where they stated that although they support the idea of inclusive education, it is only justified if it is carefully organized and sufficient support is available. They also added that inclusive education is certainly not suitable for students with more severe special needs. They point out as: “Inclusion may not be effective in case the teacher does not receive enough support and guidance regarding how to work with a special needs student and the rest of the class at the same time. If, figuratively speaking, the teacher’s strength does not overcome the situation, then the increase in behavioral problems, drop-out rates and developmental delays are real dangers.”

Moreover, this article also shed light into the perspective of parents of special needs students. They argued as: “A familiar and close-to-home school with a teacher assistant or support specialist does not outweigh the assurance that the child’s safety and well-being is guaranteed throughout the day and is cared for by a sufficient number of professionals.” Moreover, “Studying at a school close to home may not always be possible if the child needs a much more complex service due to his or her situation, including, for example, special therapies and additional activities. If such a solution is not offered during the school day, parents must find the time and opportunity, usually at the expense of working hours, to provide the necessary service to the child. Thus, the difficulty of the whole situation lies with the parents, who, despite the child’s special needs, must be able to maintain optimism, offer equal care and love to the other children of the family in other words, try to live as normal a life as possible while maintaining the ability to work, good relations with the employer and income and one’s own emotional balance.”

In brief, all these perspectives argue that the development of different students will benefit from specialized learning environments and special teachers who have good expert knowledge and skills for preparing specific educational experiences for maximizing each student’s individual potential. Similar viewpoints have also been presented in the international literature: for example, Kauffman and Hornby (2020) criticized inclusive education ideology and leading scholars in the field for the unrealistic claims regarding its implementation and outcomes. They concluded as: “Appropriate instruction is by far the most important task of education for all students, including those with disabilities. Making appropriate instruction a reality for all students requires special education, including teachers with special training, rather than a generic, ‘one size fits all’ or all-purpose preparation” (p. 10).

Inclusion for All

In contrast to voices arguing for creating different learning environments for different children, scholars, policy makers, teachers, and parents in favor of inclusion for all stress, in different talks and articles, that all children in a society should have an equal right to get adequate opportunities to develop wellbeing, agency, identities, and competences in order to become capable to participate fully and equally in the society ( UNESCO, 1994 ; Ainscow and César, 2006 ; Cigman, 2007 ; Felder, 2019 ). This objective cannot be reached if some children are educated in a segregated context.

Inspired by social constructivist approaches to learning, teacher educators supporting inclusive education argue that child development depends not only on inherited capacities, but it is also constructed by shared social values, access to educational institutions, technologies (including assistive technologies), and other relevant social resources as well as quality of support provided to the child and opportunities to participate fully and equally in a community.

Teacher educators and policy makers would agree that it is true that current educational systems (schools, teachers, initial education of teachers, practices, technologies, teaching and learning materials, etc.) in many countries have been established based on an assumption that “regular” education, schools, and teachers should work only with “typical” children and other children need to be educated in a specially designed and segregated environment, that is, “special” education ( Carrington, 1999 ; Croll and Moses, 2000 ; Dyson et al., 2002 ; Radó et al., 2016 ; Zgaga, 2019 ; Koutsouris et al., 2020 ). However, they would argue that in such an environment, children cannot develop a sense of belonging nor can become full members of the society because of marginalized status and limited opportunities to grow with others ( Freeman and Alkin, 2000 ; Farrell, 2010 ; Koller et al., 2018 ). Moreover, in a special education, setting relationships, practices, and technologies tend to be adapted to their constraints instead of being designed to enable children to fully participate in education and society in spite of constraints. Similarly, parents, teachers, and kindergarten/school leaders favoring inclusive education in Estonia would argue for social justice ideas: the importance of growing up within the community and learning at a kindergarten/school close to their home. A father of a child with speech difficulties, who was contacted by an author of this article and asked why he favored his child attending a regular kindergarten instead of a specialized kindergarten, pointed out as: “I can’t distinguish my child, who has special (or rather specific) needs, from any other child. How can I agree with her being placed in a school which labels her directly and indirectly as a person who does not fit the norm? Especially when attending kindergarten, she is as special and as normal as every other child who she plays with and a child who plays with her. This should be the norm for any healthy development of a child.” Similarly, a teacher and master student ( Konetski-Ramul, 2021 ) and a head of support specialists services ( Labi, 2019 ) have argued for inclusive education in articles published in the national teachers’ newspaper in Estonia. In these articles, the authors urged for not separating students with special needs easily to special classes or special schools, e.g., Labi (2019) pointed out as: “If today we separate one quarter of children for fear that their involvement could negatively affect the well-being of the other three quarters of children, then as adults there are people in the labor market, in families, or even in the queue at the store, who cannot cope with each other. It is more sustainable to grow together, learn from each other and cope with each other throughout the school journey.” Many parents of special needs children would also argue that the most important goal for them is for their children to adapt to society and learn to live with other people. To illustrate this idea, a mother of a young child with multiple disabilities pointed out during a public speech in Estonia that her family’s “goal is to support him so he would become a taxpayer.”

In order to have an equal opportunity, all children need to be educated in regular education that have conditions, capacities, and resources to be able to adapt to the children needs, capacities, and constraints. Following this, in a case when a school, teachers, discourses, practices, and technologies are not aligned with the needs of some students, it cannot be an acceptable reason for the exclusion of the child, but for adapting the education to the child and his/her learning and developmental needs ( Farrell, 2010 ; Arcidiacono and Baucal, 2020 ).

The majority of Estonian teachers has adopted learner-centered views about education as reported in international comparison studies, such as TALIS 2013, 2018, and a smaller group has also learned to implement these in practice (many Estonian teachers are still rather traditional and subject-oriented in their teaching practice; OECD, 2014 , 2020 ; see also Leijen and Pedaste, 2018 ). Teachers who have accepted the child-centered view might not consider a class as a unified mass, instead they might perceive children anyway as special and different, notice variety, individual differences and adapt their teaching accordingly ( Breeman et al., 2015 ). Following, adapting their teaching for a child with special needs would not be so different from any other adaptation of teaching for the child’s needs and interests. While discussing the possible challenges of inclusive education during an in-service course taught by the first author of the paper in autumn 2019, a teacher pointed out that “it is very interesting and positively challenging to teach a group of students with a large variety. These are (my) favorite classes.” This indicates that teachers might find diversity and variety enriching for themselves as professionals.

Goal of the Paper

The aim of this paper is to show, through the conceptual analysis of the two above-mentioned discourses, that it is possible to put these two narratives in a dialogical relation to identify their contribution to position children (with and without special needs) and teachers with respect to the voices they promote or silence about inclusive education, the power relations they constitute, and the values and practices they enact or prevent.

Materials and Methods

We propose an analytical approach based on the argumentum model of topics (AMT) that aims at systematically reconstructing the inferential configuration of arguments; namely, the deep structure of reasoning underlying the connection between a standpoint and the argument(s) in its support ( Rigotti and Greco Morasso, 2009 ). The general principle underlying the reconstruction of the inferential configuration of argumentation is that of finding those implicit premises that are necessary for the argumentation to be valid.

In the AMT, two fundamental components should be distinguished when bringing to light the inferential relation binding the premises to the conclusion of an argumentation. First, an argument envisages a topical component, which focuses on the inferential connection activated by the argument, corresponding to the abstract reasoning that justifies the passage from the premises (arguments) to the conclusion (standpoint). The inferential connection underlying the argument is named with the traditional term maxim. Maxims are inferential connections generated by a certain semantic ontological domain named locus. Second, an endoxical component, which consists of the implicit or explicit material premises shared by the discussants that, combined with the topical component, ground the standpoint. These premises include endoxa, i.e., general principles, values, and assumptions that typically belong to the specific context, and data, basically coinciding with punctual information and facts regarding the specific situation at hand and usually representing the part of the argument that is made explicit in the text ( Rigotti and Greco Morasso, 2011 ). Despite its particular concern for the inferential aspects of argumentation, the AMT accounts not only for the logical aspects of the argumentative exchange, but also for its embeddedness in the parties’ relationship, and thus proves to be particularly suited for the argumentative analysis of public discourses.

In the present paper, we refer to the AMT to reconstruct the inferential structure of some arguments proposed by the two above-mentioned discourses, i.e., the type of reasoning underneath the arguments. In this sense, the model is assumed to be a guiding framework for the analysis, since it provides the criteria for the investigation of argumentative positions and for the identification of different components of each discourse. It is used to highlight points of contention and dialogue, as well as the explicit and implicit arguments advanced by the involved sustainers of the two narratives. The application of this analytic method in the study of public discourses, such as the role of inclusive education, is assumed to reinforce the possibilities of understanding how people discursively position themselves as involved partners in the management of the selected issue, namely, inclusive education.

According to the AMT, the following analytical components must be identified as: the maxim on which the argumentation is based and the relative locus at work; the endoxon, i.e., the premises shared by the discussants, and the datum, i.e., the punctual information and facts regarding the specific situation at hand (usually representing the part of the argument that is made explicit in the text) to which the argument is linked. The results of the AMT’s reconstruction will be represented through graphical tools adopted to show the above-mentioned components.

Generally speaking, the different arguments used by the parties can be viewed in terms of a constellation of features ( Goodwin, 2006 ), including various interactional structures connected to aims, perceptions, directives, accounts, etc. In the present paper, we will limit our conceptual analysis of two narratives to some elements that are essential for the aim of the study, although we are aware that this is a partial choice. Accordingly, the locus at work for the maxims will not appear in our schemes and only the arguments sustaining the main ideal view of each narrative and the presumed positions associated with the selected arguments will be presented.

In the next sections, we propose two examples of AMT based on selected arguments for each discourse.

Reconstructing the Inferential Structure of the First Discourse Argument

The first discourse (“inclusion for some”) proposes as a standpoint that students with special needs require specialized educational settings. The argument advanced to sustain this position is that specialized settings are accommodating to the student’s capacities and needs.

Figure 1 shows the representation of such an argument based on the AMT. On the right hand of the diagram, the inferential principle, i.e., the maxim, on which the argumentation is based is specified as: “to provide a beneficial property to the student, it is required to adopt a system that guarantees this beneficial property.” The AMT representation allows consideration of the contextual premises that are implicitly or explicitly used in argumentation. This may be found on the left hand of the diagram, where a second line of reasoning is developed that supports the former one. This is why the first conclusion on the left becomes the minor premise on the right. In this way, the crossing of contextual and formal premises that is characteristic of argumentation is accounted for in the AMT. The endoxon refers in this case to common knowledge about the main idea of the accommodation principles: “To accommodate to the student’s capacities is a beneficial property.” The datum (“Specialized settings are accommodating to student capacities”) combined with the endoxon produces the conclusion that “Specialized settings have beneficial properties.”

Figure 1 . AMT-based reconstruction of the first discourse argument.

In the first discourse, if the accommodation is considered beneficial for a student with special needs, and if specialized settings are recognized as environments that can guarantee a process of accommodation, then it is valuable to require that students with special needs should be placed in specialized settings.

Reconstructing the Inferential Structure of the Second Discourse Argument

The second discourse (“inclusion for all”) proposes as a standpoint that all students require regular educational settings. The argument advanced to sustain this position should be summarized as follows: Regular settings offer equal opportunities to all students. Figure 2 shows the representation of such an argument based on the AMT.

Figure 2 . AMT-based reconstruction of the second argument.

On the right hand of the diagram, the inferential principle, i.e., the maxim, on which the argumentation is based is specified as: “if the offer of equal opportunities is an important educational goal, and there is a way to guarantee such a goal, then this way should be adopted.” Concerning the contextual premises that are implicitly or explicitly used in argumentation, the endoxon refers to common knowledge about the main idea of the educational goals: “Education should offer equal opportunities to all students.” The datum (“Regular settings offer equal opportunities to all students”) combined with the endoxon produces the conclusion that “All students require regular educational settings.”

The discourse indicates that if offering equal opportunities to all students (by exposing them to similar conditions) are considered an important educational goal, and if regular settings are recognized as environments that can guarantee to offer equal opportunities, then it is valuable to require that all students be placed in regular settings.

Implicit in Two Discourses

The models referring to the two discourses about inclusive education are showing in both cases reasonable arguments advanced to sustain the positions and the perspectives they intend to promote. For each discourse, accountable elements are proposed to show the pertinence of the approach and to sustain the idea of education that is considered as adequate for society.

The two discourses position the children as the main key-players in the educational endeavor: In fact, inclusive education should sustain the requirement for appropriate settings (special and regular) that are able to allow students (with and without special needs) to develop their capacities and to become members of the society. In this sense, the two discourses share a similar preoccupation and aim to play in the service of children’s development. However, it is also true that both discourses promote reasons that seem to position the children within different frames, for example, in terms of temporality. In fact, the first discourse (“inclusion for some”) focuses on the need to guarantee a process of accommodation to the children’s needs in order to guarantee a system that allows students to develop their capacities. In this sense, a short-term perspective is promoted, because the goal behind the sustained discourse is to be able to act adequately in the “here and now” of the contingent situations. By contrast, the second discourse (“inclusion for all”) advances the idea that offering equal opportunities to all students constitute the main goal of education. In this sense, a long-term perspective is promoted in terms of capacity to ensure the conditions that will guarantee the future realization of students as full members of the society. These elements, connecting the two discourses along a temporal dimension, will be discussed in the next section of the paper, as well as the implications in terms of positions that children and teachers should take according to their voice, the power relations that are connected to this, and the values that are enacted or prevented.

Although we have identified these two discourses in the current ongoing debate on inclusive education in Estonia, they encapsulated long lasting conflicting positions that can be recognized in many countries and communities. Moreover, these discourses also reflect political, policy, cultural, and identity “wars” that are present in many countries since the Salamanca Statement ( UNESCO, 1994 ), calling societies to put forward the inclusive education on their education policy agenda. The “war” on inclusive education is related to the fact that educational policies are inherently political, since they always involve values, interests, power games, choices, prioritization, and allocation of resources ( Barton, 1997 ). Moreover, different sides propose different values and ideals; that is, they postulate different desired outcomes and different visions of the future citizen ( Magnússon, 2019 ). However, it is worth noting that current conflicting debates are just another step in an historical process of a struggle of regular schools between exclusion and inclusion of children and youth perceived and treated as different from dominant groups, in relation to various characteristics, such as socioeconomic status, gender, and race ( Boroson, 2017 ). In fact, the meaningful inclusion of individuals who are different from the majority has been fraught in many ways. The evolution of educational systems with respect to the inclusion of students who are different in terms of race, gender, or ability was considered to be of questionable worth, an obstacle on teachers’ time and a threat to the status quo ( West, 2000 ). Although today education in mainstream schools is guaranteed ( Snyder et al., 2016 ), many educators and families still have a concern or even fear the “intrusion” into general education classrooms of students who are different than majority in terms of personal characteristics (physical, socioemotional, or cognitive) or ethnic, cultural, and socioeconomic background ( Boroson, 2017 ). By considering the two discourses highlighted in this paper, we can consider that, on the one hand, those who are pro-specialist settings would argue that segregation works in favor of child with special education needs; on the other hand, those who view inclusion as a social justice issue might consider specialist settings as segregating like other forms of educational and historical segregation (e.g., gender and faith).

Two conclusions could be made from this. First, as with previous inclusion “wars,” the current one will be resolved when conflicting sides will manage to dialogize their conflicting positions. The second conclusion is that the current “war” is just an episode in a continuous historical story on social inclusion, so after that one, there will be some new inclusion “war” that might not be imaginable from the perspective of our current experience and knowledge. Having said that, our main objective is to identify their frameworks in terms of assumptions, power relationships, voices, rights, and values, as well as priorities and practices in order to propose a bridging between them and to dialogize current relation that is dominantly conflicting.

As it is already said, both discourses put a stress on children’s needs and recognize the duty of the education system to provide adequate conditions for their education. However, there is also an important difference in relation to the position and rights of children with special needs. The “inclusion for some” discourse recognizes the rights of children with special needs, but at the same time, it advocates that their rights need to be limited by practical constraints related to the implementation of the full inclusion in the regular school. In this way, this discourse gives a voice to children with special needs, but also to educational practitioners who are in many occasions not competent enough nor have adequate conditions and resources to ensure quality education to children with special needs in regular schools. Although both voices are represented in the discourse “inclusion for some,” it prioritizes somewhat the voice of educational practitioners. On the other hand, the “inclusion for all” discourse privileges the voice of children with special needs and their rights that need to be served by the society in the same way as the rights of all other citizens. It also recognizes practical and policy constraints at the level of the education system, schools, and practitioners, but it does not position their voices and concerns at the same level as the rights of children with special needs. Thus, it advocates that schools and practitioners ought to be equipped by adequate policies, training, and resources to be capable of serving the rights of children with special needs for the quality education in inclusive conditions.

Difference in prioritization of voices is related to the difference in basic values and distribution of power. The discourse “inclusion for some” suggests that the current potential of the education system, schools, and teachers should be put at the first place and that rights of children with special needs should be realized progressively following the improvement of the potential of the education system to ensure high quality inclusive education. In this way, it gives more power to the majority, to the education system, and practitioners since it calls that rights on quality education need to be aligned with the potential of the education system to serve this right. However, in this way, it also creates an opportunity for using current lack of capacities in regular schools for ensuring inclusive education as a reason for postponing the realization of rights of children with special needs. If for some reason there is no political will or if the majority of educational practitioners is not willing to transform their beliefs, competences, and practices, then it might effectively maintain current conditions for some time (potentially endlessly). On the other hand, the “inclusion for all” discourse privileges the right of children with special needs over current conditions and lack of capacities and resources advocating that the latter needs to be transformed as quickly as possible. Consequently, it places higher power to the children with special needs and their fundamental rights than to eventual practical and political constraints of various kinds. Nevertheless, it might be related to some unintended negative consequence in the implementation of inclusive education. Forcing a full implementation of inclusive education when regular schools and practitioners are not prepared adequately might result in various negative consequences. These consequences might be counterproductive in terms of defending rights of children with special needs and effectively postpone the implementation of inclusive education. Therefore, in spite of differences in terms of basic values and power relations putting forward in two discourses, it is possible to identify a common interest. It is related to the successful implementation of inclusive education and the minimization of risk both for children with special needs and for education practitioners and schools including children without special needs.

Concerning the implementation of inclusive education, there are two opposite perspectives creating a major conflict between the two discourses. Being grounded on previous founding ideas, the “inclusion for some” advocates for some form of special education provision mostly in separate and specialized schools, while the “inclusion for all” discourse stands up for desegregation and full inclusion of children with special needs in regular schools. According to UNESCO (2020) , the implications in developing forms of education that are effective for all children are related to three levels: educational (to develop ways of teaching that respond to individual differences and that therefore benefit all children), social (to change attitudes to difference by educating all children within a non-discriminatory society), and economic (it is likely to be less costly to establish and maintain schools).

These positions reflect their difference in terms of future priorities ( Ydo, 2020 ). The “inclusion for some” discourse is focused to optimize provision of education as an ultimate goal. Hence, it prefers providing education in a specialized environment since it enables full accommodation to specific educational needs of children attending special schools. In this way, children with special needs might have best opportunities to learn in their way and to achieve education goals. On the other hand, the discourse “inclusion for all” calls for a more comprehensive ultimate goal. These goals ought to be to empower and enable children with special needs to become active citizens who will participate fully and equally in the society and to pursue their own life projects. Projecting this ultimate goal for education of children with special needs, the discourse “inclusion for all” pursues a full inclusion in regular schools since education in segregated institutions prevents children with special needs from becoming full members of the society. This difference in terms of the ultimate goal of education of children with special needs might seem as unresolvable. It also can make sense why the “war” between the two discourses and the communities organized upon them is very frequently concentrated on the special school issue. However, in our view, this opposition might be bridged by relating the two discourses to different time perspectives (as it has been already mentioned earlier). The common ground might be that all children with special needs are fully included in regular schools in order to enable and empower them to become active and equal future citizens, but to keep special schools and special education teachers as additional resources where different students from regular schools can get different forms of supplementary support according to their needs occasionally or in a longer period. This approach would require establishing a good and productive professional collaboration between regular and special schools as resource centers, as well as between teachers from regular schools and special education teachers. Based on a good professional collaboration and complementary professional competences of all teachers (including special education teachers), children with special needs would get an additional support during classes in regular schools or when it is needed in a special school (for example, when the child needs a specialized treatment or to get additional training for using some assistive technology). It is true that this arrangement could be challenged by some practical issues and would require a modification of regular institutional organization and practices. However, it would improve opportunities for children with special needs to become competent future citizens, and for the education system and the society to become inclusive.

Furthermore, additional common ground might be related to the pace of the long-term implementation of inclusive education. The discourse “inclusion for all” provides a strong argument why inclusive education is the principal way to empower and enable children with special needs to grow up with a feeling that they are equal members of the society and with a dignity to take part fully in the life of the community so to pursue their life projects and contribute to the society. However, the discourse “inclusion for some” pinpoints in a good way that journey toward the ultimate goal cannot be straightforward nor quick because it is related to the transformative potential of the society and the education system imposing important constraints. Although these constraints are malleable and temporary, they need to be addressed in any implementation plan for inclusive education. Therefore, we assume that the two discourses can be bridged in the sense that one of them crystalizes and advocates what ought to be long-term goals for the implementation of inclusive education, while the second one articulates practical constraints and barriers that need to be overcome in order to make inclusive education real.

In this paper, we utilized the AMT for analyzing two somewhat opposing discourses regarding inclusive education, namely, the “inclusion for some” and “inclusion for all.” We reconstructed the inferential configurations of the arguments of each narrative, identified how the two definitions contribute to position children with and without special needs and their teachers. The results showed several similarities and differences between the discourses. We also identified some possibilities to bridge the two narratives; most importantly, by relating to different time perspectives, these two discourses stress: “Inclusion for some,” which tends to focus on the present situation and attending to the particularities of the child, is valuable for realizing the long-term and sometimes idealistic goals of “inclusion for all” and vice versa , “inclusion for all,” which stresses participation and learning with peers, is beneficial for realizing the goals of “inclusion for some” – to maximize each child’s potential in real life – since regular schools resemble society more closely than segregated schools. Productive professional collaboration between different parties is required to realize both visions of inclusive education. We also suggest further investigations to deepen this research line in the future, through face-to-face interviews with politicians, school managers, teachers, and parents who could better delineate the different positions according to their role and involvement with children with special needs.

Author Contributions

All the authors originated the paper’s ideas and designed the conceptual analysis. ÄL was engaged in presenting the context of the study, as well as interpreting and discussing the findings and writing the conclusion. FA focused on the method, analysis, and interpretation of the narratives. AB focused mainly on interpreting and discussing the findings. All authors approved the final version of the manuscript to be published.

This research was conducted with financial support by the European Regional Development Fund under Grant Enhancement of Research and Development Capacity of Teacher Education Competence Centre Pedagogicum [grant no. NSVHI19074], as well as the contribution of the Research Department, University of Teacher Education BEJUNE (Switzerland).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1. ^ In line with OECD definition, in this paper, we refer to “children with special education needs” as an umbrella term indicating children who require additional resources or accommodating dominant educational practices in order to ensure equal learning opportunities to them. The term refers to children with disabilities, children with learning difficulties, and children living in disadvantage conditions ( OECD, 2007 ).

Ainscow, M., and César, M. (2006). Inclusive education ten years after Salamanca: setting the agenda. Eur. J. Psychol. Educ. 21, 231–238. doi: 10.1007/BF03173412

CrossRef Full Text | Google Scholar

Ainscow, M., and Miles, S. (2008). Making education for all inclusive: where next? Prospects 38, 15–34. doi: 10.1007/s11125-008-9055-0

Arcidiacono, F., and Baucal, A. (2020). Towards teacher professionalization for inclusive education: reflections from the perspective of the socio-cultural approach. Eesti Haridusteaduste Ajakiri. Estonian J. Edu. 8, 26–47. doi: 10.12697/eha.2020.8.1.02b

Barton, L. (1997). Inclusive education: romantic, subversive or realistic? Int. J. Incl. Educ. 1, 231–242. doi: 10.1080/1360311970010301

Basic Schools and Upper Secondary Schools Act. (2010). Riigi Teataja I, 2010,41,240. Available at: http://riigiteataja.ee/en/eli/ee/530102013042/consolide (Accessed January 03, 2021).

Google Scholar

Basic Schools and Upper Secondary Schools Act. (2019). Riigi Teataja I, 2019,120. Available at: http://riigiteataja.ee/en/eli/ee/Riigikogu/act/503062019007/consolide (Accessed January 03, 2021).

Boroson, B. (2017). Inclusive education: lessons from history. Educ. Leadersh. 74, 18–23.

Breeman, L. D., Wubbels, T., van Lier, P. A. C., Verhulst, F. C., van der Ende, J., Maras, A., et al. (2015). Teacher characteristics, social classroom relationships, and children's social, emotional, and behavioral classroom adjustment in special education. J. Sch. Psychol. 53, 87–103. doi: 10.1016/j.jsp.2014.11.005

PubMed Abstract | CrossRef Full Text | Google Scholar

Carrington, S. (1999). Inclusion needs a different school culture. Int. J. Incl. Educ. 3, 257–268. doi: 10.1080/136031199285039

Cigman, R. (2007). A question of universality: inclusive education and the principle of respect. J. Philos. Educ. 41, 775–793. doi: 10.1111/j.1467-9752.2007.00577.x

Croll, P., and Moses, D. (2000). Ideologies and utopias: education professionals’ views of inclusion. Eur. J. Spec. Needs Educ. 15, 1–12. doi: 10.1080/088562500361664

Dyson, A., Howes, A., and Roberts, B. (2002). A Systematic Review of the Effectiveness of School-Level Actions for Promoting Participation by all Students. Inclusive Education Review Group, EPPI-Centre.

Ehala, M. (2020). Tulevik on erikoolide päralt. [Future is for special schools]. Postimees. Available at: https://leht.postimees.ee/6901395/tulevik-on-erikoolide-paralt (Accessed January 03, 2021).

Farrell, M. (2010). Debating Special Education. London: Routledge.

Felder, F. (2019). Inclusive education, the dilemma of identity and the common good. Theory Res. Educ. 17, 213–228. doi: 10.1177/1477878519871429

Florian, L., and Becirevic, M. (2011). Challenges for teachers’ professional learning for inclusive education in central and Eastern Europe and the commonwealth of independent states. Prospects 41, 371–384. doi: 10.1007/s11125-011-9208-4

Freeman, S. F. N., and Alkin, M. C. (2000). Academic and social attainments of children with mental retardation in general education and special education settings. Remedial Spec. Educ. 21, 3–26. doi: 10.1177/074193250002100102

Goodwin, M. H. (2006). Participation, affect, and trajectory in family directive/response sequences. Text Talk 26, 515–543. doi: 10.1515/TEXT.2006.021

Haug, P. (2017). Understanding inclusive education: ideals and reality. Scand. J. Disabil. Res. 19, 206–217. doi: 10.1080/15017419.2016.1224778

Hornby, G. (2015). Inclusive special education: evidence-based practices for children with special needs and disabilities. British J. Special Educ. 42, 232–252. doi: 10.1111/1467-8578.12101

Kauffman, J. M., and Hornby, G. (2020). Inclusive vision versus special education reality. Educ. Sci. 10:258. doi: 10.3390/educsci10090258

Kivirand, T., Leijen, Ä., Lepp, L., and Malva, L. (2020). Kaasava hariduse tähendus ja tõhusa rakendamise tegurid Eesti kontekstis: õpetajaid koolitavate või nõustavate spetsialistide vaade [The meaning of inclusive education and factors for effective implementation in the Estonian context: A view of specialists who train or advise teachers]. Eesti Haridusteaduste Ajakiri. Estonian J. Educ. 8, 48–71. doi: 10.12697/eha.2020.8.1.03

Kivirand, T., Leijen, Ä., Lepp, L., and Tammemäe, T. (2021). Designing and implementing an in-service training course for school teams on inclusive education: reflections from participants. Educ. Sci. 11:166. doi: 10.3390/educsci11040166

Koller, D., Le Pouesard, M., and Rummens, J. A. (2018). Defining social inclusion for children with disabilities: A critical literature review. Child. Soc. 32, 1–13. doi: 10.1111/chso.12223

Konetski-Ramul, K. (2021). Kaasav haridus ehk Elevant keset tuba. [Inclusive education as an Elephant in the room.] Õpetajate Leht . https://opleht.ee/2021/02/kaasav-haridus-ehk-elevant-keset-tuba/ (Accessed January 03, 2021).

Koutsouris, G., Anglin-Jaffe, H., and Stentiford, L. (2020). How well do we understand social inclusion in education? Br. J. Educ. Stud. 68, 179–196. doi: 10.1080/00071005.2019.1658861

Kupper, B., Õun, M., Tatomir, T., and Simso, T. (2020). Haridusinnovatsioon: kaasav haridus – kas oleme ikka kõigele mõelnud? [Educational innovation: Have we really thought abouteverything?] Postimees . https://arvamus.postimees.ee/6999120/haridusinnovatsioon-kaasav-haridus-kas-oleme-ikka-koigele-moelnud (Accessed January 03, 2021).

Labi, N. (2019). Kaasavast haridusest on kasu kõigile [Inclusive education is beneficial for everyone.] Õpetajate Leht . https://opleht.ee/2019/05/kaasavast-haridusest-on-kasu-koigile/ (Accessed January 03, 2021).

Leijen, Ä., and Pedaste, M. (2018). “Pedagogical beliefs, instructional practices, and opportunities for professional development of teachers in Estonia” in The Teacher’s Role in the Changing Globalizing World. eds. H. Niemi, A. Toom, A. Kallioniemi, and J. Lavonen (Leiden, Netherlands: BRILL), 33–46.

Magnússon, G. (2019). An amalgam of ideals – images of inclusion in the Salamanca statement. Int. J. Incl. Educ. 23, 677–690. doi: 10.1080/13603116.2019.1622805

Nelis, P., and Pedaste, M. (2020). Kaasava hariduse mudel alushariduse kontekstis: süstemaatiline kirjandusülevaade [A model of inclusive education in the context of Estonian preschool education: A systematic literature review]. Eesti Haridusteaduste Ajakiri. Estonian J. Educ. 8, 138–163. doi: 10.12697/eha.2020.8.2.06

OECD. (2007). Students with Disabilities, Learning Difficulties and Disadvantages Policies. Statistics and Indicators. Paris: OECD Publishing.

OECD. (2014). TALIS 2013 Results: An International Perspective on Teaching and Learning, TALIS. Paris: OECD Publishing.

OECD. (2020). TALIS 2018 Results: Teachers and School Leaders as Valued Professionals. Vol . 2 Paris: OECD Publishing.

Radó, P., Setenyi, J., Petrović, D., Stanković, D., and Markovits, G. (2016). Formative Evaluation of Implementation of Inclusive Practices in the Education System in Serbia (2009–2014). UNICEF. https://evaluationreports.unicef.org/GetDocument?fileID=8922 (Accessed January 03, 2021).

Räis, M.-L., Kallaste, M., and Sandre, S.-L. (2016). Haridusliku erivajadusega õpilaste kaasava hariduskorralduse ja sellega seotud meetmete tõhusus. Lõppraport [Effectiveness of inclusive education arrangements and related measures for students with special educational needs. Final report]. Eesti Rakendusuuringute Keskus CENTAR [Estonian Centre for Applied Research CENTAR].

Räis, M.-L., and Sõmer, M. (2016). Haridusliku erivajadusega õpilaste kaasava hariduskorralduse ja sellega seotud meetmete tõhusus. Temaatiline raport: kaasamise tähenduslikkus [Effectiveness of inclusive education organization and support for students with special educational needs. Thematic report: The meaning of inclusion]. Eesti Rakendusuuringute Keskus CENTAR [Estonian Centre for Applied Research CENTAR].

Rigotti, E., and Greco Morasso, S. (2009). “Argumentation as an object of interest and as a social and cultural resource,” in Argumentation and Education. Theoretical Foundations and Practices. eds. N. Muller Mirza and A.-N. Perret-Clermont (New York: Springer), 9–66.

Rigotti, E., and Greco Morasso, S. (2011). Comparing the argumentum model of topics to other contemporary approaches to argument schemes: the procedural and material components. Argumentation 24, 489–512. doi: 10.1007/s10503-010-9190-7

Snyder, T. D., de Brey, C., and Dillow, S. A. (2016). Digest of Education Statistics 2014 (NCES 2016–006). Washington: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education.

Stepaniuk, I. (2019). Inclusive education in eastern European countries: a current state and future directions. Int. J. Incl. Educ. 23, 328–352. doi: 10.1080/13603116.2018.1430180

UN. (1989). Convention on the Rights of the Child. https://treaties.un.org/doc/Treaties/1990/09/19900902%2003-14%20AM/Ch_IV_11p.pdf (Accessed January 03, 2021).

UNESCO. (1994). Salamanca Statement and Framework for Action on Special Needs Education. Available at: https://unesdoc.unesco.org/ark/48223/pf0000098427 (Accessed January 03, 2021).

UNESCO (2020). “Towards inclusion in education: status, trends and challenges,” in The UNESCO Salamanca Statement 25 Years on (Paris: UNESCO).

Van Mieghem, A., Verschueren, K., Petry, K., and Struyf, E. (2018). An analysis of research on inclusive education: a systematic search and meta review. Int. J. Incl. Educ. 24, 675–689. doi: 10.1080/13603116.2018.1482012

West, J. (2000). Back to School on Civil Rights: Advancing the Federal Commitment to Leave no Child Behind. Washington: National Council on Disability.

Ydo, Y. (2020). Inclusive education: global priority, collective responsibility. Prospects 49, 97–101. doi: 10.1007/s11125-020-09520-y

Zgaga, P. (2019). “Inclusion in education: Between opportunities and limits. Introduction to the theme,” in Inclusion in Education: Reconsidering Limits, Identifying Possibilities (Berlin: Peter Lang), 7–28.

Keywords: inclusive education, special education, public discourse, argumentum model of topics, dialogue

Citation: Leijen Ä, Arcidiacono F and Baucal A (2021) The Dilemma of Inclusive Education: Inclusion for Some or Inclusion for All. Front. Psychol . 12:633066. doi: 10.3389/fpsyg.2021.633066

Received: 04 January 2021; Accepted: 16 August 2021; Published: 10 September 2021.

Reviewed by:

Copyright © 2021 Leijen, Arcidiacono and Baucal. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Äli Leijen, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Front Psychol

How Inclusive Interactive Learning Environments Benefit Students Without Special Needs

Silvia molina roldán.

1 Department of Pedagogy, Universitat Rovira i Virgili, Tarragona, Spain

Jesús Marauri

2 Faculty of Psychology and Education, University of Deusto, Bilbao, Spain

Adriana Aubert

3 Department of Sociology, University of Barcelona, Barcelona, Spain

Ramon Flecha

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Growing evidence in recent years has led to an agreement on the importance and benefits that inclusive education has for students with special educational needs (SEN). However, the extension and universalization of an inclusive approach will also be enhanced with more evidence on the benefits that inclusion has for all students, including those without SEN. Based on the existing knowledge that learning interactions among diverse students are a key component of educational inclusion, the aim of this study is to identify the impact on students without SEN of being educated with students with SEN in shared, inclusive, interactive learning environments. Data were collected in three schools using a qualitative approach with a communicative orientation. Semistructured interviews were held with teachers as well as community volunteers participating in the schools. Further, focus groups were conducted with students and teachers. The results show that students without SEN benefit from participating in interactive learning activities with peers with SEN in different ways: (1) they learn to respect others, accept differences, and acknowledge different abilities, thereby creating opportunities for new friendships to develop; (2) they learn about abilities related to helping others participate and learn, to be patient and to gain the satisfaction in helping others learn and behave better; and (3) they benefit from the cognitive effort required to explain themselves and from the contributions of peers with SEN from which they can learn.

Introduction

The extension and universalization of an inclusive approach is a goal and a challenge for educational systems around the globe, as reflected in the United Nations’ Sustainable Development Goals. Inclusive education means that all children learn together in schools that recognize and respond to the diverse needs of students, ensure quality education for all through appropriate curricula, organization, teaching strategies and resource use ( UNESCO, 1994 ), and overcome the barriers to the presence, participation, and achievement of all students in general education classes ( UNESCO, 2017 ). However, the original idea of inclusive education focuses on the education of a particular group of students—those with special educational needs (SEN)—to overcome practices of special education that have traditionally segregated students based on a medical model of disability ( Kurth et al., 2018 ). In this regard, inclusive education is generally acknowledged as the venue to enhance both the learning and social development of students with disabilities and other SEN, and therefore the way to fulfill their right to shared quality education in mainstream settings ( United Nations, 2007 ). Consequently, discourse, arguments and research about inclusive education have often centered on the collective of students with SEN, and growing evidence has led to an agreement on the benefits that inclusive education has for these students, as found in reviews of recent research. For instance, the meta-analysis conducted by Oh-Young and Filler (2015) compared the outcomes of students with disabilities between placement settings and found that students in more integrated settings outperformed those in more segregated settings, both in the academic and social domains. The recent review of research by Kefallinou et al. (2020) concluded that there is plenty of research that justifies inclusion both from the educational and the social angles, due to the proven positive effects of educational inclusion on the academic outcomes of students with disabilities, and its positive impact on the subsequent social inclusion of people with disabilities in terms of further academic opportunities and qualifications, access to employment and developing personal relationships within the community.

Because inclusive education is about quality education for all, it is important to look at the potential benefits of inclusion for all students. In this regard, the fact that most of the research on inclusive education concerns categories of learners, particularly those with disabilities and other SENs, may cause us to overlook the impacts on other collectives of learners and may not be consistent with a definition of inclusive education geared toward all learners ( Messiou, 2017 ). The objective of extending and universalizing an inclusive approach would benefit from evidence showing that it is positive—or at least not negative—for all students, including those without SEN.

For this reason, some studies have considered the impact of inclusion on students without special needs. Some of these studies have examined the development of students’ attitudes, empathy and understanding of others. For instance, Smith and Williams (2001) showed that children without disabilities can be sensitive to the consequences of different types of impairments and generally have a positive perception of the capabilities of children with different kinds of impairments, which has positive implications for inclusion. Tafa and Manolitsis (2003) found that typically developing children educated in inclusive programs with children with SEN have increased respect, awareness, and acceptance of their peers’ needs, develop less prejudices, and learn to be more helpful and supportive toward people with disabilities, according to parents’ perspectives. This is consistent with other studies that concluded that inclusive education can play a role in challenging disabling attitudes by transforming non-disabled children’s attitudes toward people with disabilities, therefore contributing to building a more inclusive society ( Beckett, 2009 ). Grütter et al. (2017) analyzed the role of friendship between students with and without SEN and found that opportunities to forge close friendships between students with and without SEN enhance the positive attitudes of students without SEN toward students with SEN; this suggests that inclusive education may benefit from educational practices that actively promote friendship among students with and without SEN. Research has also studied the impact of inclusion on the development of cognitive abilities such as theory of mind (ToM), finding that children without SEN educated in inclusive classes with children with SEN develop a better ToM than their peers educated in traditional classes ( Smogorzewska et al., 2020 ). According to Smogorzewska et al. (2020) , a greater understanding of diversity, tolerance, acceptance of others and the use of prosocial behaviors in inclusive classrooms seem to promote ToM development.

Other studies have explored the impact on academic learning. Although some studies find that the presence of SEN students in regular classes is related to slightly lower performance of their peers without SEN (e.g., Hienonen et al., 2018 ), the conclusions of different reviews of research suggest the contrary. Ruijs and Peetsma (2009) revealed that inclusive education has neutral to positive effects for both students with and without SEN compared to non-inclusive education, especially regarding academic achievement. Focusing on the impacts of students without SEN, Kalambouka et al. (2007) showed no evidence of adverse effects of the inclusion of children with SEN, indicating that most findings involved positive or neutral effects on children without SEN. Similarly, Szumski, Smogorzewska and Karwowski’s meta-analysis (2017) underscored a significant and positive—although weak—effect of the presence of students with SEN on the academic achievement of students without SEN. In none of the examined conditions were significant negative impacts found; in contrast, they were at worst neutral and positive in many cases. More recently, Kefallinou et al. (2020) signaled in their review that the inclusion of students with disabilities did not negatively affect the learning outcomes or the social development of their peers without disabilities, and there was a small—but positive—impact on the academic achievement of students without SEN. In addition, the benefits of inclusive education were connected to effective classroom practices characterized by learning interactions, such as cooperative and dialogic learning, peer tutoring, or collaborative problem-solving, which are beneficial for all learners in the classroom ( Kefallinou et al., 2020 ). As argued in these studies, the results support the idea that inclusive education is not against the right of the majority of students to receive quality education, as not only students with SEN, but also those without SEN, may benefit from being educated together.

One of the key characteristics of inclusive educational environments is the opportunity to have rich and diverse learning interactions among heterogeneous students. The role of social interactions in children’s learning and development has long been investigated by psychologists of education since the onset of the sociocultural theory of learning ( Vygotsky, 1978 ; Bruner, 1996 ). Bruner’s concept of communities of mutual learners helps us to understand the benefits of learning interactions between peers in contexts of diversity. According to Bruner (1996) , group work in schools in the form of communities of mutual learners allows for an equilibrium between individuality and group effectiveness, ensuring that everyone progresses according to their ability and giving all children the opportunity “to enter the culture with awareness of what it is about and what one does to cope with it as a participant” (p. 82). Interactive learning spaces, especially when they are mediated by dialogue, permit collective thinking and learning, enhance academic achievement, social skills, and social cohesion, and are especially beneficial for vulnerable groups of students ( Fernández-Villardón et al., 2020 ; García-Carrión et al., 2020 ). Hence, the objectives of inclusive education would be better attained when such interactive and dialogic learning environments are promoted.

Interactive groups (IGs) and dialogic literary gatherings (DLGs) are specific interactive learning environments that take into account the value of diversity, interaction, and dialogue for learning. Both IGs and DLGs have been identified as successful educational actions (SEAs) that foster successful educational outcomes in diverse student populations ( Flecha, 2015 ). In IGs, classrooms are arranged into small groups of heterogeneous students (e.g., 4–5 students each) who work on instrumental learning activities (especially literacy and math) proposed by the teacher using interaction and dialogue to help each other solve the activity, while a volunteer from the community (e.g., a family member, a former student, or a neighbor) supports each group, dynamizing students’ interactions and mutual help. IGs boost students’ academic learning and—due to the solidary bases of the IG, where students are prompted to help each other—improve the school climate; new friendships are also encouraged, as well as multicultural coexistence ( García-Carrión and Díez-Palomar, 2015 ; Valero et al., 2018 ; Zubiri-Esnaola et al., 2020 ).

Dialogic literary gatherings consist of debating books from classical literature that students have previously read. After agreeing to the chapters that will be discussed at the next gathering, students read the text individually or with help from their family members, a teacher, or a peer, and select a piece of text they found relevant to share at the gatherings. There, they discuss and reflect on the text based on the principles of dialogic learning ( Flecha, 2000 ). DLGs contribute not only to a better understanding of the text, but also enhance students’ reading, reasoning, and argumentative abilities, and deepen understanding of others’ perspectives and emotional well-being ( García-Carrión, 2015 ; Garcia et al., 2018 ; Foncillas et al., 2020 ).

Both DLGs and IGs have been implemented with students with SEN included in mainstream classrooms, and shared with students without SEN. The interactive learning environments created through IGs and DLGs improve the learning and relationships of students with SEN; therefore IGs and DLGs encompass inclusive learning environments ( Duque et al., 2020 ). Less is known about the impact of IGs and DLGs on students without SEN when they are shared with students with SEN. The aim of this study is to identify impacts for students without SEN of being educated with students with SEN in shared, inclusive, interactive learning environments such as IGs and DLGs.

Materials and Methods

This research is a qualitative study of schools that implement interactive learning environments—specifically interactive groups (IGs) and dialogic literary gatherings (DLGs)—with students with and without special needs. The study was conducted within the framework of a broader competitive research project titled “Interactive learning environments for the inclusion of students with and without disabilities: Improving learning, development and relationships” (INTER-ACT). More specifically, this study is part of the project’s second objective: “To analyze in depth successful cases of schools implementing IGs and DLGs with students with disabilities to identify the best conditions to increase the impact on the improvement of learning, development, and relationships.”

The specific objectives of this study were: (1) to determine whether participating in IGs and DLGs with students with SEN has an impact in terms of learning and/or development for children without SEN; (2) to identify types of impacts on students without SEN as a result of participating in IGs and DLGs with students with SEN; and (3) to understand how these impacts are related to being educated with students with SEN in shared, inclusive, interactive learning environments such as IGs and DLGs.

Data from the three mainstream educational centers that participated in the second objective of the INTER-ACT project were considered. These centers were one primary school, one primary and secondary school, and one secondary school that educate students with and without special needs in shared learning environments, and which have already implemented interactive learning environments (IGs and DLGs) in the framework of an inclusive project. The schools were selected for their participation in the INTER-ACT project according to the following criteria: (a) schools that had been organizing classrooms in IGs and/or DLGs for at least two academic years; (b) these schools serve a higher percentage of students with disabilities than the average in the region; (c) these schools implement IGs and DLGs inclusively, involving students with SEN with their peers who do not have SEN; and (d) these schools had observed improvements in their students, recorded through quantitative or qualitative evidence, since they have implemented IGs and/or DLGs.

Data Collection

Qualitative data were collected in each school with the aim of understanding, from the participants’ experiences, how the interactive learning environments that were being facilitated with students with and without SEN contributed to students’ cognitive and social development. The data collection techniques used were semistructured interviews with teachers and community volunteers participating in the schools, and focus groups with students and teachers (see Table 1 ). For the purpose of data collection, students with SEN were considered those with an official report that entailed learning difficulties in the school context. Conversely, students without SEN were those without an official report and who did not present particular learning difficulties in the school context. Purposeful sampling was employed to select participants who could be especially knowledgeable about the object of study. In all cases, the participants selection was agreed with the school principals to select those participants that could be more representative. All data collection techniques were carried out on the school premises for the participant convenience. Interviews with teachers lasted between 60 and 75 min. The duration of the focus groups was approximately 40 min for teachers and between 30 and 45 min for students. In the case of volunteers, interviews lasted approximately 20 min.

Data collection techniques implemented in each school.

Participant teachers in the interviews and in the focus groups were selected based on their experience of implementing IGs and/or DLGs with students with and without SEN. All of them had been implementing IGs and/or DLGs and all of them had—at the moment of the data collection or in the past—students with SEN participating in IGs and/or DLGs together with students without SEN.

Two interviews with teachers were conducted, one in school 1 and one in school 3. They were female teachers in both cases. The teacher interviewed at school 1 was the school principal and a language teacher who implemented DLGs with the two sixth-grade classes, which contained five students with SEN. She had more than 10 years of experience facilitating IGs and DLGs. The teacher interviewed in school 3 taught the third grade of compulsory secondary education. In that class, eight students had SEN.

Two focus groups were held with teachers, one in school 1 and one in school 2. In school 1, four female teachers participated. One of them was a teacher in the first and second grades of primary education, another was a teacher in the third and fourth grades, and two more were teachers in the fifth and sixth grades. They had between 4 and 12 years of experience in the school implementing IGs and/or DLGs. In school 2, three female teachers participated. One of them was a teacher of first and second grade, another was a special education teacher, and the third was a teacher of second grade of compulsory secondary education and educational advisor. They had between 1 and 10 years of experience in the school implementing IGs and/or DLGs.

Three focus groups were held with students, two in school 1 and one in school 3. In school 1, one focus group was conducted with each of the two sixth-grade classes. They have been implementing IGs since second grade and DLGs since third grade. In these classes, cases of special needs included hearing impairment and intellectual disability (one boy), intellectual disability (one boy), dyslexia (two boys and one girl) and ADHD (one boy). Five students participated in the first focus group (three boys and two girls), and seven participated in the second focus group (five girls and two boys). In the first group, there was one girl and one boy with SEN, and in the second group, there was one boy with SEN. In school 3, one focus group was conducted with two girls: one in second grade of compulsory secondary education, and one in third grade of compulsory secondary education. Both participated in IGs and DLGs. One of them had special needs (a syndrome entailing visual and hearing impairment, as well as an intellectual disability) and participated in IGs and DLGs with her classmates without special needs, while the other student did not have SEN and had a classmate with autism who participated in IGs and DLGs along with the rest of the class.

Finally, two interviews were conducted in school 2 with two male volunteers who participated in IGs in classes containing students with and without SEN. One of them had taken part in IGs in preprimary and primary education classes for 2 years, while the other had participated in IGs for 3 years in fifth and sixth grades of primary education and in third grade of compulsory secondary education.

Both the interviews and the focus groups included questions regarding, on the one hand, the characteristics of the implementation of the interactive learning environments and, on the other, the impacts on the participating students. The data collection was conducted using a communicative orientation that involves creating the conditions for egalitarian dialogue between researchers and the end-users of research to reach a shared interpretation of the reality being studied ( Gómez et al., 2019 ). Sample questions for teachers and volunteers included: “How would you describe the interactions between students with SEN and their peers without SEN when they participate in IGs and/or DLGs?” “Have these interactions between students changed over time?” “Have you observed an impact on students that could be related to such interactions?” Sample questions for students were: “How do you work in IGs and DLGs with your classmates?,” “When you or some of your classmates have some difficulties when participating in IGs or DLGs, what do you do?,” “Have you improved on something since you have taken part in IGs and DLGs?,” “And your classmates?,” “Can you give an example?”

Before data collection, school boards and individual participants were informed about the aims of the research. All participants were informed that their participation was voluntary and that the data would be recorded anonymously. Informed consent was obtained from the participant teachers and community volunteers and from the parents or guardians of the minors. To ensure ethical integrity of the study, the research responded to the Universal Declaration of Human Rights adopted by UNESCO, the UN Convention on the Rights of the Child, and the Charter of Fundamental Rights of the EU (2000/C 364/01) regarding scientific and ethical procedures, the European Code of Conduct for Research Integrity ( ALLEA, 2017 ), the Ethics Review Procedure established by the European Commission (2013) for EU research, and the Data Protection Directive 95/46/EC. The study was fully approved by the Ethics Board of the Community of Researchers on Excellence for All (CREA).

Data Analysis

Interviews and focus groups were audio recorded and transcribed verbatim. Transcriptions were subsequently revised to identify the excerpts that referred to interactions between students with and without SEN that could indicate an impact on students without SEN. A second reading was conducted to identify recurrent themes that emerged from the excerpts, and three main themes were identified that led to the inductive creation of the three categories of analysis: (1) impact on students’ attitudes, (2) impact on students’ social skills, and (3) impact on students’ academic learning and cognitive development (see Table 2 ). One researcher coded the excerpts according to the categories created; some excerpts were assigned to more than one category. Subsequently, a second researcher revised the coded excerpts, taking into account the definition of the categories. The second researcher agreed on the coding and proposed the assignment of some of the citations to additional categories. The final coding was agreed upon by both researchers.

Categories of analysis.

The results of our analysis allowed us to identify a series of impacts for students without SEN of sharing interactive learning environments with students with SEN. According to the categories of analysis, our findings show that participating together in learning activities, mediated by interaction and dialogue, allows students without SEN to: (1) build understanding and respectful attitudes toward diversity; (2) learn about social abilities related to facilitating others’ learning; and (3) enhance opportunities for academic learning and cognitive development as a result of engaging in learning together, exchanging questions and knowledge. As seen in Table 2 , the category with a higher number of quotes is (1) impact on students’ attitudes, with more than half of the quotes referring to such an impact, followed by (2) impact on students’ social skills, and finally by (3) impact on students’ academic learning and cognitive development.

Building Positive Attitudes Toward Diversity in Interactive Learning Environments Shared With Peers With Special Needs

Category 1 included evidence regarding the attitudes of students without SEN toward students with SEN when they learned together in IGs and/or DLGs. Participants in the three schools, including teachers, students and volunteers, provided evidence in this regard.

When students without SEN share interactive learning environments with students with SEN, they have unique opportunities to learn firsthand about diversity. They share their learning time and space with peers of the same age, who often need special attention because of their individual characteristics, which differ to a greater or lesser extent and in different ways from those of most students. This is a necessary first step to develop positive attitudes on diversity and educational and social inclusion, which cannot be completely achieved when education on respect for diversity, valuing its potential, and educational and social inclusion is not based on the daily experiences of sharing these learning opportunities with individuals with SEN, who have a face and a name. However, interactive learning environments allow students to share not only learning space and time, but also interactions and dialogue around shared learning activities (such as solving a math problem or sharing a personal reflection on an excerpt from a book), which create opportunities to learn about diversity and its value based on the personal experiences of those individuals with whom the activity is shared. In this way, students can learn about diversity with those children who have not only a name and a face but also a personality, preferences, and struggles.

Ana, a secondary education student without SEN who has a classmate with autism spectrum disorder, Jose, explained that getting to know him in the school allowed her to learn about diversity in a way that she could not have done before:

• Until I first entered this school last year, I had no idea what the communication and language classroom was, I had no idea that there were people with ASD who could be in schools like this, I was not aware at all of this. However, when I arrived in this school, they put me in the class with Jose, and when I saw him, I said “wow” and I don’t know, from that moment on, he transmitted something to me that made me feel that he was special and that I was going to help him in some way. In addition, as time went by, Jose turned my life around. (Student, school 3)

The interactive learning environment fostered in the classroom, where students learn in dialogue with others, is, according to teachers, what generates the opportunity to acknowledge diversity, while students learn that it is part of human diversity and normalize it:

• I believe that it favors inclusion, for sure, because they talk constantly, leaving the classic model of children sitting alone, individually. So yes, they are all integrated. As she said, they always look the same to each other; they do know that one has more difficulties in one thing or another, but they all treat each other equally. (Teachers’ focus group, school 1)

Teachers in the different schools reported a change in attitudes in their students without SEN, who in the interactive learning environments learned about difference, learned to accept it, and to be more respectful about it. Teachers referred, on the one hand, to children’s acknowledgement of individual differences in their peers’ learning process, which became evident as learning activities were shared among the class, either in small interactive groups or in dialogic literary gatherings with the entire class. Students understood that children could learn at different paces and that they can need different kinds of support or adapted materials, but this does not mean that they cannot share the experience of learning; as one teacher explained: “a dynamic of respect and understanding that not everyone does the same has been created” (Teacher, school 1). Importantly, being aware of these differences does not turn into a stigmatization of students with SEN; in contrast, knowing them allows their peers to learn more about their weaknesses, and to better understand their performance in class. The example of shared reading activities illustrates this impact on students’ attitudes:

• And the other students, for me this is important, they respect their reading rhythm, they respect it, they know that, depending on which children, they go slowly because they have difficulties, but nobody says so, because we all know that they have difficulties and that they go at their own pace and, if they read it slowly, they understand it well. (Teacher, school 1)

Special needs can be related to areas of curricular learning, but can also be expressed in other ways. Teachers’ experience shows that in interactive learning environments, children learn to be more understanding about other types of difficulties, such as behavioral problems that their classmates may exhibit. Although it may sometimes be annoying, they develop the understanding that these children do not have, at that moment, the ability to behave better and learn to accept it, while teachers work to improve children’s ability to control their behavior. This is the case of what this teacher explained:

• There are days when these children—I’m thinking of another one who hasn’t taken the medication—then, he comes in very nervous, he doesn’t stop making noises, he doesn’t shut up. Obviously, holding the gatherings in these conditions is very hard, but they are there, and the group already understand that this child acts this way because he has no other way to do it. Therefore, I think that they have all learned to accept the difference. (Teacher, school 1)

Overall, these episodes show the opportunities created for children without SEN to better understand children with SEN, to be more sensitive to others’ needs, and to be more empathetic. From the perspective of teachers, interactive learning environments such as DLGs entail the learning of values that facilitate the transformation of attitudes. These values emerge from the reading of classic works of literature, which is characteristic of a DLG, where topics such as love, friendship, truth, loyalty, and courage become part of the debate:

• In the gatherings many values arise, students work a lot on values and then have a more complete experience, and they share, and they make. They feel empathy for each other. (.) in the classroom it is very difficult for them to put themselves in the other’s place (.) but in the gatherings it isn’t, empathy does come out. (Teacher, school 1)

This learning of values and empathy is also related to the fact that in DLGs, children often link the episodes of reading to episodes about their own lives or other realities they know of. This is how children expressed this idea in their own way:

• Because when we give our opinion in the gatherings, sometimes he explains something of his life, and so when he says it, we know slightly more about him, and he says more and more things about his life, and so we get to know each other better and become [better] friends, because in this way we get to know each other much more easily. (Student, school 1)

In this process of knowing their classmates with SEN better as a result of sharing interactive learning environments, children also learn that each individual has different abilities, that all of them may need help at some point, and can help others as well, and that the best learning outcomes are obtained when they share these abilities and help each other. IGs facilitate this process, as in IGs all group members are expected to ensure that all other members understand the activity and complete it; therefore, everyone shares the knowledge and abilities they have and that can contribute to the group work. Teachers in one of the schools reflected on this idea, which also contributed to the change of perceptions and attitudes mentioned, as typically developing students realize that students with SEN have challenges but also have abilities: “In those moments they have truly helped each other. Then, they have realized that it is not always the same people who have to help, but they, who have a challenge, are good at it.” (Teachers’ focus group, school 1)

This acknowledgement of diversity (including difficulties, but also possibilities and diverse abilities), which is due to sharing interactive learning environments, facilitates overcoming prejudices. Students with SEN start to be seen not only as those with poor learning, that always struggle and usually need help, but also as students who are capable of learning and making progress, as one teacher noted:

• Academically brilliant boys and girls, who perhaps in third grade looked at these classmates and even knowing them since they were in preschool [3 or 4 years old] thought, “Well, this is clear, they don’t know anything,” have made a positive change because they see these children as classmates with the possibility of learning. (Teacher, school 1)

As shown in this quote from a teacher’s interview, it was not the fact of being educated in the same classroom with SEN students that shaped a realistic perception of their difficulties and capabilities (since both SEN and typically developing students had been educated together for years). Rather the opportunity to learn in interactions with SEN students allowed students without SEN to transform their perceptions and attitudes. Along the same lines, in view of Ana, sharing learning opportunities with her classmate Jose entailed learning that everyone has both difficulties and abilities, and that these can be overcome:

• Jose has taught me that many times people have barriers, because we all have barriers, whether it is at the time of learning, at the time of adults finding a job. Whatever, anything, but there is always a way to overcome them, always, and Jose has taught me many things. In fact, I think he has taught me more than I have taught him. (Student, school 3)

This involved shifting the focus from difficulties to possibilities and transforming learning expectations toward them. Importantly, the peer group learned that students with SEN were not only able to learn, but also contributed to the learning of others, which reinforces this change in expectations and the overcoming of prejudices. This might help typically developing students learn to value people not only based on their more evident characteristics—as may be the case with SEN in the school context—but also to pay attention to other traits (which are sometimes hidden) that can give a broader picture of a person and allow for identifying other enriching features. According to teachers, interactive learning environments such as IGs and DLGs permit this to happen:

• And from that moment on, I think, that’s when we all realized that children like Javi can participate by making very good contributions, and that girls like Laura don’t know everything. I think that this was a very important moment. (Teacher, school 1)

Further, this greater knowledge of peers with SEN and the development of respect for diversity has led in some cases to the blossoming of new friendships. Ana talked about her special relationship with Jose as something that makes going to school more meaningful for her: “And one of the reasons why I love coming to school is to have Jose’s smile there every morning (.) and it’s something I wouldn’t change for anything in the world” (Student, school 3). Blanca, a girl with SEN in the same secondary school, explained something similar in terms of when she thinks of her classmate and friend Jaume:

• Like Ana said, she is very happy with Jose. I am exactly the same with Jaume (.) I am very happy with him and I am happy to have him as a friend, and he is special and very important to me. (Student, school 3)

The building of these friendships not only has had an impact within the school, but has also transferred and expanded the benefits of interactions between students with and without disabilities to new contexts outside school premises and across time, as a teacher in that school explained:

• [His] friendship within the school [was] prolonged on weekends (.) He has come to meet [his] friends of the classroom to go out to dinner 1 day, to see a movie and that is very interesting (.) I think the fact of having worked in groups has facilitated doing things, not only in his group of six, because these groups have been changing more or less. (Teacher, school 3)

Learning Social Skills Related to Helping Others Participate and Learn

Category 2 included evidence regarding an impact on the social abilities of students without SEN as a result of learning together with students with SEN in IGs and/or DLGs. Participants in the three schools, including teachers, students and volunteers, offered evidence in this regard.

In addition to the transformation of thoughts, attitudes and the acknowledgment of others’ abilities and difficulties, engaging in learning interactions with peers with SEN helps to develop a series of social skills. Children acquire these skills because they are necessary to interact with their classmates in IGs and DLGs, specially with those with SEN. These interactive learning environments pose this demand, and these skills become part of the repertoire of abilities that children can use in multiple contexts and with diverse people. First, in interactive learning environments such as IGs and DLGs, children are expected to help each other; thus, children progressively get used to and develop this ability to support their peers, as well as receiving help when necessary. Both teachers and volunteers reflected on the way children learned about this ability through time: “Last year I did notice a change, yes (.) in the end they learn to collaborate, above all, to help each other, and that it goes well, and the work comes out, which is what we are looking for.” (Volunteer, school 2)

With the practice of helping each other in interactive and diverse learning environments, children come to see that collaboration among all helps everyone’s learning, as it allows for one to take advantage of the diverse abilities in the group; therefore, they become progressively more motivated and more proficient in this activity:

• Everyone has some skills; some have some skills for one thing and others have some skills and some abilities for another. After all, if there is a collaboration between all, it is where you have to reach an end, and they help each other to reach this end. (Teacher, school 2)

Once they acquire this ability, they use it to help anyone who needs it, including children with more learning difficulties; they normalize helping others and realize they can make a difference in the learning opportunities of the students with the most difficulties. Therefore, and as a volunteer explained, all students in her class were willing to help those who were more in need: “Yes, let’s say, the whole group was dedicated to helping them” (Volunteer, school 2). Consequently, when they share learning activities with students who especially struggle with learning, they find the opportunity to strengthen this ability to help. Blanca explained something similar when not just one, but three classmates went to help her with the activity:

• For example, in History, we also do [interactive] groups. We were doing a mapping exercise and (.) I got lost a little bit, then I asked my classmate sitting next to me to help me and so on, then she came to help me, then two more came to help me, and I was happy because I did not make myself clear, I got nervous, I did not know how to do it, then (.) they came to help me (.), and that is the best thing about being in a group. (Student, school 3)

Second, in this attempt to help their peers with SEN and facilitate their participation in interactive learning environments, they learn to adjust their interactions to the particular needs of each child. For instance, they learn to be patient and to give the necessary time when their peers have a slower learning pace, which is an evidence of the empathy developed:

• In the gatherings they have also learned to give time. For example, a girl I have in class has a hard time explaining herself, but in the end, she gets it out. Therefore, they have learned to be patient with her and not to stand up and let her talk. Then, in the end, they realize that she does, that she gets out, that she explains well. (Teacher, school 1)

In this regard, they learn to provide adjusted support, building on the abilities they acknowledge in these peers, and try to find alternative ways so that these children can participate in the activity. This entails a metacognitive effort when they try to understand what these children know and how they can help them participate in the activity and progress in their learning.

• The atmosphere in the classroom, when there is a group with a child with SEN, the others, as they live it in their daily life, apart from understanding the difficulty he has and stay on their level, they also look for ways in which he can participate and get involved in some way in the activity. (Teacher, school 1)

This effort to facilitate the learning and participation of children with SEN becomes part of the class routine. so as the teachers explained, it unites the group around this shared purpose and the group members become more sensitive to the needs of their peers. This is also achieved thanks to the guidance that teachers and volunteers provide in order to help typically developing students adjust the support they offer to their SEN peers, and also to encourage typically developing students to help their SEN peers while avoiding overprotection:

• In other words, their classmates, or at least what I experience from my class, they are very supportive and, as Maria said, they are very sensitive on this subject. In this case, I have two students [with SEN], and they take care of them, not too much, because they must be reminded to let them think, too. However, they do take them very much into account in regard to working in [interactive] groups. They try to make sure they can participate like everyone else. Of course, within their possibilities. (Teacher, school 1)

As a result, the situations created not only turn into a higher ability to help others, but also in the satisfaction of seeing others learn better due to their help, which reinforces this behavior. Teachers noted this impact on children: “They help each other and it is going very well; and they love it, it is something they like very much” (Teacher, school 2), as well as students themselves: “And, when you help him and you see that he understood it, you feel satisfied” (Student, school 2). “When I help Joan or even when Joan helps me more, I feel more fulfilled with myself, happier” (Student, school 3). Such rewarding experiences motivates them to continue participating in these activities and to help others, which benefits everyone’s learning.

Enhancing the Opportunities for Academic Learning and Cognitive Development

Category 3 included evidence regarding opportunities for the academic learning and cognitive development of students without SEN when they learned together with students with SEN in IGs and/or DLGs. Participants in school 1 and school 2, including teachers, students and volunteers, mentioned this type of impact.

Sharing learning activities with students with SEN in interactive learning environments triggers an additional cognitive effort for typically developing children when they try to explain themselves to their peers with SEN. It entails, on the one hand, putting oneself in the other’s shoes, trying to understand his/her difficulties and thinking of how to help him/her overcome these difficulties, thus gaining from the cognitive effort made and reinforcing their learning. On the other hand, it also entails discovering one’s own difficulties when trying to make oneself be understood and to do one’s best to achieve it. In this regard, such situations allow students who do not usually have learning challenges to experience them, and underscore the need to make an effort to achieve their objective, which contributes to being more empathetic and understanding of their peers with SEN and, sometimes, humbler regarding their own abilities, as one volunteer explained:

• They do this effort of trying to make them be understood by the other, and this is very interesting, as the know-it-all can see his/her own limitations with respect to the others. Therefore, it demands a much greater effort from oneself than usual. (Volunteer, school 2)

In addition, in interactive learning environments, students without SEN can learn from the explanations and contributions of children with SEN. IGs and DLGs are characterized by promoting a framework of open and egalitarian dialogue where all contributions are valued based on validity claims (i.e., the value of the contribution’s content, regardless of who made the contribution, and in this case, regardless of whether it is a student with or without SEN). Learning from students with SEN can occur both in IGs and in DLGs when these students have a good understanding of the concepts they are working on. As noted by one teacher, these episodes are opportunities for the entire group to learn:

• Children with many special difficulties, have been the ones who have given the clarification, the definition, the explanation for the rest of the group to understand, and this has created a situation, which is not seen, but it is noticed, of improvement for all. (Teacher, school 1)

In DLGs, it also occurs when children with SEN share the paragraph or idea they selected to bring to the gathering, or when they raise doubts about the meaning of particular words that other students had not paid attention to—although they might not understand it either—and this opens up a debate on the meaning of that word or on the ideas of that paragraph that may have not existed without the participation of these children. In the following quote from a teacher, we find first a reference to those situations when a child with SEN does not understand something and their peers explain it to him/her, provoking the additional cognitive effort of trying to make something be understood. Next, we find the reference to these other situations when children with SEN contribute to the group bringing their questions, doubts, and interventions to the gathering, opening a learning opportunity for all:

• If they do not understand it, their classmates explain the meaning to them. Then, when we do this rereading of the chapter or the pages, other vocabulary words often appear that, perhaps nobody had chosen or they do not know the meaning of, and then another debate starts about knowing what it means. Or someone raises their hand and says, “I had not chosen this because when I read it perhaps it did not catch my attention, but now when I reread the chapter, I want to comment on it,” and right after it is commented on. This is done both by children with SEN and by the rest of the class, regardless of their level of ability and everything else. A climate is created that is similar to magic. (Teacher, school 1)

According to the participants’ experiences, interactive learning environments shared between students with and without SEN create the opportunity for all to acknowledge that everyone has abilities and difficulties. Children with SEN can surprise others with their questions, responses, and contributions, generating new opportunities for learning, and everyone can learn that children without SEN do not always know everything. As one teacher explained based on her experience over the years, the fact that children with SEN share interactive learning environments with their peers without SEN has not only benefitted these SEN children, but also the dynamics of the classroom, as it is enriched with diversity, and therefore becomes a benefit for all:

• The fact that these children are in the group—and I can talk about it already for the past 4 years—has improved the dynamics of the gatherings. I think it has been beneficial for everyone, and I am sure it has, because they make interventions that even they themselves are often surprised to have made, and their peers have seen this. (Teacher, school 1)

Interactive groups and DLGs are interactive learning environments that have already been demonstrated to be inclusive and lead to positive academic and social impacts for students with SEN ( Duque et al., 2020 ). The study presented here is the first to analyze the potential impacts of IGs and DLGs on students without SEN when they share these interactive learning environments with students with SEN. The results of our study show that students without SEN can benefit from participating in interactive learning environments (such as IGs and DLGs) with peers with SEN in at least three different ways: (1) building positive attitudes as they learn to respect others, accept differences, and acknowledge different abilities, creating opportunities for new friendships; (2) enhancing their social skills, as they learn about abilities related to helping others participate and learn, to be patient, and gain satisfaction from helping others learn; and (3) producing opportunities to enhance academic learning and foster cognitive development, as they gain from the cognitive effort needed to explain themselves and from the contributions of peers with SEN from which they can learn. Importantly, we did not find negative impacts for students without SEN or for those with SEN as a result of sharing these interactive learning environments. In contrast, all impacts identified—either at the attitudinal, social, or cognitive level—were positive for both groups of students.

In the cases studied, children without SEN developed positive attitudes toward diversity in IGs and DLGs. This is in the line of previous research which found that inclusive educational environments are related to more positive attitudes toward diversity, and especially more positive attitudes among typically developing peers toward children with disabilities or other SEN ( Smith and Williams, 2001 ; Beckett, 2009 ). It is also consistent with research that found that solidarity can be learned in the school context and that it contributes to creating genuine attitudes of inclusion beyond the norms that benefit everyone ( Hernández Arteaga et al., 2020 ).

Additionally, we found that students without SEN had the opportunity to develop social skills when they learned together with students with SEN in IGs and DLGs. Identifying particular types of classroom arrangements and learning dynamics (such as IGs and DLGs) that help one to cultivate such attitudes and skills is important not only for students with SEN—who are more respected, accepted, and integrated in their group of peers—but also beneficial for students without SEN. Attitudes of understanding diverse identities; the values of justice, equality, dignity and respect; cognitive skills (including the ability to adopt a multiperspective approach); social skills (such as empathy and conflict resolution), communication skills and aptitudes for interacting with diverse people, and the capacity to act collaboratively and responsibly have been highlighted as key competences necessary in the 21st century ( UNESCO, 2014 ).

Moreover, we found a positive impact of the interactive learning environments created with IGs and DLGs on opportunities for the learning and cognitive development of children without SEN. This is in line with previous research comparing the learning outcomes of students without SEN, who are educated with students with SEN, and those who are not, which overall revealed no negative impacts on these students but, on the contrary, positive impacts or neutral in the worst cases ( Kalambouka et al., 2007 ; Ruijs and Peetsma, 2009 ; Szumski et al., 2017 ; Kefallinou et al., 2020 ).

These findings should be taken cautiously. On the one hand, because the study is based on a reduced sample, the conclusions cannot be generalized. On the other hand, because data were collected in schools that were already implementing IGs and DLGs, a pre-post intervention comparison cannot be made to ascertain the changes that occurred in students without SEN due to sharing IGs and DLGs with students with SEN. Finally, the qualitative nature of the data facilitates an understanding of the reality studied but does not allow for a precise assessment of the impacts on students without SEN. Subsequent research could expand the analysis to a broader sample and include an examination of quantitative data, especially of students’ academic progress, since the third category of analysis (impact on students’ academic learning and cognitive development) is the one for which we obtained the least evidence.

However, as the first study on this topic, this research enables an initial approximation based on the participants’ experiences, which is consistent with previous knowledge and can be the basis for further investigation. First, it is in line with the results of previous research on DLGs and IGs which shows their impact on improving students’ academic learning, a better understanding of others and positive coexistence ( García-Carrión, 2015 ; García-Carrión and Díez-Palomar, 2015 ; Garcia et al., 2018 ; Valero et al., 2018 ; Foncillas et al., 2020 ; Zubiri-Esnaola et al., 2020 ). Our study suggests that sharing IGs and DLGs with students with SEN creates new conditions in which these improvements can be promoted. Second, it is aligned with past research on inclusion, which has associated the benefits of inclusive education with classroom practices characterized by interaction, dialogue, and collaboration ( Kefallinou et al., 2020 ), all of which are characteristics of IGs and DLGs and could thus explain the benefits observed. Third, it is in line with theoretical contributions that refer to the relevant role of peer help and other forms of sharing learning interactions. When children try to explain learning content to their peers with SEN or try to help them solve a problem, they expand what Vygotsky called the zone of proximal development (1978) or what Bruner called scaffolding (1996). Both authors emphasized (stemming from the sociocultural theory of learning) the importance of interactions for children’s learning and argued that these interactions could emerge not only from adults but also from more capable peers. Interactions allow for the creation of shared learning ( Mercer and Littleton, 2007 ), and our data indicate that more capable peers can also benefit from these interactions and find opportunities to advance their learning and cognitive development. Indeed, research has suggested thinking of the zone of proximal development not in terms of knowledge transmission, but as an encounter of consciousness that mutually benefits the participants in the interaction ( Roth and Radford, 2010 ).

Although further research is necessary to have a more precise description of the impact of IGs and DLGs for students without SEN when they share these learning environments with students with SEN, the evidence presented can contribute to the understanding that inclusive education not only benefits the most vulnerable students (such as students with disabilities and other SENs), but can also benefit all students when interactions and dialogue are promoted in contexts of diversity. Therefore, it is the right of everyone—with or without SEN—to be educated in inclusive, interactive learning environments, as they produce unique conditions for the academic and human development of all students.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by the Ethics Board of the Community of Researchers on Excellence for All (CREA). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Author Contributions

RF conceptualized the research. SM conducted the literature review, a preliminary analysis of the data, and a first draft of the manuscript. JM revised the data analysis. RF, AA, and JM revised the manuscript and provided feedback and corrections. SM revised the final version of the manuscript. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. This study was funded by INTER-ACT: Interactive learning environments for the inclusion of students with and without disabilities: improving learning, development and relationships, The Spanish National Program for Research Aimed at the Challenges of Society, Ministry of Economy, Industry and Competitiveness. Reference Number: EDU2017-88666-R.

• ALLEA (2017). The European Code of Conduct for Research Integrity. Available online at: https://www.allea.org/wp-content/uploads/2017/05/ALLEA-European-Code-of-Conduct-for-Research-Integrity-2017.pdf [accessed January 5, 2021] [ Google Scholar ]
• Beckett A. E. (2009). Challenging disabling attitudes, building an inclusive society: considering the role of education in encouraging non-disabled children to develop positive attitudes towards disabled people. Br. J. Sociol. Educ. 30 317–329. 10.1080/01425690902812596 [ CrossRef ] [ Google Scholar ]
• Bruner J. (1996). The Culture of Education. Cambridge, MA: Harvard University Press. [ Google Scholar ]
• Duque E., Gairal R., Molina S., Roca E. (2020). How psychology of education contributes to research with social impact on the education of students with special needs: the case of successful educational actions. Front. Psychol. 11 : 439 . [ PMC free article ] [ PubMed ] [ Google Scholar ]
• European Commission (2013). Ethics for Researchers. Facilitating Research Excellence in FP7. Available online at: http://ec.europa.eu/research/participants/data/ref/fp7/89888/ethics-for-researchers_en.pdf [accessed January 5, 2021] [ Google Scholar ]
• Fernández-Villardón A., Álvarez P., Ugalde L., Tellado I. (2020). Fostering the social development of children with special educational needs or disabilities (send) through dialogue and interaction: a literature review. Soc. Sci. 9 : 97 . 10.3390/socsci9060097 [ CrossRef ] [ Google Scholar ]
• Flecha R. (2000). Sharing Words: Theory and Practice of Dialogic Learning. Lanham, M.D: Rowman & Littlefield. [ Google Scholar ]
• Flecha R. (2015). Successful Educational Action for Inclusion and Social Cohesion in Europe. Berlin: Springer. [ Google Scholar ]
• Foncillas M., Santiago-Garabieta M., Tellado I. (2020). Análisis de las tertulias literarias dialógicas en educación primaria: un estudio de caso a través de las voces y dibujos argumentados del alumnado. Multidisciplinary J. Educ. Res. 10 205–225. 10.17583/remie.2020.5645 [ CrossRef ] [ Google Scholar ]
• Garcia C., Gairal R., Munté A., Plaja T. (2018). Dialogic literary gatherings and out-of-home child care: creation of new meanings through classic literature. Child Fam. Soc. Work 23 62–70. 10.1111/cfs.12384 [ CrossRef ] [ Google Scholar ]
• García-Carrión R. (2015). What the dialogic literary gatherings did for me. Qualitative Inquiry 21 913–919. 10.1177/1077800415614305 [ CrossRef ] [ Google Scholar ]
• García-Carrión R., Díez-Palomar J. (2015). Learning communities: pathways for educational success and social transformation through interactive groups in mathematics. Eur. Educ. Res. J. 14 151–166. 10.1177/1474904115571793 [ CrossRef ] [ Google Scholar ]
• García-Carrión R., López, de Aguileta G., Padrós M., Ramis-Salas M. (2020). Implications for social impact of dialogic teaching and learning. Front. Psychol. 11 : 140 . [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Gómez A., Padrós M., Ríos O., Mara L. C., Pukepuke T. (2019). Reaching social impact through communicative methodology. researching with rather than on vulnerable populations: the roma case. Front. Educ. 4 : 9 . [ Google Scholar ]
• Grütter J., Gasser L., Malti T. (2017). The role of cross-group friendship and emotions in adolescents’ attitudes towards inclusion. Res. Dev. Disabil. 62 137–147. 10.1016/j.ridd.2017.01.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hernández Arteaga I., Fernández López K. M., Estela Vasquez A. C., Mestizo Nuzcue E. J. (2020). Educación y solidaridad: un camino hacia la inclusión educativa. Soc. Educ. History 9 227–251. [ Google Scholar ]
• Hienonen N., Lintuvuori M., Jahnukainen M., Hotulainen R., Vainikainen M. P. (2018). The effect of class composition on cross-curricular competences – Students with special educational needs in regular classes in lower secondary education. Learn. Instruction 58 80–87. 10.1016/j.learninstruc.2018.05.005 [ CrossRef ] [ Google Scholar ]
• Kalambouka A., Farrell P., Dyson A., Kaplan I. (2007). The impact of placing pupils with special educational needs in mainstream schools on the achievement of their peers. Educ. Res. 49 365–382. 10.1080/00131880701717222 [ CrossRef ] [ Google Scholar ]
• Kefallinou A., Symeonidou S., Meijer C. J. W. (2020). Understanding the value of inclusive education and its implementation: a review of the literature. Prospects 49 135–152. 10.1007/s11125-020-09500-2 [ CrossRef ] [ Google Scholar ]
• Kurth J. A., Miller A. L., Toews S. G., Thompson J. R., Cortés M., Dahal M. H., et al. (2018). Inclusive education: perspectives on implementation and practice from international experts. Intellect. Dev. Disabil. 56 471–485. [ Google Scholar ]
• Mercer N., Littleton K. (2007). Dialogue and the Development of Children’s Thinking, a Socio-Cultural Approach. Milton Park: Routledge. [ Google Scholar ]
• Messiou K. (2017). Research in the field of inclusive education: time for a rethink? Int. J. Inclusive Educ. 21 146–159. 10.1080/13603116.2016.1223184 [ CrossRef ] [ Google Scholar ]
• Oh-Young C., Filler J. (2015). A meta-analysis of the effects of placement on academic and social skill outcome measures of students with disabilities. Res. Dev. Disabil. 47 80–92. 10.1016/j.ridd.2015.08.014 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Roth W. M., Radford L. (2010). Re/thinking the zone of proximal development (Symmetrically). Mind Cult. Act. 17 299–307. 10.1080/10749031003775038 [ CrossRef ] [ Google Scholar ]
• Ruijs N. M., Peetsma T. T. D. (2009). Effects of inclusion on students with and without special educational needs reviewed. Educ. Res. Rev. 4 67–79. 10.1016/j.edurev.2009.02.002 [ CrossRef ] [ Google Scholar ]
• Smith L. A., Williams J. M. (2001). Children’s understanding of the physicals cognitive and social consequences of impairments. Child Care Health Dev. 27 603–617. 10.1046/j.1365-2214.2001.00236.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Smogorzewska J., Szumski G., Grygiel P. (2020). Theory of mind goes to school: does educational environment influence the development of theory of mind in middle childhood? PLoS One 15 : e0237524 . 10.1371/journal.pone.0237524 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Szumski G., Smogorzewska J., Karwowski M. (2017). Academic achievement of students without special educational needs in inclusive classrooms: a meta-analysis. Educ. Res. Rev. 21 33–54. 10.1016/j.edurev.2017.02.004 [ CrossRef ] [ Google Scholar ]
• Tafa E., Manolitsis G. (2003). Attitudes of Greek parents of typically developing kindergarten children towards inclusive education. Eur. J. Special Needs Educ. 18 155–171. 10.1080/0885625032000078952 [ CrossRef ] [ Google Scholar ]
• UNESCO (1994). The Salamanca Statement and Framework for action on special needs education: Adopted by the World Conference on Special Needs Education, Access and Quality. Paris: UNESCO. [ Google Scholar ]
• UNESCO (2014). Global Citizenship Education. Preparing learners for the challenges of the 21st century. Paris: UNESCO. [ Google Scholar ]
• UNESCO (2017). A Guide for Ensuring Inclusion and Equity in Education. Paris: UNESCO. [ Google Scholar ]
• United Nations (2007). Convention on the Rights of Persons with Disabilities (CRPD). Available online at: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html [accessed January 5, 2021] [ Google Scholar ]
• Valero D., Redondo-Sama G., Elboj C. (2018). Interactive groups for immigrant students: a factor for success in the path of immigrant students. Int. J. Inclusive Educ. 22 787–802. 10.1080/13603116.2017.1408712 [ CrossRef ] [ Google Scholar ]
• Vygotsky L. S. (1978). Mind in Society: the Development of Higher Psychological Processes. Boston: Harvard University Press. [ Google Scholar ]
• Zubiri-Esnaola H., Vidu A., Rios-Gonzalez O., Morla-Folch T. (2020). Inclusivity, participation and collaboration: learning in interactive groups. Educ. Res. 62 162–180. 10.1080/00131881.2020.1755605 [ CrossRef ] [ Google Scholar ]

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 17 April 2024

Students with special educational needs in regular classrooms and their peer effects on learning achievement

• V. B. Salas García   ORCID: orcid.org/0000-0001-7568-3879 1 &
• José María Rentería   ORCID: orcid.org/0000-0001-6486-0032 2  

Humanities and Social Sciences Communications volume  11 , Article number:  521 ( 2024 ) Cite this article

713 Accesses

9 Altmetric

Metrics details

• Development studies

This study explores the impact of inclusive education on the educational outcomes of students without Special Educational Needs (non-SEN) in Peru, utilizing official Ministry of Education data and implementing cross-sectional regression analyses. Inclusive education is a complex issue that, without appropriate adaptations and comprehensive understanding, can present substantial challenges to the educational community. While prior research from developed nations offers diverse perspectives on the effects of inclusive education on non-SEN students, limited evidence exists regarding its impact in developing countries. Our study addresses this gap by examining inclusive education in Peru and its influence on non-SEN students, thereby contributing to the existing literature. Our findings reveal that, on average, the presence of SEN students in regular classrooms does not significantly affect their non-SEN counterparts. However, we uncover heterogeneous results contingent on the specific type of SEN and students’ academic placement. These results emphasize the importance of targeted resources and parental involvement in facilitating successful inclusive education, particularly for specific SEN types. In summary, this study underscores the need for tailored strategies and additional resources to foster the success of inclusive education and calls for further research in this field to expand our understanding and enhance educational policy.

Similar content being viewed by others

The concept of inclusive education from the point of view of academics specialising in special education at Saudi universities

Dreams and realities of school tracking and vocational education

Persistent association between family socioeconomic status and primary school performance in Britain over 95 years

Introduction.

Inclusive education has become a significant policy for improving access to and the quality of education for children with special educational needs (SEN), who often encounter physical and social barriers hindering their access to education and entry into the labor market, which in turn is detrimental to the economic and social progress of a country (Filmer, 2008 ; Mitra and Sambamoorthi, 2008 ). Thus, the United Nations has declared “inclusive and equitable quality education” as the fourth 2030 Sustainable Development Goal, which aims to reduce the disability gap in education. Likewise, there exist international declarations like the Salamanca Statement in 1994 (UNESCO, 1994 ) or the Declaration of the Decade of the Americas for the Rights and Dignity of Persons with Disabilities 2016–2026 (OAS, 2018 ) that incorporate the principle of inclusive education to guarantee education for all.

There are different education approaches Footnote 1 to ensure education for children with SEN, but the inclusive approach, unlike others, promotes equal participation of SEN students in regular schools by attending classes alongside same-aged non-SEN students (Dixon, 2005 ). Inclusive education goes beyond the placement of pupils; it refers to a unified system that receives all students regardless of their abilities or disabilities (Dixon, 2005 ). Under the inclusive approach, governments and schools should provide the means (i.e., physical and human resources) to reduce or eliminate physical, academic, and social hurdles faced by SEN students within regular schools (Dixon, 2005 ). Thus, inclusive education aims for social cohesion and a less discriminatory education approach that helps enhance the human capital acquisition of children with SEN (Kiuppis, 2014 ).

Despite the efforts for an inclusive education agenda worldwide, children with SEN remain behind in education indicators such as years of education, school attendance, or academic achievement (Filmer, 2008 ; Rangvid, 2022 ). This raises concerns about the impact that placement of children with SEN in regular schools may have on the educational achievement of children without SEN since these children are also involved in the inclusive education system (Rangvid, 2019 ; Ruijs and Peetsma, 2009 ). In Peru, for instance, some teachers in regular schools as well as some leaders of deaf organizations, do not support inclusive education as they think it is detrimental for both SEN and non-SEN students (Goico, 2019 ; Peruvian Ombudsman, 2019 ). Nevertheless, there is little empirical literature focused on the effects of inclusive education not only on SEN students but also on non-SEN students, especially in developing countries that shelter a high percentage of people with disabilities (Olusanya et al., 2022 ). This paper, therefore, aims to fill that gap by using information from a developing country, namely Peru. It investigates the impact of inclusive education, quantified through the presence of students with SEN in regular classrooms, on the academic performance of their non-SEN counterparts. Analyzing the peer effects of inclusive education is of utmost interest for policymakers aiming to increase the presence of SEN students in regular schools, as policy implications should consider the effects on all children.

The present work provides three main contributions to the existing literature regarding peer effects in the context of inclusive education. First, we provide new evidence using unusual and rich data from a middle-income country. To our knowledge, there is only one study focusing on a developing country. Indeed, Contreras et al. ( 2020 ) analyze the Chilean case and find that placement of children with SEN in regular classrooms negatively affects the standardized test scores in mathematics and reading of their non-SEN peers, but it is neutralized when schools receive additional resources and specialized professionals. Nevertheless, Contreras et al. ( 2020 ) use panel data for students attending primary schools in two periods, 2007 and 2011, without including types of SEN. In contrast, we study children attending primary and secondary schools using cross-section data between 2011 and 2019 and disaggregate our analysis by types of SEN Footnote 2 .

Our second contribution is to disaggregate our analysis by type of SEN. We are aware of two studies that use an overall indicator to reflect the presence of SEN students and disaggregate it by type of SEN. On one hand, Hanushek et al. ( 2002 ) examine two types of special educational needs: learning or emotional and speech; while, Ruijs ( 2017 ) examines four types: visual, hearing, physical or intellectual, and behavioral. In our case, besides evaluating the consequences of placing children with mobility, vision, hearing, and intellectual or learning disabilities in a regular classroom, we also evaluate the repercussions of placing children with autistic spectrum disorder in a regular classroom, which is a much less studied topic.

Finally, our third contribution is to explore the heterogeneous results of inclusive education on the non-SEN student population. Unlike previous studies, we explore the potential different impact of inclusive education between male and female non-SEN students. As most reproductive work has traditionally been done by women (cf. Razavi, 2012 ), it could be argued that female non-SEN students are more likely to take care of or help SEN students, which in turn may influence their educational achievement. Our heterogeneity analysis also takes into account school characteristics like classroom size as well as mother’s characteristics.

In our analysis, we take significant steps to mitigate potential biases stemming from endogenous classroom selection and the sorting of SEN students. We achieve this by focusing on schools with one class per grade level, which provides a more controlled setting for our study. Moreover, our dataset allows us to identify the class composition, which is vital for investigating educational peer effects. The classroom environment is particularly relevant, as classmates have a substantial impact on each other’s educational outcomes, given their shared classroom experience throughout the school day (Balestra et al., 2022 ; Burke and Sass, 2013 ; Lazear, 2001 ).

Our findings suggest that the inclusion of students with SEN in regular classrooms, on average, exerts a neutral influence on their non-SEN peers. A nuanced examination reveals varied results contingent upon the specific categories of SEN. This variability is consistent with the fact that SEN encompasses a broad spectrum of support requirements arising from diverse degrees and types of individual abilities, spanning physical, psychological, cognitive, and sensory domains. Hence, the influence of inclusive education would vary according to the distinct profile of the SEN student integrated into a conventional classroom setting. Furthermore, our results underscore the importance of accounting for temporal dynamics and the particular educational phase in gauging the impact of SEN students on their non-SEN counterparts. This observation aligns with the differential results discerned across academic grades.

The rest of the paper is organized as follows. The literature review and institutional setting are presented in the next section, followed by a description of the data and empirical strategy. After that, we discuss our results, and finally, we conclude.

This section starts with a brief literature review and then describes the main features of the Peruvian educational system as well as its public policy approach to inclusive education.

Literature review

The inclusion of students with SEN in regular schools remains a subject of debate due to the mixed findings within the empirical literature. Proponents of inclusive education argue that attending regular schools is not only a fundamental human right for children with SEN (Ainscow and César, 2006 ; Rangvid, 2022 ; Ruijs and Peetsma, 2009 ) but can also yield benefits for non-SEN students, particularly in terms of their learning development. This is attributed to the additional resources allocated to inclusive education (Keslair et al., 2012 ; Ruijs, 2017 ). Besides, inclusive education may help children without SEN to develop soft skills like kindness, tolerance, and patience, which are important to living in a diverse society (Contreras et al., 2020 ; Dixon, 2005 ). On the other hand, the main concerns regarding inclusive education are related to negative peer effects. The literature on class composition states that students’ performance is influenced by their peers’ characteristics (Ammermueller and Pischke, 2009 ; Burke and Sass, 2013 ; Lavy et al., 2012 ). Since children with SEN may require more teaching attention and show disruptive behaviors (Ahmed et al., 2021 ; Contreras et al., 2020 ; Rangvid, 2019 ; Ruijs, 2017 ), they could be considered “bad” students who could interfere with the educational development of their classmates without SEN (Lavy et al., 2012 ; Lazear, 2001 ), especially for those who are at the bottom of the ability distribution (Balestra et al., 2022 ; Lavy et al., 2012 ).

The quantitative studies that examine the peer effects of inclusive education mainly use data from developed countries. Most of them have found that inclusive education has a negative or null effect on non-SEN students’ outcomes. For instance, using data from Switzerland, Balestra et al. ( 2022 ) find that placing SEN students in regular classrooms harms not only educational outcomes but also labor market outcomes for non-SEN students. Similarly, studies from the United States (Fletcher, 2010 ) and Denmark (Kristoffersen et al., 2015 ; Rangvid, 2019 ) show that exposure to SEN students decreases reading test scores of non-SEN students. Also, for the United States, Gottfried ( 2014 ) and Gottfried et al. ( 2016 ) present evidence that inclusive education worsens the non-cognitive skills of non-SEN students. Fletcher ( 2010 ), however, points out that the negative effect of inclusive education in the United States disappears for reading when their lagged scores are considered in the analysis. Likewise, studies for Canada (Friesen et al., 2010 ), England (Keslair et al., 2012 ), and the Netherlands (Ruijs, 2017 ) also find that the presence of SEN students does not affect the academic performance of their non-SEN peers; but they point out that this result may be due to additional resources received by regular schools with SEN students. Conversely, other studies have found positive externalities of SEN students on the educational achievement of their non-SEN peers. For instance, Cole et al. ( 2004 ) point out that non-SEN students in the United States perform better at reading and mathematics tests since they may benefit from the additional resources allocated to inclusive education. Likewise, Hanushek et al. ( 2002 ) find that non-SEN students attending inclusive classrooms in the United States improve their mathematics test scores. Using data from the same country, Gottfried and McGene ( 2013 ) go beyond by showing that having a sibling with SEN helps to improve the schooling achievement of those siblings without SEN.

Several meta-analyses and systematic reviews have examined the effects of inclusive education on students with and without SEN. The coincidences lie in the varied impacts of inclusive education on non-SEN students, demonstrating a nuanced and context-dependent picture. While Dell’Anna et al. ( 2021 ) hint at positive peer attitudes in inclusive settings, the academic outcomes and the experience of non-SEN students diverge, with high achievers potentially benefiting more than low achievers (Ruijs and Peetsma, 2009 ). Kart and Kart ( 2021 ) and Szumski et al. ( 2017 ) contribute to the discussion, highlighting mixed academic effects across different grade levels. The meta-analyses by Oh-Young and Filler ( 2015 ) and Krämer et al. ( 2021 ) emphasize the overall positive impact of inclusive settings for students with SEN while still acknowledging variations in outcomes. Finally, Van Mieghem et al. ( 2020 ) emphasize the pivotal role of teacher professional development in the successful implementation of inclusive education.

Finally, it is worth mentioning that the conflicting results found in the literature may be explained by the differences in the criteria used to identify a SEN student. Most of the previous studies have used an aggregated measure to encompass all SEN students without considering the types of SEN (e.g., Contreras et al., 2020 ; Rangvid, 2019 ). On the other hand, some studies have focused on one or two types of special needs; such as emotional disturbances and mental disabilities (e.g., Cole et al., 2004 ; Fletcher, 2010 ; Hanushek et al., 2002 ; Kristoffersen et al., 2015 ), or learning and behavioral disabilities (e.g., Cole et al., 2004 ; Friesen et al., 2010 ; Hanushek et al., 2002 ). The present paper addresses these limitations found in the literature by taking into account different types of SEN and also by exploring the potential heterogeneous results of inclusive education for non-SEN students.

Institutional setting: The educational system in Peru

Primary and secondary education in Peru is compulsory and provided by the government at no cost and by the private sector with a wide tuition range. Peruvian children between 6- and 11- years old attend primary school and start secondary school by the age of 12 for a period of 5 years. The last National Population Census in 2017 reports that roughly 5.4% and 7.0% of Peruvians who are primary-school and secondary-school-aged, respectively, have at least one disability. However, according to the School Census of the same year, <1% of children attending regular schools are categorized as SEN students, which suggests that inclusive education in Peru is not well developed. Despite this low enrollment rate, the percentage of SEN students grew from 0.26% in 2007 to 0.96% in 2019.

Since primary and secondary schools in Peru must comply with a mandatory national curriculum, the same courses are taken by children who attend the same grade level across different schools. Schools may have more than one class per grade level, which are called sections , which students are assigned when they start primary school, which makes it less likely that students are sorted in a non-random fashion. Besides, every section has a specific classroom where students are instructed in most of their courses; thus, students do not need to move among different classrooms throughout the school day. At the primary school, the teacher assigned to a section is usually responsible for the majority of the courses; whereas, at the secondary school, it is often the case that there is a different teacher for each course. Another characteristic of the Peruvian education system is that it allows parents to send their children to any school, public or private, even if that school is outside their district of residence.

According to the last National Population Census in 2017, Peru has achieved almost universal coverage of education, 94.9% of the population aged 12 or over have primary education, and 74.5% aged 17 or over have secondary education. These numbers, however, mask a disability gap. Among adults aged 17 or over, 14.1% of people with at least one disability report having no education, whereas only 3.9% of people with no disabilities report the same. There is also an educational disability gap of 11.9 percentage points (p.p.) among the female population, but it decreases to 7.1 p.p. among the male population. These figures suggest that having a disability poses a larger burden for females than for males.

In this context, the Peruvian National Education Law recognized in 2003 inclusive education as the main approach to providing education to students with SEN, which should be accompanied by supplementary one-to-one attention by specialists (Congreso de la República, 2003 ). Thus, the Peruvian legal framework advocates an inclusive approach to integrating children and youth with disabilities into society. Aligned with the national inclusive policy, the state, as per the 2012 General Law of Persons with Disabilities (Law 29973), ensures access to quality inclusive education that accommodates individual needs. This entails adjustments in infrastructure, furniture, materials, curriculum, and teaching processes, all aimed at facilitating quality learning and fostering the comprehensive development of each student. It is worth noting, however, that empirical evidence indicates that many regular schools lack the necessary infrastructure, materials, and human resources to accommodate students with disabilities (Cueto et al., 2018 ; Peruvian Ombudsman, 2011 ).

The basic education system comprises three modalities: regular basic education (EBR), alternative basic education (EBA), and special basic education (EBE). EBR represents conventional formal education. EBA caters to students who lack access to EBR, emphasizing vocational and entrepreneurial skills. EBE is designated for students with SEN related to disability, talent, or giftedness. EBA and EBR schools, when admitting students with SEN, are termed inclusive schools . EBE operates in both inclusive schools and standalone EBE schools. In inclusive schools that accept students with mild disabilities and giftedness, EBE provides support and guidance through programs like Support and Advisory Services for Special Educational Needs (SAANEE). This includes personalized services and support to students, parents, teachers, and school principals through weekly visits of specialized professionals (Congreso de la República, 2006 ). Nevertheless, the evidence shows that inclusive education in Peru is far from successfully being implemented, and it is combined with an “integration approach” (Peruvian Ombudsman, 2011 ). On the other hand, dedicated EBE schools directly serve severe and multi-disabled students with needs beyond the scope of EBR or EBA schools. EBR and EBA schools are mandated to reserve at least two slots per classroom during the enrollment period for the inclusion of students with mild or moderate disabilities. However, in practice, this requirement is not systematically fulfilled (Cueto et al., 2018 ).

Data and methodology

In this study, we use three datasets that are collected by the Peruvian Ministry of Education (MINEDU). First, we utilized the Student Census Evaluation (ECE) as our primary data source, which encompasses the scores achieved by students in the national standardized tests of reading and mathematics Footnote 3 . To create our dependent variable, “learning achievement”, we transformed these scores into z -scores, standardizing them by grade level and by subject to have a mean of zero and a standard deviation of one for use in our econometric analysis. Furthermore, the ECE dataset includes additional demographic information such as gender and the primary language spoken by the students. The ECE started in 2007, with annual assessments of students in the 2nd grade of primary (2P). Subsequently, it was expanded in 2015 to encompass students in the 2nd grade of secondary (2S). In 2017, however, the ECE was not conducted. Our second dataset is the National School Census (CE) which contains information regarding school characteristics and grade composition. The CE has been yearly collected since 2004, and it covers public and private schools. We use it to measure inclusive education by identifying the presence of SEN students at the section level. These two datasets are merged at the school level through a school identifier; thus, each student is linked to section characteristics in the school he or she is attending. The last dataset is the Information System to Support the Management of the Education Institution (SG), which was implemented in 2003 but has been mandatory only since 2011. The SG contains information that is uploaded every year by teachers or school principals. This includes students’ age, mothers’ age and education, and number of siblings. The SG is merged with the other datasets by using a student identifier.

For our analysis, we focus on students attending 2P in the period dating from 2011 to 2016 (excluding 2014) Footnote 4 and students attending 2S from 2015 to 2019 (excluding 2017). Footnote 5 For both grades, 2P and 2S, we account for potential grade advancement and delay. Footnote 6 Therefore, in the case of 2P where students are usually 7 years old, we include children aged between 6 and 8 years, and for 2S where students are usually 13 years old, we include children aged between 12 and 14 years. The final number of observations for 2P comprises 55,637 students who took the reading test and 55,614 students who took the mathematics test. And, for 2S, we have 47,491 students who took the reading test and 47,484 students who took the mathematics test.

To evaluate the influence of inclusive education on non-SEN students’ learning achievement, we use the CE where the school principal reports the number of SEN students placed in each grade level every year and per type of SEN. Footnote 7 This report is based on medical certificates, psycho-pedagogical certificates, and parents’ affidavits. Thus, we can identify the presence of SEN students per section to measure inclusive education. Footnote 8 Besides, we disaggregate the presence of SEN students per type. Specifically, we distinguish, for each section, the presence of students with mobility, vision, hearing, and intellectual or learning disabilities, as well as those with autistic spectrum disorder (ASD). In the case of intellectual or learning disabilities, the CE includes those students with Down syndrome, brain injury, dyslexia, and developmental aphasia. The other SEN types considered in the CE include students with speech impairment, deaf-blindness, and hospitalized. Although gifted students are identified as SEN students in the CE, we exclude them in our measure of SEN.

There are three main challenges to estimating peer effects, as stated by Manski ( 1993 ), that could hinder proper identification of the influence of SEN students on the learning achievement of their non-SEN peers. First, students in the same cohort could face similar environmental factors or have similar unobserved characteristics that may influence their academic outcomes rather than having classmates with SEN. To disentangle the environment from peer effects, we follow the literature by using a large number of observations and fixed effects (Balestra et al., 2022 ; Burke and Sass, 2013 ).

Second, there is a potential reflection problem as classmates may influence each other and determine their outcomes simultaneously. Since we focus on SEN characteristics related to physical disabilities, health issues, and injuries determined by specialists, it is less likely that the SEN status of students was determined by the learning achievement of their non-SEN peers.

The third problem is related to self-selection. In the Peruvian school system, parents may choose to send their children to any school regardless of their district of residence; thus, specific school characteristics may attract certain types of students. To address this problem, we restrict the analysis to schools with similar characteristics. We select schools located in urban areas providing mixed-sex education that operate on the main school campus only during the morning shift and with 10–30 students per section. In the case of primary education, we select full-grade schools. Footnote 9 Besides, to address a potential sorting problem that could make it difficult to identify whether the learning outcome is due to the presence of SEN students or one’s ability, we select schools with one section per grade level. In this way, we avoid the possibility for school administrators to group students into sections based on their characteristics or for parents to choose a section without SEN students. Finally, more than 90% of non-SEN students take the standardized national tests, which suggests that school principals do not select high-performance students to take these tests.

To test the validity of our identification strategy, we perform two balancing checks for 2P and 2S, presented in Tables 1 and 2 , respectively. To perform these balancing checks, we use only students who took both reading and mathematics standardized tests, rather than separating them by subject as we do for the econometric analyses. Panels A, B, and C show that the presence of at least one SEN student does not determine the gender, language, or age of non-SEN students, respectively. We observe that coefficients are statistically not significant, and their size is smaller in comparison to those from the main analysis, except for reading test scores in 2S. In addition, panel D shows that individual characteristics do not determine the presence of at least one SEN student in the classroom. These results provide evidence against the likelihood of selection into classrooms.

To examine the impact of inclusive education on standardized test performance of non-SEN students, we estimate the following linear model:

Equation ( 1 ) is estimated separately for each grade level (2P or 2S) and subject (reading or mathematics) using a linear regression. \({{{\rm {EDC}}}}_{{i{\rm {s}}t}}\) is the learning achievement of student \(i\) in section \({s}\) at year \(t\) , measured by the z -score of the standardized test. \({{{\rm {SEN}}}}_{{{\rm {s}}}t}\) is a dichotomous variable capturing the presence of at least one SEN student in section \({s}\) at year \(t\) ; thus, \({\alpha }_{1}\) is our parameter of interest. In other specifications below, \({{{\rm {SEN}}}}_{{{s}t}}\) will be differentiated by type of SEN. \({{{\rm {STD}}}}_{{i{s}t}}\) is a vector of student-level control variables that include age in years and indicators for gender (1 = women) and spoken language (1 = indigenous). The vector \({{{\rm {SEC}}}}_{{st}}\) controls for section-level variables without student \(i\) . It includes mean age, proportion of male students, proportion of indigenous speakers, and number of students. The vector \({{{\rm {SCH}}}}_{t}\) includes number of students at the school level. \({{{\rm {HH}}}}_{{it}}\) includes the following household characteristics: mother’s age, mother’s education, and the number of siblings. We also include school-fixed effects \(\left({\gamma }_{{s}}\right)\) Footnote 10 and year-fixed effects \(\left({\gamma }_{t}\right)\) . Finally, \({\varepsilon }_{{i{s}t}}\) is an unobserved error term, and we cluster standard errors at the section level as this is the common environment shared by students (Balestra et al., 2022 ).

To assess potential heterogeneous influences, we follow recent literature Footnote 11 and estimate Eq. ( 1 ) using split samples by the characteristic of interest (Feigenberg et al., 2023 ). In particular, we evaluate the gender of the student \(i\) . For section characteristics, we evaluate the number of students. Finally, we assess the varying estimates based on the mother’s age and the mother’s education. In the case of characteristics that are represented by continuous or categorical variables, we convert them into dichotomous variables. For the number of students, we split the sample between sections that have 20 or fewer students and sections with 21 or more students. In the case of the mother’s age, we use the mean age to split the sample above and below the mean. The mean age is 41.5 for those mothers with children who attend 2P and 44.8 for those with children who attend 2S. Finally, for mothers’ education, we split the sample between those with and without tertiary education.

The descriptive statistics for our final cross-section subpopulations are presented in Table 3 . All descriptive and econometric analyses were conducted using Stata 18. In this case, we combine observations that include students who took both reading and mathematics standardized tests, as the characteristics of the separated subpopulations are similar to each other. According to Table 3 , students with SEN generally have lower reading and mathematics scores compared to their peers without SEN across both primary and secondary grades. This trend is more pronounced in 2S compared to 2P. We also observe in Table 3 that the proportions of women and indigenous language speakers are relatively consistent across SEN and non-SEN cohorts. Approximately 48% of the students are female, and the average age is 6.9 in 2P and 12.9 in 2S. However, it is interesting to note that the mean proportion of indigenous language speakers is higher in 2S (~22%) compared to 2P (~12%), indicating a potential demographic shift as students progress through the education system. A similar trend for indigenous language speakers is observed at the section level. Moreover, figures in Table 3 show that the mean age in a section is ~7.2 in 2P and 13.3 in 2S, the sample is balanced between male and female students at the section level, and there are around 20 students per section. Regarding household characteristics, the average age of mothers is 41.5 for those with children in 2P and 44.8 for those with children in 2S, around 6 out of 10 students have mothers with primary or secondary education, and the majority of students have more than two siblings. Finally, students enrolled in primary education typically attend larger schools, characterized by a pupil population exceeding 120, in contrast to those in secondary education, where schools typically accommodate fewer than 100 students.

Empirical results

Regression results from Eq. ( 1 ) are shown in Table 4 . Footnote 12 For column (1), we use ECE and CE datasets, which do not include students’ age or household characteristics. For columns (2) through (6), we add the SG dataset to incorporate students’ age and household characteristics. Columns (1) through (4) include the proportion of repeaters and the presence of at least one specialized teacher when students were 3 years old, and they were not attending school; thus, the presence of an SEN student should not influence the proportion of repeaters or presence of a specialized teacher. Columns (5) and (6) do not include those variables, and the results remain similar to those obtained in the previous columns. In addition, as a robustness check, we try different subpopulations based on students’ age (columns (2) through (4)) and schools with variation in SEN students (column (6)). For all the specifications, our results consistently show that the presence of at least one SEN student as a measure of inclusive education does not have a significant influence on the learning achievement of students who attend 2P or 2S. Our findings align with similar results from other countries such as Canada (Friesen et al., 2010 ), England (Keslair et al., 2012 ), and the Netherlands (Ruijs, 2017 ), indicating that inclusive education does not have a significant impact on the academic achievement of non-SEN students.

Nevertheless, we notice in Table 4 that, after including students’ age and household characteristics, the negative relationship between inclusive education and learning achievement (column 1) turned into a positive relationship (columns 2 through 6). Even in the case of students who attend 2S, the magnitude of the positive relationship between inclusive education and mathematics scores increased when student’s age and household characteristics were included in the regression. This suggests that the attributes of a student’s household, along with individual traits correlated with them, such as motivation, self-discipline, and parental support, may exert a positive influence on their learning environment. This influence could potentially counterbalance any adverse effects of inclusive education. An alternative explanation lies in the interaction effects between inclusive education and these supplementary factors. For instance, older students or those from more privileged households could potentially derive greater benefits from inclusive education due to their increased adaptability to the classroom environment. We further explore these issues in the Heterogeneity analysis section.

The main results, however, may mask different outcomes by type of SEN. Table 5 shows the results from Eq. ( 1 ) using the presence of at least one student with a certain type of SEN as a measure of inclusive education. Results Footnote 13 in Table 5 are estimated by gradually adding control variables in each column. Columns (1) and (6) do not include any control variable. Columns (2) and (7) add student controls. Cohort controls are added in columns (3) and (8), and school controls are added in columns (5) and (9). Finally, family controls are added in columns (5) and (10). As we can see in Table 5 , adding variables does not substantially change the estimates. We also notice that the sign of the relationship between inclusive education and learning achievement varies by type of SEN, and only vision disability (panel A) and mobility disability (panel B) have a significant positive relationship with the standardized test scores of students who attend 2P and 2S, respectively. As we can observe in Table 5 , even when we use the Romano-Wolf multiple hypothesis correction, the significance of our findings remains similar across different specifications (cf. Clarke, 2021 , Clarke et al., 2020 ). These findings confirm our main results that inclusive education would not harm the learning performance of non-SEN students, regardless of the type of SEN presented by their peers.

Results in Table 5 show that the impact of attending an inclusive classroom with at least one SEN student with a vision disability increases the reading and mathematics scores of students who attend 2P by 0.135 (adjusted p -value < 0.05) (column 5) and by 0.154 (adjusted p -value < 0.05) (column 10) of a standard deviation, respectively. In the case of students who attend 2S, the impact of the presence of at least one student with mobility disability increases the performance on reading and mathematics tests by 0.099 (adjusted p -value < 0.01) (column 5) and by 0.100 (adjusted p -value < 0.05) (column 10) of a standard deviation, respectively. Similar to our results, Ruijs ( 2017 ) found that the presence of students with vision disabilities as well as physical and intellectual disabilities in the third level of pre-vocational secondary education in the Netherlands increases standardized test scores of non-SEN students. Moreover, previous studies pointed out that non-SEN students show more positive attitudes toward their peers with physical disabilities (de Boer et al., 2012 ), which may explain the positive influence of SEN students with vision and mobility disabilities that we have found on the learning achievement on non-SEN students.

Heterogeneity analysis

We further undertake several analyses to understand the differences in the impact of inclusive education. Footnote 14 Clogg’s z -test is implemented for testing the statistical significance of the difference between the coefficients estimated separately by splitting Eq. ( 1 ) (Clogg et al., 1995 ).

Estimates of inclusive education by gender of non-SEN students are presented in Table 6 . The results show that the influence of inclusive education on learning achievement is not statistically significant for men or women, and there is no statistical difference between them.

To explore the influence of inclusive education by usage of adequate resources, we analyze the influence of the total number of students at the section level. We find that inclusive education is associated with higher scores in reading and mathematics for non-SEN students who attend classrooms with 10–20 students and with lower scores for those who attend classrooms with 21–30 students, regardless the student attends 2P or 2S. This result may reflect that small groups foster a closer interaction between students and teacher which in turn may allow the teacher to develop better teaching strategies since they know each student better. The result of inclusive education by section size, however, is statistically different only for the reading score obtained by non-SEN students who attend 2S. This result underscores the complexity of inclusive education’s effects and the importance of context-specific considerations. Authorities should pay special attention to the number of students assigned to an inclusive classroom.

To analyze the household’s characteristics, we use the mother’s age and education. In the case of reading and mathematics in 2P, it seems that older mothers help to improve the scores of non-SEN students who attend an inclusive classroom; but there is not a clear pattern in the case of 2S. The differences in the test scores by mother’s age, however, are not statistically significant in any case, 2P or 2S. We have to take this result with caution as it is possible that other family characteristics rather than the mother’s age act as a moderator that could influence the effect of inclusive education on children’s outcomes in school (Leigh and Gong, 2010 ; López Turley, 2003 ).

We also present in Table 6 the estimates of inclusive education on test scores of non-SEN students by mother’s education. We observe that the difference in inclusive education’s influence on test scores in reading and mathematics is not statistically different regardless mother’s education. Although the difference is small and not significant, we observe that among non-SEN students in 2P and 2S with well-educated mothers (i.e., tertiary education), inclusive education is associated with lower scores in reading and mathematics. This finding may suggest that well-educated mothers may dedicate fewer hours to helping their children as they are more likely to work outside the home in comparison to less-educated mothers.

The current study focused on the learning achievement of non-SEN students in Peru who attend an inclusive classroom. We use three rich administrative datasets that allow us to measure inclusive education by the presence of at least one SEN student in the classroom, which is the appropriate setting as students spend their school day mostly within the classroom. Thus, we are able to capture the influence of inclusive education on the test scores of non-SEN students on national standardized tests in reading and mathematics.

Inclusive strategies in regular classrooms are undeniably crucial, but without appropriate adaptations and a comprehensive understanding by all involved, inclusive education can pose considerable challenges for the entire educational community, including non-SEN students (Edwards et al., 2019 ; Nilsen, 2020 ). While some studies for developed countries show that the learning achievement of non-SEN students is improved by attending inclusive classrooms and others point to negative effects, there is limited evidence regarding the impact of inclusive education for developing countries. From this perspective, our study contributes to the literature by examining the case of inclusive education in Peru and its consequences on non-SEN students. To the best of our knowledge, this topic has not been previously analyzed in the Peruvian context. Further, we explore the influence of inclusive education by type of SEN and undertake a heterogeneity analysis.

Overall, this study has found that the inclusion of SEN students in regular classrooms, on average, yields no substantial implications for their non-SEN counterparts. Our results have shown consistency among the different model specifications estimated using several subpopulations with different age ranges as well as an additional sub-population restricted to schools with variation in the presence of SEN students. Nevertheless, it is worth noticing that there is a negative relationship between inclusive education and learning achievement of non-SEN students that turns into a positive relationship when the mother’s characteristics are included in the analysis. This may present an opportunity for school authorities to involve parents in the learning process of their kids to enhance inclusive education programs, as the literature suggests that the way inclusive education is implemented may lead to positive results on the academic performance of non-SEN students (Szumski et al., 2017 ).

We also found that the implications of inclusive education are contingent upon the specific type of SEN. In particular, non-SEN students benefit from attending classrooms with at least one student with a vision disability in 2P and a mobility disability in 2S. This finding underscores differential effects between lower and later grades, a phenomenon previously noted in the literature (Kart and Kart, 2021 ). Also, this result should draw attention from policymakers interested in inclusive education as schools may be more suitable to assist this type of SEN students, whereas the potential lack of resources to support other types of SEN might detrimentally affect SEN and non-SEN students (Edwards et al., 2019 ). In addition, we find that the influence of inclusive education is heterogeneous. We find that the small size of the classroom (20 or fewer students) helps to improve learning achievement in reading for non-SEN students who attend an inclusive classroom in 2S. Similar to previous literature (e.g., Szumski et al., 2017 ), this finding points to the need for educational policymakers to increase the budget for inclusive education, targeting to hire more and adequate resources. Finally, the mother’s characteristics are not relevant to explain differences in the estimates of inclusive education on academic achievement of non-SEN students.

Despite the contributions made by this study, some potential limitations could be addressed by future research. First, due to a lack of data, we are not able to incorporate a measure that reflects the diverse intensity of a disability (Oh-Young and Filler, 2015 ) that could be associated with different costs (Nicoriciu and Elliot, 2023 ). Second, the datasets employed in this analysis are unavailable for certain years, precluding our use of data from ECE before 2011. Additionally, the variable indicating the language spoken in 2S was not present in the same dataset (CE) for the years 2018 and 2019. Finally, despite our efforts to mitigate concerns related to omitted variable bias, we concede the possibility of residual biases. Specifically, we omitted socioeconomic status from our analysis due to substantial rates of missing data.

Data availability

The datasets used in this study are available from the Peruvian Ministry of Education repository upon request.

In the literature, there are three main approaches: (i) segregation, (ii) integration, and (iii) inclusive (see e.g., Dixon, 2005 ; Kiuppis, 2014 ; Madhesh, 2023 ).

It is worth noting that results from countries like Peru are not directly comparable to those previously presented by Contreras et al. ( 2020 ). Indeed, academic performance in Peru is poorer relative to Chile, as reported by the Program for International Student Assessment (PISA) and it does not receive monetary incentives to enroll children with SEN. Furthermore, Chile displays a particular institutional framework worldwide since state-subsidized private schools (voucher schools) have around 50% of total enrollment (CEM, 2019 ). Thus, insights from the Peruvian case are valuable for other comparable countries.

Although the ECE evaluates other subjects, only mathematics and reading were evaluated in every ECE. Students attending 2nd grade of primary were evaluated from 2007 to 2016 on mathematics and reading. In the case of students attending 2nd grade of secondary, they were evaluated on mathematics and reading from 2015 to 2019 (except 2017), social sciences in 2016 and 2018, and science and technology in 2018 and 2019.

Unfortunately, information for SG was not available before 2011, and the MINEDU did not provide information for 2014.

The ECE was not conducted in 2017.

Advancement and delay in 2P (2S) are determined based on the chronological age of the students as of March 31. If a student is one year younger than the standard age of 7 (13), it would be considered advancement. Conversely, if a student is one year older than the standard age, that is, age of 8 (14), it would be considered within a delay.

Since we only include schools with one section per grade, the number of SEN students reported by grade is used to account for the presence of SEN students at the section level.

A cohort refers to the students within the same section for each grade level and year.

Full-grade refers to primary schools where teachers do not teach more than one grade in the same classroom.

Since we work with schools that have only one section, school-fixed effects can also be understood as section-fixed effects.

Feigenberg et al. ( 2023 ) state that using a split-sample approach is equivalent to a fully interacted model but avoids losing statistical power. Likewise, they state that, unlike a model with only one interaction, the split-sample approach reduces bias due to omitted variables.

Results, including all control variables, are presented in the Supplementary Information. Tables S1 and S2 for reading and mathematics in 2P, respectively. Tables S3 and S4 for reading and mathematics in 2S, respectively.

Results, including all control variables, are presented in Supplementary Information Table S5 .

Results, including all control variables, are presented in Supplementary Information from Table S6 to Table S10 .

Ahmed A, Hammarstedt M, Karlsson K (2021) Do schools discriminate against children with disabilities? A field experiment in Sweden. Educ Econ 29(1):3–16

Article   Google Scholar  

Ainscow M, César M (2006) Inclusive education ten years after Salamanca: setting the agenda. Eur J Psychol Educ 21(3):231–238

Ammermueller A, Pischke J (2009) Peer effects in European primary schools: evidence from the progress in international reading literacy study. J Labor Econ27(3):315–348

Balestra S, Eugster B, Liebert H (2022) Peers with special needs: effects and policies. Rev Econ Stat 104(3):602–618

Burke M, Sass T (2013) Classroom peer effects and student achievement. J Labor Econ 31(1):51–82

CEM (2019) Estadísticas de la educación 2018. Publicación 2019. Centro de Estudios MINEDUC

Clarke D (2021) rwolf2 implementation and flexible syntax https://www.damianclarke.net/computation/rwolf2.pdf

Clarke D, Romano J, Wolf M (2020) The Romano-Wolf multiple-hypothesis correction in Stata. Stata J 20(4):812–843

Clogg C, Petkova E, Haritou A (1995) Statistical methods for comparing regression coefficients between models. Am J Sociol 100(5):1261–1293

Cole C, Waldron N, Majd M (2004) Academic progress of students across inclusive and traditional settings. Mental Retard 42:136–144

Congreso de la República (2003) Ley General de Educación. Ley 28044. https://leyes.congreso.gob.pe/Documentos/Leyes/28044.pdf

Congreso de la República (2006) Directiva No. 076-2006-VMGP/DINEBE https://www.minedu.gob.pe/normatividad/resoluciones/rd_0354-2006-ed.pdf

Contreras D, Brante M, Espinoza S, Zuñiga I (2020) The effect of the integration of students with special educational needs: evidence from Chile. Int J Educ Dev 74:102163

Cueto S, Rojas V, Dammer M, Felipe C (2018) Cobertura, oportunidades y percepciones sobre la educación inclusiva en el Perú. GRADE

de Boer A, Pijl S, Minnaert A (2012) Students’ attitudes towards peers with disabilities: a review of the literature. Int J Disabil Dev Educ 59(4):379–392

Dell’Anna S, Pellegrini M, Ianes D (2021) Experiences and learning outcomes of students without special educational needs in inclusive settings: a systematic review. Int J Incl Educ 25(8):944–959. https://doi.org/10.1080/13603116.2019.1592248

Dixon S (2005) Inclusion—not segregation or integration is where a student with special needs belongs. J Educ Thought 39(1):33–53

Google Scholar  

Edwards B, Cameron D, King G, McPherson A (2019) How students without special needs perceive social inclusion of children with physical impairments in mainstream schools: a scoping review. Int J Disabil Dev Educ 66(3):298–324

Feigenberg B, Ost B, Qureshi J (2023) Omitted variable bias in interacted models: a cautionary tale. Rev Econ Stat https://doi.org/10.1162/rest_a_01361

Filmer D (2008) Disability, poverty, and schooling in developing countries: results from 14 household surveys. World Bank Econ Rev 22(1):141–163

Fletcher J (2010) Spillover effects of inclusion of classmates with emotional problems on test scores in early elementary school. J Policy Anal Manag 29(1):69–83

Friesen J, Hickey R, Krauth B (2010) Disabled peers and academic achievement. Educ Financ Policy 5(3):317–348

Goico S (2019) The impact of “inclusive” education on the language of deaf youth in Iquitos, Peru. Sign Language Stud 19(3):348–374

Gottfried M (2014) Classmates with disabilities and students’ noncognitive outcomes. Educ Eval Policy Anal 36(1):20–43

Gottfried M, Egalite A, Kirksey J (2016) Does the presence of a classmate with emotional/behavioral disabilities link to other students’ absences in kindergarten? Early Child Res Q 36:506–520

Gottfried M, McGene J (2013) The spillover effects of having a sibling with special educational needs. J Educ Res 106(3):197–215

Hanushek J, Kain J, Rivkin S (2002) Inferring program effects for special populations: does special education raise achievement for students with disabilities? Rev Econ Stat 84(4):584–599

Kart A, Kart M (2021) Academic and social effects of inclusion on students without disabilities: a review of the literature. Educ Sci 11(1):1. https://doi.org/10.3390/educsci11010016

Keslair F, Maurin E, McNally S (2012) Every child matters? An evaluation of “special educational needs” programmes in England. Econ Educ Rev 31(6):932–948

Kiuppis F (2014) Why (not) associate the principle of inclusion with disability? Tracing connections from the start of the ‘Salamanca process. Int J Incl Educ 18(7):746–761

Krämer S, Möller J, Zimmermann F (2021) Inclusive education of students with general learning difficulties: a meta-analysis. Rev Educ Res 91(3):432–478. https://doi.org/10.3102/0034654321998072

Kristoffersen J, Krægpøth M, Nielsen H, Simonsen M (2015) Disruptive school peers and student outcomes. Econ Educ Rev 45:1–13

Lavy V, Silva O, Weinhardt F (2012) The good, the bad, and the average: evidence on ability peer effects in schools. J Labor Econ 30(2):367–414

Lazear E (2001) Educational production. Q J Econ 116(3):777–803

Leigh A, Gong X (2010) Does maternal age affect children’s test scores? Aust Econ Rev 43(1):12–27

López Turley R (2003) Are children of young mothers disadvantaged because of their mother’s age or family background? Child Dev 74(2):464–474

Madhesh A (2023) The concept of inclusive education from the point of view of academics specialising in special education at Saudi universities. Humanit Soc Sci Commun 10:278

Manski C (1993) Identification of endogenous social effects: the reflection problem. Rev Econ Stud 60:531–542

Article   MathSciNet   Google Scholar  

Mitra S, Sambamoorthi U (2008) Disability and the rural labor market in India: evidence for males in Tamil Nadu. World Dev 36(5):934–952

Nicoriciu A, Elliot M (2023) Families of children with disabilities: income poverty, material deprivation, and unpaid care in the UK. Humanit Soc Sci Commun 10:519

Nilsen S (2020) Inside but still on the outside? Teachers’ experiences with the inclusion of pupils with special educational needs in general education. Int J Incl Educ 24(9):980–996

OAS (2018) Program of action for the decade of the Americas for the rights and dignity of persons with disabilities. OAS, Washington, DC

Olusanya B, Kancherla V, Shaheen A, Ogbo F, Davis A (2022) Global and regional prevalence of disabilities among children and adolescents: analysis of findings from global health databases. Front Public Health 10:977453

Article   PubMed   PubMed Central   Google Scholar  

Ombudsman P (2011) Los niños y niñas con discapacidad: Alcances y limitaciones en la implementación de la política de educación inclusiva en instituciones educativas del nivel primaria. Serie Informes Defensoriales, Informe 155. Lima, Defensoría del Pueblo

Ombudsman P (2019) El derecho a la educación inclusiva. Barreras en la implementación de los servicios educativos públicos y privados para estudiantes con discapacidad y con otras necesidades educativas. Serie Informes Defensoriales, Informe 183. Lima, Defensoría del Pueblo

Rangvid B (2019) Returning special education students to regular classrooms: externalities on peers’ reading scores. Econ Educ Rev 68:13–22

Rangvid B (2022) Special educational needs placement in lower secondary education: the impact of segregated vs. mainstream placement on post-16 outcomes. Educ Econ 30(4):399–425

Razavi S (2012) World development report 2012: gender equality and development—a commentary. Dev Change 43(1):423–437

Ruijs N (2017) The impact of special needs students on classmate performance. Econ Educ Rev 58:15–31

Ruijs N, Peetsma T (2009) Effects of inclusion on students with and without special educational needs reviewed. Educ Res Rev 4:67–79

Szumski G, Smogorzewska J, Karwowski M (2017) Academic achievement of students without special educational needs in inclusive classrooms: a meta-analysis. Educ Res Rev 21:33–54. https://doi.org/10.1016/j.edurev.2017.02.004

Oh-Young C, Filler J (2015) A meta-analysis of the effects of placement on academic and social skill outcome measures of students with disabilities. Res Dev Disabil 47:80–92. https://doi.org/10.1016/j.ridd.2015.08.014

Article   PubMed   Google Scholar  

UNESCO (1994) T he Salamanca statement and framework for action on special needs education. Adopted by the world conference on special needs education: access and quality. UNESCO

Van Mieghem A, Verschueren K, Petry K, Struyf E (2020) An analysis of research on inclusive education: a systematic search and meta review. Int J Incl Educ 24(6):675–689. https://doi.org/10.1080/13603116.2018.1482012

Download references

Acknowledgements

This paper was supported by the Peruvian Economic and Social Research Consortium (grant No. A1-PB03, CIES 2022). The authors express their gratitude to the participants of the XXXIV Annual Research Seminar 2023 hosted by the Economic and Social Research Consortium (CIES), as well as to two anonymous referees for their invaluable feedback, which contributed to the improvement of this manuscript. Special thanks to Juan Castañeda and Jonatan Amaya for their outstanding research assistance in earlier versions of this study. All remaining errors are our own.

Author information

Authors and affiliations.

Facultad de Ciencias Económicas y Empresariales, Universidad de Piura, Av. Ramón Mugica 131, Urb. San Eduardo, Piura, Perú

V. B. Salas García

Departamento de Economía, Pontificia Universidad Católica del Perú, Av. Universitaria 1801, Lima, 15088, Perú

José María Rentería

You can also search for this author in PubMed   Google Scholar

Contributions

All the authors contributed equally to this work.

Corresponding author

Correspondence to V. B. Salas García .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

Additional information.

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Salas García, V.B., Rentería, J.M. Students with special educational needs in regular classrooms and their peer effects on learning achievement. Humanit Soc Sci Commun 11 , 521 (2024). https://doi.org/10.1057/s41599-024-03002-8

Download citation

Received : 09 November 2023

Accepted : 27 March 2024

Published : 17 April 2024

DOI : https://doi.org/10.1057/s41599-024-03002-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Open access
• Published: 26 April 2024

Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study

• Jerry Draper-Rodi   ORCID: orcid.org/0000-0002-1900-6141 1 , 2 ,
• Hilary Abbey 1 ,
• John Hammond 3 ,
• Oliver T. Thomson 1 ,
• Kevin Brownhill 1 ,
• Andrew MacMillan 1 , 4 ,
• Yinka Fabusuyi 1 &
• Steven Vogel 1  

BMC Medical Education volume  24 , Article number:  468 ( 2024 ) Cite this article

Metrics details

Individuals from minority groups have historically faced social injustices. Those from underrepresented groups have been less likely to access both healthcare services and higher education. Little is known about the experiences of underrepresented students during their undergraduate studies in osteopathy in the UK. The aim of this project was to explore awareness of cultural diversity and beliefs about patients from underrepresented groups in current osteopathic educational environments and evaluate students’ preparedness to manage patients from diverse groups. The project also aimed to investigate the educational experiences of students from underrepresented backgrounds during their training and their opinions on changes that could support better levels of recruitment and achievement. The findings were discussed with stakeholders in interactive workshops with the aim to develop recommendations for action and change.

A transformative action research paradigm informed this mixed methods project. It included: 1/ a survey of students from all seven osteopathic educational providers in the UK using the Multidimensional Cultural Humility Scale (MCHS); 2/ a series of focus groups with students from underrepresented groups (women, students with disabilities, students from minority ethnic backgrounds, and students identifying as LGBTQIA+); and 3/ a workshop forum to discuss findings.

A total of 202 participants completed the MCHS and demographic questionnaire and seven focus groups were conducted. A model was developed to describe participants’ training experiences comprising two main themes: institutional contextual obstacles (with four sub-themes) and underrepresented students’ conceptual understanding of Equity, Diversity and Inclusion (EDI). Recommendations for change identified in the workshops were based on three topics: institutions, staff, and students.

Our findings confirm conclusions from other institutions that staff education is urgently needed to create and maintain equitable, inclusive environments in osteopathic educational institutions in the UK to support all students, particularly those from underrepresented groups. Institutional EDI processes and policies also need to be clarified or modified to ensure their usefulness, accessibility, and implementation.

Peer Review reports

Social injustices affecting people from minority groups have been highlighted in recent worldwide initiatives such as the ‘Black Lives Matter’ [ 1 ] and ‘Me Too’ [ 2 ] movements and investigations have identified institutional racism, sexism and homophobia in the police, other public services, and business organisations [ 3 , 4 , 5 , 6 ]. Limited demographic diversity and evidence of discrimination against minority groups have been reported in higher education in the United Kingdom (UK) [ 7 ] and in healthcare services including medicine, psychiatry, and physiotherapy [ 8 , 9 , 10 ]. Data from higher education institutions suggest there is an urgent need to improve recruitment, educational experiences, and attainment for students from minority groups [ 11 , 12 , 13 ].

The terms ‘minority’ or ‘under-represented’ are often used interchangeably to describe groups of people identified by specific demographic or cultural characteristics. In this paper, the term ‘under-represented’ is used to emphasise that experiences of inequity are typically created and maintained by social constructs such as ‘othering’: the process of identifying people as different from oneself or the mainstream culture, often associated with negative beliefs and expectations [ 14 ]. Social constructs can provide both unearned advantage (‘privilege’) and disadvantage (‘oppression’) [ 15 ]. Characteristics used to identify others can include skin colour, ethnicity, religion, gender identity, sexual identity, ability, size, socioeconomic status, history of trauma, addiction, and family environment [ 15 ].

People from under-represented groups (UrGs) have historically been less likely to access higher education [ 16 ], although the number of BAME, LGBTQIA + and disabled students is gradually increasing in England [ 17 , 18 ]. Enrolled students from these groups are reported to experience more negative experiences during training and more limited later career opportunities afterwards [ 19 , 20 ]. The General Medical Council (GMC) recently set new targets to improve access and outcomes for students from UrGs [ 21 ] as lack of diversity and limited cultural awareness among practitioners from different healthcare professions also impacts the quality and outcomes of healthcare for patients from UrGs [ 12 , 22 , 23 ]. The Council of Deans recently published a report on how to build an inclusive environment which highlights issues that affect students from minority ethnic groups in Allied Health Professions [ 24 ].

Patients from UrG experience substantial health disparities in the UK and across the globe due to structural and interpersonal discrimination [ 25 , 26 ]. Developing cultural humility in clinicians is seen as key to bridging the gap of interpersonal discrimination. Cultural competence was once considered as an adequate way to provide an inclusive environment. It is defined as “a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or professions to work effectively in cross-cultural situations” ([ 27 ] p. iv). The concept shifted to cultural humility, defined as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” ([ 28 ] p. 354).

Osteopathy is a form of manual therapy which is now recognised as one of 14 Allied Healthcare Professions in England [ 29 ]. In the UK, there are currently seven osteopathic education providers (OEPs) and approximately 5,300 qualified osteopaths. Training is typically over four or five years in the form of Bachelor’s or Integrated Masters awards and practitioners then register with the statutory regulator, the General Osteopathic Council (GOsC), and are required to comply with professional standards of practice [ 30 ].

There is little known about discrimination, bullying and harassment in osteopathy education as highlighted in a recent systematic review [ 31 ]. Therefore, the current research project aimed to assess osteopathic students’ awareness of cultural diversity and beliefs about patients from UrGs and their preparedness in managing them; to explore the educational experiences of students with UrG backgrounds during training and their opinions on changes to support better levels of recruitment and achievement. Finally, the research was disseminated to stakeholders in workshops with the overall aim of developing recommendations for action and creating change.

To meet the multiple aims, a mixed methods approach was implemented and included the following stages; a survey of students attending all seven OEPs in the UK; focus groups with UrG students; and a workshop forum to explore the findings with diverse stakeholders. This design was based on a transformative action research paradigm with students participating as collaborators (Mertens 2007; 2010), informed by previous research into EDI, cultural competence and cultural humility in healthcare education, outlined below. The research complies with the Good Reporting of A Mixed Methods Study (GRAMMS) guidance [ 32 ] (see supplementary material 1 – GRAMMS reporting).

Figure  1 below details the mixed method stages with the quantitative data collection (top half of figure), qualitative data collection (bottom half), and mixed methods stages (middle). The stages are represented chronologically, starting on the left.

Study design

Methodology

This research project sits within a transformative paradigm that places central importance on studying the lives and experiences of marginalised groups and is appropriate for addressing inequality and injustice in society [ 33 ]. An explanatory sequential mixed methods design (survey followed by focus groups) was implemented to gain insight [ 34 ] and community members were involved in initial discussions about operationalising the research focus. Transformative research has power issues and inequalities at its core and a political agenda that aims to change the experiences of the participants and institutions involved [ 35 ]. The study was approved by the University College of Osteopathy Research Ethics Committee.

Community engagement

Two community engagement meetings with students from underrepresented groups were established prior to the project to ensure it was designed ‘with’ students rather than ‘to’, ‘about’ or ‘for’ them. Based on principles by [ 36 ], these community engagement meetings co-created the study design, modified the research questionnaire and recruitment approaches.

Quantitative stage

A survey of all students currently enrolled on an osteopathic course in the UK was chosen to explore the research objectives. All students enrolled at the seven OEPs in the UK (excluding postgraduate and CPD courses) were eligible to take part in the anonymous online survey on Qualtrics©. Invitations, study information and accessible links were disseminated via OEP contacts who sent it to their student body between 7th and 31st March 2022. Two reminders were sent.

Survey instrument

The Multidimensional Cultural Humility Scale (MCHS) was selected for this project as there is good evidence of convergent and discriminant validity and internal reliability [ 37 ]. The MCHS has five dimensions, contains 15 items with a 6-point Likert scale from ‘strongly disagree’ to ‘strongly agree’ where higher scores represent greater levels of cultural humility. The MCHS was used to understand to understand awareness of cultural sensitivity in the environment in which UrG students were learning. This project was not about clinical services. Modifications to the MCHS were necessary to contextualise it for osteopathy students, so a factor analysis was conducted to assess the validity of the adapted version. Following the community engagement meetings, a 7th category was added: ‘This has never crossed my mind’ to assess whether students were comfortable, confident or aware of particular issues (see supplementary material 2 for the adapted versions used in this study).

Questions related to demographics and personal characteristics (clinical or pre-clinical student, age, birth sex, gender, ethnicity, health and disability status, sexual orientation, and religion), and to their experience of education were included at the end of the MCHS and were analysed separately to the MCHS questionnaire.

Qualitative stage

Focus groups were selected for this phase and represented four UrG: ethnic minority, disability, LGBTQIA + or women. Whilst women are not numerically under-represented in UK osteopathic undergraduate training, socially they are more oppressed than men, including in manual therapy training [ 31 ]. The choice of these four groups was discussed and agreed as important priorities in the community engagement meetings. For sensitive topics, homogeneous groups foster a sense of belonging and facilitate disclosure [ 38 ]. Focus groups usually comprise 6 to 8 people who meet once for approximately 90–120 min, and the usual number of groups is around 4 but depends on the complexity of the topic and heterogeneity of the samples [ 39 ].

Students from any UK OEP who identified as belonging to at least one UrG (ethnic minority, disability, LGBTQIA + or women) were eligible to participate with students from the same and/or other OEPs. Each OEP was responsible for forwarding invitations to participate to their students. For convenience, focus groups were conducted online as students from different OEPs were geographically dispersed [ 40 ]. The research team members acting as focus group facilitators identified with one or more minority groups, representing diversity and were therefore part of the data, as is good practice in transformative paradigmatic research [ 41 ]. All facilitators had previously used focus group methods, participated in training, or were used to managing student group discussions. Teams© created automatic initial draft transcriptions to aid later transcription if participants talked simultaneously [ 39 ]. Final transcripts only included pseudonyms, as is common in qualitative research [ 42 ]. Focus groups sessions ran for approximately 90 min. Students who had participated in one of the four initial groups were invited to join one final mixed group to discuss the previous findings, and students who participated in at least one group were invited to take part in the workshop forum.

Dissemination forum and discussion workshops

An interactive face-to-face workshop-based forum was held on 06/04/2023 to disseminate the survey and focus group results, discuss their implications, and develop recommendations for action. Key stakeholders invited to attend free of charge included UK OEPs, the General Osteopathic Council, the Institute of Osteopathy, the Osteopathic Foundation, and other healthcare profession organisations, NHS representatives, and Health Education England. Approximately 70 people attended the event. Three interactive workshops focusing on specific aspects of EDI (students, staff and institutional governance), with different methods to promote open discussion, explored responses about ways to develop a more supportive educational environment and inclusive curriculum.

Mixed methods analysis

To assess whether the 5-factor model of the MCHS remained valid following changes made to the scale, a confirmatory factor analysis was carried out using using R (version 4.3.2) [ 43 ]and the R lavaan package (version 0.6–16) [ 44 ]. Missing MCHS data was imputed using multivariate imputation by chained equations [ 45 ]. MCHS data was checked for normality using QQ plots and the Henze-Zirkler test.

A sum of all MCHS items (reverse coded as appropriate) was calculated as an overall measure of cultural humility. Linear regression was carried out to determine which demographic factors influenced this total score. Additionally, a Welch Two Sample t-test [ 46 ] was carried out to determine if MCHS total score differed between clinical and pre-clinical students. Chi-squared tests, with p-values estimated by Monte-Carlo simulation, were used to test for associations between students’ report of having been treated differently one the one hand, and demographic factors on the other. Descriptive statistics were used to report survey results.

Focus group data analysis was conducted within a reflexive thematic analysis framework [ 47 ], which aligns with a transformative paradigm (Creswell 2014). Data was co-created by participants and facilitators, and themes were co-created with analysts through their thoughtful engagement with the data [ 47 ]. After conducting one focus group with each UrG ( n  = 4), early analysis was conducted. Another 4 focus groups with different students were conducted to analyse how these participants’ experiences resonated with the initial findings. The last focus groups ran with students from mixed UrGs to discuss the findings, conduct a meta-synthesis, and prioritise what actions students thought OEPs should prioritise.

Three interactive workshops were run to explore the resonance and implications of the quantitative and qualitative findings to date. Each workshop focused on either student, staff or institutional EDI issues, although there was inevitably some overlap, and each workshop ran three times to enable participants to contribute fully. Small groups of mixed stakeholders worked took part in varied activities to discuss the study’s findings and their ideas were recorded on post-it notes, flipcharts or noted by facilitators during plenary discussions. After the workshop, written comments were collated by the facilitators (YF, HA, SV) and categorised into themes by members of the research team (JDR, HA), using frequency analysis (where data was available) to identify strong and recurring recommendations for change.

The data from the quantitative and qualitative phases were analysed separately, but then were considered together both in the forum workshops and within the research team. When considering the quantitative and qualitative datasets together, the research team operated within the methodological spirit of pragmatism, whereby both data sets were integrated in such a way that a useful insight to the research provided useful insights to participants’ experiences and generate knowledge with social utility [ 48 ]. In practice, this meant that survey results were presented to focus group participants to stimulate reflection and discussion and explore how the results compared with their personal experiences. Finally, the workshops provided an additional method to explore, situate and integrate the synthesised qualitative and quantitative data sets to support development of the final thematic model.

Quantitative results

Two hundred and two participants filled in the survey, of which 117 (58%) were complete. The response rate was 20% (Table  1 ). Responses per OEP ranged between 6 and 68 (Table  2 – OEP Responses).

Seventy percent of the respondents provided demographic information ( n  = 142). Participants were mostly white ( n  = 95), female ( n  = 74), without a disability ( n  = 106), heterosexual ( n  = 89), and identifying with no religion ( n  = 69) (see Table  3 – respondent demographics).

Most participants identified to some extent with an UrG ( n  = 62, 53%). Of all the students who responded (53% self-identifying as UrG to some extent, and 47% who did not identify as UrG), 67.8% ( n  = 80) reported that they had not been treated differently because of their cultural background or identity. Those who had been treated differently ( n  = 19; 16%) stated that it happened at least a few times per year ( n  = 15, 79%) (supplementary material 3 , table a– underrepresented groups treatment). Of the 28 who reported having been treated differently, 18 reported whether they had complained: 15 had not complained (6 open-ended responses: not significant enough ( n  = 2), unlikely to lead to change ( n  = 2), fear of being identified ( n  = 1), happened once and felt that mistakes happen ( n  = 1)). Six of the 15 who did not complain did not know how or to whom to complain.

Associations between demographic characteristics and UrG self-identification found that ethnicity (merging all categories excluding White), Disability and Sexual Orientation (merging all categories excluding heterosexual) were significantly associated with identifying as belonging to an UrG group (Supplementary material 3 , Table b - UrG identification vs. demographic group).

No significant associations were found between demographic characteristics and reports of being treated differently (Supplementary material 3 , table c - treated differently vs. demographic group).

Of the 19 participants who reported having been treated differently because of their culture or identity, 79% ( n  = 15) did not report it to their OEP, 15.8% ( n  = 3) did, and 5.2% ( n  = 1) did not answer.

It was not possible to confirm or deny the adequacy of the 5-factor model proposed by Gonzales et al. [ 37 ] (Supplementary material 4 ), so our analysis was based on their 5-factor model (see Table  4 – MCHS results). Regarding the MCHS total score, no differences were found between clinical and preclinical students (Welch’s t = -0.194, df = 79.3, p  = 0.847). A weak correlation between MCHS total score and importance to individual was found (Spearman’s rho(114) = 0.27, p  = 0.003), and a weak relationship between self-rating of skills and MCHS total score (rho(114) = 0.26, p  = 0.005). There was no apparent relationship between MCHS total score and participants’ perception of support in the clinical environment for exploring patients’ backgrounds and experiences (rho(106) = 0.097, p  = 0.3). No scores on these three questions differed significantly between clinical and preclinical students.

Qualitative results

Seven groups were conducted, each were facilitated by two members of the research team (from AMM, HA, JDR, SV, YF). Data from the first six focus groups were organised into two themes which provide descriptive insights of participants’ reflections on the quantitative findings and how these results related to and resonated with their own experiences. The two primary themes were named institutional contextual obstacles (with 4 sub-themes) and UrG students’ conceptual understanding of EDI (with 3 sub-themes). The themes and sub-themes were modelled and presented to the final focus group to facilitate reflective discussions, see Fig.  2 .

Model based on focus groups’ themes and sub-themes

Theme 1: Institutional contextual obstacles

The first sub-theme, Faculty’s lack of awareness & knowledge , was a commonly reported barrier.

I think there’s a lot of talk of self-reflection, at least at the OEP, and it doesn’t to me feel like all of our teachers practise that. I’ve had more problems with staff understanding than student understanding”. (Talking about their disability) There was no awareness, you know, of that within the class or from the tutors, in those circumstances (managing an LGBTQ + patient), what do we do, what language do we use, (…) when it was raised the tutor was sort of like, actually, I don’t have an answer, I’m not sure.

Racist, sexist and ableist comments made by staff negatively affected the way students interacted with patients in the OEPs clinics, and with other students, particularly in practical classes.

I was doing a neck and then teacher wants me to talk when I’m doing it and I say, because / when I’m doing it, I can’t talk and he made a comment, as a woman, you should talk and you should do it, you should multi-task and at that time I couldn’t say anything because I [was] already panicking and I’m doing this thing. I couldn’t say anything. [A male tutor] put [a female tutor acting as a model] side-lying and [he] was going to crack her back but then when he pulled her shirt up her scrubs pants were like mid-way / quite / kind of showing her underwear (…) When we told him that he should pull her scrubs up, he made the thing super uncomfortable. When they make an attack, as a joke, and people laugh, that’s positive behaviour, they’re going to make the joke again because it’s funny, so I don’t know if they can understand that it’s actually a knife that you’re throwing at someone and not just a joke.

The second sub-theme related to a lack of support from institutions for students from UrG, and a lack of clarity of processes available to them to complain about discriminatory behaviours against them.

When I was sort of going through the process of applying for the disabled students’ allowance, which I didn’t even know that I was / its existence to be honest, (…) I had to get the OEP to fill out a form and rubber stamp it and it seemed to get lost in this abyss of I don’t know where it went. (…) but there was a lot of chasing up to do [laughs] and even getting the form signed again, because I have to reapply every year, was a bit of a faff.

Participants who reported discrimination, were lacking certainty that reported these instances would lead to change.

Particularly when it’s a comment like that that’s made and it almost leaves you like gobsmacked and you’re like well what do I say to that, how do I go about telling someone about that?

The third sub-theme was Student attitudes e.g., peers making sexist comments and using negative language about UrGs.

People have said things, especially kind of bisexual tropes and things like that about you know being greedy and I know it’s / (…) people think oh that’s funny (…) it just makes you feel like you are going inward kind of thing. I was practicing thoracic HVT with (…) some first years [students] and I started doing thoracic HVT and one of the first years asked me to do it on him, so I was like, okay, umm, I explained to him you know everything, asked for his consent and stuff, but because he was like a funny guy, he was talking all the time, I was like, okay, can you just sit down for me to do the technique and I told him my nationality before that and then he goes like oh that’s how I know you are Brazilian, your attitude, you probably go on top. I’m just like what? You know / yes, I didn’t even know what to say at this time, because I was just / I just told him, look, I’m not doing the technique, I thought, goodbye.

Participants reported instances where students from privileged backgrounds remained silent when facing discriminatory comments from educational faculty; a factor that perpetuated a non-inclusive culture, as people who used discriminatory or ‘othering’ language were not challenged to reflect on their attitudes and behaviour. In contrast, participants from UrGs felt a sense of duty to raise concerns:

I don’t create problems and stuff, but if there is something if I see it not going right, I like to raise my voice as much as I can and I try to make changes.

The fourth sub-theme was Lack of representation in the student body, patient population and the curriculum.

Everything that we get taught is 99% on like a male sex anatomy. Like I remember when I was learning how to do all the like umm cardiac testing and respiratory we were taught by a male teacher on a male body and then when it came to like a female and like you have boobs and they’re like, oh, you can’t do this bit at the front, or you have to be more careful, but then there was no example of how. I think I felt surprised when coming into the / into osteopathy how less diverse (in student demographics? ) it is than my previous position. I feel quite diverse but people that we see in clinic are mainly Caucasian, so I also think there’s something about the outreach of osteopathy into different cultural communities, for example, most of my family, though we’ve all been brought up here, nobody would use an osteopath (…). When we learn about physiology and pathologies, I feel like there’s now a real effort to talk about say like black people, which is fantastic, but then you know what about Asian (…).

Theme 2: Underrepresented students’ understanding of EDI

The first sub-theme related to the definition of discrimination and echoed findings from community engagement discussions. Students distinguished between ‘othering’ and ‘intent’. Participants perceived discrimination only when actions had an intent to discriminate against individuals or communities, rather than actions that led to people or groups being treated differently regardless of intent. During the focus groups, participants reported equal treatment, but data analysis suggests instances of discrimination.

No, only in so much as, you know, the reasonable adjustments aspect, but then I’ll ask for that, but besides that, I haven’t / I haven’t had any different treatment. I’ve definitely been treated differently as a woman and / but I’ve witnessed the / in my class Asian women being treated differently, but the Asian men not so much so.

The second sub-theme related to the advocacy of UrG students as role models for their peers. Students used their own experience of belonging to an UrG as personal knowledge to help inform their peers about what it is like to be a person from wider UrG communities. This helped to fill gaps in the EDI training or make up for a lack of training received by educators. UrG students acted as advocates to prevent wrong messages, jokes being shared, e.g.,

I think it’s / not just from my disability, but yes, from / for all other students I think when they / things come up, sometimes quite surprising things actually, it’s usually / yes, pretty interesting and helpful for all of us. We use it [disability] sometimes in class as part of like chronic pain, as part of that kind of presentation and things like that because I have an understanding of it, whereas instead of just pulling stories out of thin air.

The third related sub-theme was that students from UrGs appeared to have a better understanding of EDI than their peers and faculty members. Students’ advocacy role included training and supporting their peers in how they should manage situations when facing patients with specific conditions, e.g. type 1 diabetes, and offered a useful insight which would be valued by patient.

I mean do they have to? Should they? I think you know, like I’ve said, the only reason I do [disclose] it is because you know I wouldn’t want to put anybody else in a tricky position if I was to, you know, have like a hypo in class or anything like that, which you know, I may do one day.

This created an environment where students from UrGs not only had to teach other students and faculty, but also had to learn on their own, as they were not able to gain knowledge from staff on topics related to UrG, and then had to teach what they learned to their peers and faculty members.

But we don’t get taught about how to deal with somebody that’s transgender or anything like that. It’s like well you’ll have to you know just find out about that yourself. I don’t have that much of an understanding of the difference that ethnicity has on sort of different diseases and different morphologies and things like that, so it’s something (…) I’d love to learn more about.

The final mixed focus group was used to explore whether the above findings represented the experiences of these participants, and to generate suggestions for OEP action to become more inclusive. Goals thought to be quickly achievable and likely to lead to sustained change was providing urgent training for staff, and then students, to improve awareness and knowledge, and to break the issue of the cycle of unaware students becoming unaware teachers.

Lack of diversity ‘breeds’ a lack of diversity. A lot of the main institutional barriers is the university’s lack of knowledge and the best way to deal with that is directly linked to how the under-represented students can like just you know break this barrier by teaching others and also by getting contact with the university.

Active bystander training was recommended to promote collective responsibility in challenging bias and negative views. Other suggestions included providing support for students from UrGs, countering negative views amongst peers and faculty, employing active strategies to promote patient diversity, being more equitable in services offered, and ensuring training was implemented. The final recommendation was to increase representativeness in the curriculum, as a way of training staff and students through regular exposure to up-to-date information regarding UrGs.

if the institutions were to be more aware [of EDI] and have [EDI training]…., I don’t know what training’s mandatory training’s given, but it would seem like potentially a lot of it [othering] could potentially be stopped. It just seems because you’ve got the lack of representation to faculty, race in faculty, they all sort of interlink with the other parts.

Participants felt that more and better training was needed for staff on EDI issues; a potential barrier to implementation was time, but short courses were expected to be effective.

every job I’ve ever done, either private sector, public sector, there is mandatory training and EDI’s, (…) human trafficking, (…) blackmail. (…) But I think we’re only talking like a half an hour.

Workshop results

Comments from nine workshop sessions (three each on student, staff and institutional EDI issues) were combined using frequency analysis to identify key themes and recommendations for change (Table  5 ). The strongest theme addressed stakeholders’ opinions about staff issues (96 comments in total), with recommendations about the need to improve staff attitudes [ 36 ], increase their awareness of students’ needs [ 15 ], and enhance communication skills [ 26 ]. The second main theme was student support [ 49 ], including the need to explore barriers to change [ 26 ] and improve access to support services [ 14 ]. Two other themes focused on the need to clarify and improve institutional EDI policies and processes [ 26 ] and ways to improve representation and diversity among student osteopaths, OEP staff and patients seeking osteopathic treatment [ 25 ] (also see Supplementary Material 5 ).

Overlapping themes were organised in Fig.  3 in relation to the groups involved in the recommended actions.

Workshop themes

The aims of this innovative mixed methods study were to survey student osteopaths’ levels of cultural humility to assess levels of awareness in the current educational environment and as a proxy for preparedness to work with patients from diverse backgrounds. It also explored the educational experiences of UrG students with the aim of improving equity, diversity and inclusivity (EDI) and sense of belonging in Osteopathic Educational Providers (OEPs). The survey response rate was 20%, but data was collected from 202 students from seven OEIs. 62 students identified with at least one UrG and 19 reported that they had been treated differently but 15 had not reported it.

Qualitative data from focus groups with students from the four selected UrGs suggested the main challenges faced were staff attitudes and lack of awareness; limited student support; and lack of representation in the curriculum and in institutional processes. These themes were explored and refined in interactive workshops, which generated recommendations to improve staff education, support students, and develop effective institutional policies. The implications of these findings are discussed below.

Educating staff

Cultural humility is a lifelong commitment to developing awareness to disparities experienced by people from diverse cultural groups, reflecting and being open to learning [ 49 , 50 , 51 , 52 ]. This model encourages practitioners to collaborate with patients, and educators to collaborate with students, to find solutions to discrimination and inequality based on their lived experiences and priorities [ 53 ]. Qualitative findings from the focus groups and workshops in this study indicated that experiences of ‘othering’ and discrimination were often associated with lack of cultural humility, self-awareness, ignorance, or overtly negative attitudes, mainly among staff. (Focus group theme 1: “ I don’t know if they can understand that it’s actually a knife that you’re throwing at someone and not just a joke ”).

There is limited evidence exploring the impact of cultural humility training with healthcare professional educators. Bakaa et al. [ 54 ] surveyed cultural competence in a sample of 3,000 chiropractors and reported similar findings which suggested that gaps between knowledge and self-reported behaviour required further research to clarify barriers and guide future training. Flateland et al. [ 55 ] concluded that inclusivity could be increased through mandatory diversity training which emphasised individual learning needs for students from all backgrounds and was supported by mentoring from personal academic tutors and a buddy system for UrG students.

A focus group study by Shapiro et al. [ 56 ] suggests that training increased awareness among third year medical students (first year of clinical training) but was less helpful in developing specific management skills. In contrast, another study found that, medical students tended to minimise the importance of self-awareness or the need to reflect on, and confront, personal biases [ 50 ]. Despite uncertainty about the impact of training, there is consensus that lack of training is also problematic. Whether based on concepts of cultural awareness, competence and humility [ 51 ] it is important that the sceptical perception that training is trying to be ‘politically correct’ is transformed into a way of rehumanising healthcare education [ 56 ]. Education in EDI and inclusive communication skills was strongly recommended by the participants in this study, but the challenges cited above suggest that ongoing monitoring would be needed to explore its’ impact on staff and students (Focus group theme 2: “ I don’t know what mandatory [EDI] training’s given, but it would seem like potentially a lot of it [othering] could potentially be stopped ”).

Supporting students

Inequalities in healthcare education are well documented [ 11 , 12 , 16 , 18 ]. Physiotherapy students from black, Asian and minority ethnic (BAME) backgrounds received lower marks in observed assessments compared to white students, with gaps in attainment also recorded for people with disabilities and students with non-traditional entry routes [ 10 ]. Overseas students, especially those who do not speak English as a first language, report isolation, loneliness, and lack of support, which is increased by intersectionality including race and gender [ 9 , 57 ]). In the survey, 15 students who felt they had been treated differently because of UrG characteristics did not report their difficulties, sometimes because they were unclear about whether an incident would count as discrimination or whether reporting a problem would have negative consequences (Workshop theme 3: “ Need to clarify what language/behaviour (e.g., ‘banter’) is acceptable ”).

Barriers to reporting misconduct include fear of not being believed, fear of repercussions and lack of confidence that complaints will be taken seriously [ 58 ]. Focus group and workshop comments suggested that students felt concerns were ignored, whether reported by individuals or year group representatives. The institution was rarely seen to take action to address the problems identified and there were concerns about consequences for people who spoke out. In contrast, some participants felt that whistleblowers should be valued and that incidents of discrimination could be reduced by encouraging more people to speak up (Workshop theme 4: “ Value all experiences and validate the ‘disruptor’ voice ”).

Research suggests that some of the factors that hinder the delivery of effective student support include limited disclosure of individual difficulties, especially for ‘invisible’ disabilities [ 18 ], the complex challenges faced by students with intersectional backgrounds [ 59 , 60 ], and lack of staff awareness, as discussed above [ 20 , 61 ]. Inconsistent institutional support practices also reinforce students’ disabled status and limit participation, rather than optimising their abilities and resilience [ 61 ], so there is a need to develop clear, robust systems to support students from UrGs, such as Active Bystander training (Workshop theme 2).

Improving institutional policies and processes

The practical processes used to support students and manage staff are grounded in an institution’s values and policies. Training inequalities are known to be a concern in medical and allied health professions and all HEIs in the UK have a responsibility to overcome the challenges of inaction in the face of discrimination. The General Medical Council has recently set new targets to eradicate disadvantage and discrimination in medical education and training [ 21 ]. Equality, diversity and inclusion pose challenges for small specialist universities, as noted in the ‘Changing the Culture’ (2016) framework, developed by Universities UK and GuildHE [ 62 ]. OEPs are expected to cultivate and maintain a culture of inclusion between staff, students and patients, train staff in EDI and ensure that staff are involved in the development of EDI policies [ 63 ]. This is reflected in the Quality Assurance Agency for Higher Education Subject Benchmark Statement for Osteopathy [ 64 ]: expectations and guidance on how OEPs can promote an EDI culture are provided. Participants in this study reported concerns about institutional knowledge (Focus group theme 2) and lack of clarity about how to access and use existing EDI policies (Focus group theme 1: “ How do I go about telling someone about that? ”).

In recent decades, access and participation from minority groups to higher education in the UK has been a core focus and entry rates for non-white students have increased: in 2019 they were higher for all ethnic groups compared with rates in 2006 and the entry rates increased in 2019 compared with 2018 [ 65 ]. There is limited information about experiences of inequalities reported by UrG students in osteopathic education or discrepancies in levels of attainment. A systematic review by MacMillan et al. [ 31 ] analysed discrimination, bullying and harassment in manual therapy education. They reported that there was evidence of widespread discrimination, harassment and bullying within manual therapy education; and there was a clear need for further research to focus upon the intersection of the characteristics identified as being linked to these experiences. Unfortunately, no osteopathic studies were found, although findings from physiotherapy and chiropractic education are likely to be transferable. Practising osteopaths from UrGs are also reported to be dissatisfied with lack of diversity within the profession and concerns have been raised about a lack of cultural competence training in OEPs [ 66 ].

Norris et al. [ 61 ] recommended that healthcare education institutions need to provide consistent and accessible information to help students find appropriate support and education to increase staff awareness about how individual experiences of disability affect learning. Complex EDI issues require university-wide approaches and AdvanceHE’s UK Equality Charter team proposes an ‘holistic approach’ [ 62 ]. Further research is needed to identify actions which would enhance educational experiences and outcomes for student osteopaths from UrGs. New data would also provide insights into the extent that osteopathic education prepares students to work with patients from UrGs and support long-term plans to enhance access and quality of patient care and attract more students from these UrGs to enhance the profession and represent more inclusively the communities they serve [ 31 , 64 ].

Limitations of the study

It is difficult to collect data from people who feel marginalised or vulnerable to discrimination, as demonstrated by low survey response rates with participants who typically have strong positive or negative views but few from the ‘silent majority’ (Shapiro et al. 2016). The MCHS is a new instrument which was adapted to osteopathy students, and due to the small sample size, it was not possible to get useful results with the confirmatory factor analysis. More research is also needed with this instrument to establish meaningful scores for dimensions of questionnaire. The response rate to this survey was low at 20% and there were fewer than 8 participants in all the focus groups. However, mixed designs enable compensation for some limitations of individual methods and data was collected from all seven UK OEPs. Two stages of qualitative analysis (focus groups and workshops) also enabled triangulation of the findings. The impact of facilitators as ‘insiders’ on data collection was not assessed and it was challenging to synthesise and weight results from the three stages.

Conclusions

The aims of this mixed methods study were to assess awareness of cultural humility among student osteopaths in the UK and to explore educational experiences of discrimination and ‘othering’ among students from underrepresented groups. Our findings are consistent with conclusions from other studies and the suggestions for action generated in workshops with diverse stakeholders are aligned with current EDI guidelines. Our three main recommendations are that OEIs prioritise actions to clarify institutional policies and processes to ensure they are accessible and effective in maintaining an inclusive educational environment; to review the adequacy of current student support services, particularly for underrepresented groups; and to provide EDI and communications skills training for staff to increase awareness about students’ learning needs and explore attitudinal barriers to change.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the sensitivity of data collected and risk of identification of participants but are available from the corresponding author on reasonable request.

Szetela A. Black lives matter at five: limits and possibilities. Ethn Racial Stud. 2020;43(8):1358–83.

Article   Google Scholar  

Regulska J. The #MeToo movement as a global learning moment. Int High Educ. 2018;94:5–6.

Dodd V. Met police found to be institutionally racist, misogynistic and homophobic. The guardian [Internet]. 2023 Mar 21 [cited 2024 Jan 10]; https://www.theguardian.com/uk-news/2023/mar/21/metropolitan-police-institutionally-racist-misogynistic-homophobic-louise-casey-report .

Quinn B. People like you still uttered: BAME armed forces personnel on racism in services. The guardian [Internet]. 2020 Jan 7 [cited 2024 Jan 10]; https://www.theguardian.com/uk-news/2020/jan/07/people-like-you-still-uttered-bame-armed-forces-personnel-on-racism-in-services .

The report of the Commission on Race. and Ethnic Disparities [Internet]. Gov.uk. 2021 [cited 2024 Jan 10]. https://www.gov.uk/government/publications/the-report-of-the-commission-on-race-and-ethnic-disparities .

Adams R. Minority ethnic Britons’ educational success not reflected in pay. 2022.

Higher Education Statistics Agency. Higher Education Graduate Outcomes Statistics: UK, 2017/18 - Graduate activities and characteristics [Internet]. 2020 [cited 2024 Jan 10]. https://www.hesa.ac.uk/news/18-06-2020/sb257-higher-education-graduate-outcomes-statistics/activities .

Rimmer A. One in four trainee doctors report discriminatory behaviours from colleagues, GMC finds. BMJ. 2023;1601.

British Medical Association. Factors preventing progress of ethnic minority doctors into senior positions [Internet]. 2022 [cited 2024 Jan 10]. https://www.bma.org.uk/media/5748/bma-why-are-we-still-here-commissioned-report-june-15-2022.pdf .

Norris M, Hammond JA, Williams A, Grant R, Naylor S, Rozario C. Individual student characteristics and attainment in pre registration physiotherapy: a retrospective multi site cohort study. Physiotherapy. 2018;104(4):446–52.

Neves J, Hillman N. Student academic experience survey. H. E. P. I. a. H. E. Academy, editor.; 2020.

Bachmann CL, Gooch B. LGBT in Britain - universities Report. London: Stonewall; 2018.

Google Scholar  

Universities, and Colleges Admissions Service. Entry rates into higher education. Ethnicity, factsfigures [Internet]. 2023 [cited 2024 Jan 10]. https://www.ethnicity-facts-figures.service.gov.uk/education-skills-and-training/higher-education/entry-rates-into-higher-education/latest#by-ethnicity .

Johnson JL, Bottorff JL, Browne AJ, Grewal S, Hilton BA, Clarke H. Othering and being othered in the context of health care services. Health Commun. 2004;16(2):255–71.

Nixon SA. The coin model of privilege and critical allyship: implications for health. BMC Public Health. 2019;19(1):1637.

ESFA. Education and Skills agreements 2020 to 2021 [Internet]. Gov.uk. 2020 [cited 2024 Jan 10]. https://www.gov.uk/guidance/esfa-education-and-skills-agreements-2020-to-2021 .

Office for Students. Equality, diversity and student characteristics data - Office for Students. 2022 Jun 7 [cited 2024 Jan 10]; https://www.officeforstudents.org.uk/publications/equality-diversity-and-student-characteristics-data/?_cldee=Hgjd4C0mN-Ei1iAE9EzevenIhwSZ7Dxxo3wjIT8PIAo1SUA3S-H3H-VFCowOM6WI&recipientid=lead-46be407d3275ec1189430022481aa1a1-74564b23bb16438c9a14de1abd81377a&esid=cd365273-6de5-ec11-bb3c-002248004e75

UCAS. What is the experience of disabled students in education? [Internet]. 2022 [cited 2024 Jan 10]. https://www.ucas.com/file/610106/download?token=1kwt_gKE .

Hammond J, Marshall-Lucette S, Davies N, Ross F, Harris R. Spotlight on equality of employment opportunities: a qualitative study of job seeking experiences of graduating nurses and physiotherapists from black and minority ethnic backgrounds. Int J Nurs Stud. 2017;74:172–80.

Hammond JA, Williams A, Walker S, Norris M. Working hard to belong: a qualitative study exploring students from black, Asian and minority ethnic backgrounds experiences of pre-registration physiotherapy education. BMC Med Educ [Internet]. 2019;19(1). https://doi.org/10.1186/s12909-019-1821-6 .

General Medical Council. GMC targets elimination of disproportionate complaints and training inequalities [Internet]. 2021 [cited 2021 Autumn 5]. https://www.gmc-uk.org/news/news-archive/gmc-targets-elimination-of-disproportionate-complaints-and-training-inequalities .

Ross MH, Setchell J. People who identify as LGBTIQ + can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiother. 2019;65(2):99–105.

Ross MH, Setchell J. Physiotherapists vary in their knowledge of and approach to working with patients who are LGBTQIA+: a qualitative study. J Physiother. 2023;69(2):114–22.

Council of Deans. Anti-racism in AHP Education: Building an Inclusive Environment [Internet]. 2023 [cited 2024 Jan 10]. https://www.councilofdeans.org.uk/wp-content/uploads/2023/03/Anti.racism.in_.ahp_.education.report.pdf .

House of Commons. House of Commons Women and Equalities Committee Black maternal health Third Report of. Session 2022–23 Report, together with formal minutes relating to the report Ordered by the House of Commons [Internet]. 2023 [cited 2024 Jan 10]. https://committees.parliament.uk/publications/38989/documents/191706/default/ .

Gonzales G, Przedworski J. Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States: Results from the National Health…. JAMA Intern Med [Internet]. 2016; https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2530417?casa_token=CRF1uNk3F_8AAAAA:pJQ_7UypXiwhMMO0KeqLEGf5Jb6fZC_EBg0QrmXRF507vY5Pl7srcTta6fWsDqHmuOQCZYIGoQ&casa_token=OWWuxn8UEDwAAAAA:4YRNKNxWmG-6LZfnl_MEATduHjHiawDrLprat8Y59Nopll1K-Yw1HV-zL5K15z5lZBn1X9FPUg

Cross TL. Towards a culturally competent system of care: a monograph on effective services for minority. Washington, DC: Georgetown University; 1989.

Hook JN, Davis DE, Owen J, Worthington EL, Utsey SO. Cultural humility: measuring openness to culturally diverse clients. J Couns Psychol. 2013;60(3):353–66.

NHS England. Chief Allied Health Professions Officer extends her remit to two additional professions [Internet]. 2017 [cited 2024 Jan 10]. https://www.england.nhs.uk/2017/04/chief-allied-health-professions-officer-extends-her-remit-to-two-additional-professions/ .

General Osteopathic Council. Standards of Practice [Internet]. 2023 [cited 2024 Jan 10]. https://www.osteopathy.org.uk/standards/ .

MacMillan A, Hohenschurz-Schmidt D, Migliarini DV, Draper-Rodi DJ. Discrimination, bullying or harassment in undergraduate education in the osteopathic, chiropractic and physiotherapy professions: a systematic review with critical interpretive synthesis. Int J Educ Res Open. 2022;3(100105):100105.

O’Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008;13(2):92–8.

Creswell JW, Clark VP. Designing and conducting mixed methods research. SAGE; 2018.

Mertens DM. Transformative paradigm. J Mix Methods Res. 2007;1(3):212–25.

Creswell JW. Research Design: qualitative, quantitative, and mixed methods approaches. SAGE; 2014.

Ball S, Harshfield S, Carpenter A, Bertscher A, Marjanovic S. Patient and public involvement and engagement in research. Santa Monica: RAND Corporation; 2019.

Gonzalez E, Sperandio KR, Mullen PR, Tuazon VE. Development and initial testing of the multidimensional cultural humility scale. Meas Eval Couns Dev. 2021;54(1):56–70.

Finch H. Focus groups. Qualitative research practice: A guide for social science students and researchers. Ritchie J, London LJ, editors. J Ritchie and L J. 2003;170–98.

Holloway I, Wheeler S. Qualitative research in nursing and healthcare. Wiley; 2010.

Kite J, Phongsavan P. Insights for conducting real-time focus groups online using a web conferencing service. F1000Res. 2017;6:122.

Mertens DM. Transformative mixed methods research. Qual Inq. 2010;16(6):469–74.

Kaiser K. Protecting respondent confidentiality in qualitative research. Qual Health Res. 2009;19(11):1632–41.

R Core Team. A Language and Environment for Statistical Computing [Internet]. R Foundation for Statistical Computing, Vienna, Austri; 2023 [cited 2024 Oct 1]. https://www.R-project.org/ .

Rosseel Y. lavaan: AnRPackage for Structural Equation Modeling. J Stat Softw [Internet]. 2012;48(2). https://doi.org/10.18637/jss.v048.i02 .

Van Buuren S. Groothuis-Oudshoorn, mice: Multivariate imputation by chained equations in r. J Stat Softw. 2011;45:1–67.

Welch BL. The generalization of ‘student’s’ problem when several different population varlances are involved. Biometrika. 1947;34(1–2):28–35.

Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589–97.

Yvonne Feilzer M. Doing mixed methods research pragmatically: implications for the rediscovery of pragmatism as a research paradigm. J Mix Methods Res. 2010;4(1):6–16.

Tollemache N, Shrewsbury D, Llewellyn C. Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education. BMC Med Educ [Internet]. 2021;21(1). https://doi.org/10.1186/s12909-021-02532-y .

Shepherd SM. Cultural awareness workshops: limitations and practical consequences. BMC Med Educ. 2019;19(1):14.

Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–25.

Foronda C, Baptiste D-L, Reinholdt MM, Ousman K. Cultural humility. J Transcult Nurs. 2016;27(3):210–7.

Solchanyk D, Ekeh O, Saffran L, Burnett-Zeigler IE, Doobay-Persaud A. Integrating cultural humility into the medical education curriculum: strategies for educators. Teach Learn Med. 2021;33(5):554–60.

Bakaa N, Southerst D, Côté P, Macedo L, Carlesso LC, MacDermid J et al. Assessing cultural competency among Canadian chiropractors: a cross-sectional survey of Canadian Chiropractic Association members. Chiropr Man Therap [Internet]. 2023;31(1). https://doi.org/10.1186/s12998-023-00474-4 .

Flateland SM, Pryce-Miller M, Skisland AV-S, Tønsberg AF, Söderhamn U. Exploring the experiences of being an ethnic minority student within undergraduate nurse education: a qualitative study. BMC Nurs [Internet]. 2019;18(1). https://doi.org/10.1186/s12912-019-0389-0 .

Jowsey T. Three zones of cultural competency: surface competency, bias twilight, and the confronting midnight zone. BMC Med Educ [Internet]. 2019;19(1). https://doi.org/10.1186/s12909-019-1746-0 .

Shapiro J, Lie D, Gutierrez D, Zhuang G. That never would have occurred to me: a qualitative study of medical students’ views of a cultural competence curriculum. BMC Med Educ [Internet]. 2006;6(1). https://doi.org/10.1186/1472-6920-6-31 .

Equality. and Human Rights Commission. Tackling racial harassment: Universities challenged. 2019.

Gottlieb M. The case for a cultural humility framework in social work practice. J Ethn Cult Divers Soc Work. 2021;30(6):463–81.

LeBlanc C, Sonnenberg LK, King S, Busari J. Medical education leadership: from diversity to inclusivity. GMS J Med Educ. 2020;37(2):Doc18.

Norris M, Hammond J, Williams A, Walker S. Students with specific learning disabilities experiences of pre-registration physiotherapy education: a qualitative study. BMC Med Educ [Internet]. 2020;20(1). https://doi.org/10.1186/s12909-019-1913-3 .

GuildHE. EDI & ANTI-RACISM BRIEFING #15. Tackling Harassment and the importance of EDI. 2021.

General Osteopathic Council. Graduate Outcomes and Standards for Education and Training [Internet]. London. 2022. https://www.osteopathy.org.uk/news-and-resources/document-library/publications/graduate-outcomes-and-standards-for-education-and-training/ .

Quality Assurance Agency for Higher Education. Subject Benchmark Statement Osteopathy. Gloucester: QAA; 2024.

Universities, and Colleges Admissions Service. Entry rates into higher education [Internet]. Entry rates into higher education. Ethnicity, factsfigures. 2020 [cited 2021 Aug 2]. https://www.ethnicity-facts-figures.service.gov.uk/education-skills-and-training/higher-education/entry-rates-into-higher-education/latest#by-ethnicity .

MacMillan A, Corser A, Clark Z. Inclusivity and accessibility in undergraduate osteopathic education for students with disability: a scoping review. Int J Osteopath Med. 2021;40:38–45.

Download references

Acknowledgements

Our thanks to Dr Phil Bright and Mr Dévan Rajendran for their support with the project, including the community engagement meetings.

This project received funding from four organisations: The Osteopathic Foundation provided £20,000, the General Osteopathic Council provided £7,500, the University College of Osteopathy provided £7,500, and the Institute of Osteopathy provided £3,000. The authors, including the Principal Investigator, are employed by the University College of Osteopathy. However, the University College of Osteopathy and other funders did not have any specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and affiliations.

University College of Osteopathy, 275 Borough High Street, SE1 1JE, London, UK

Jerry Draper-Rodi, Hilary Abbey, Oliver T. Thomson, Kevin Brownhill, Andrew MacMillan, Yinka Fabusuyi & Steven Vogel

National Council for Osteopathic Research, 275 Borough High Street, SE1 1JE, London, UK

Jerry Draper-Rodi

School of Allied and Public Health Professions, North Holmes Road, CT1 1QU, Canterbury, Kent, UK

John Hammond

University of Portsmouth, University House, Winston Churchill Ave, PO1 2UP, Hampshire, Portsmouth, England

Andrew MacMillan

You can also search for this author in PubMed   Google Scholar

Contributions

JDR, HA and SV designed the study and applied for ethical approval. AMM, HA, JDR, SV, YF facilitated the focus groups. KB collected and analysed the quantitative data; OT analysed and interpreted the qualitative data. HA, JDR, SV, YF facilitated the workshops. HA and JDR analysed the workshop data. All authors contributed, read and approved the final manuscript.

Corresponding author

Correspondence to Jerry Draper-Rodi .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by the University College of Osteopathy Research Ethics Committee. For the survey, consent was assumed by return of the completed questionnaire (this was explained in the participant information sheet), and for the focus groups, informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, supplementary material 3, supplementary material 4, supplementary material 5, supplementary material 6, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Draper-Rodi, J., Abbey, H., Hammond, J. et al. Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study. BMC Med Educ 24 , 468 (2024). https://doi.org/10.1186/s12909-024-05404-3

Download citation

Received : 02 February 2024

Accepted : 09 April 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s12909-024-05404-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Underrepresented
• Social Justice
• Equity diversity and inclusion
• Transformative action research
• Osteopathic undergraduate education
• Ethnic minorities

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

• Publications
• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

What federal education data shows about students with disabilities in the U.S.

Public K-12 schools in the United States educate about 7.3 million students with disabilities – a number that has grown over the last few decades. Disabled students ages 3 to 21 are served under the federal  Individuals with Disabilities Education Act (IDEA) , which guarantees them the right to free public education and appropriate special education services.

For Disability Pride Month , here are some key facts about public school students with disabilities, based on the latest data from the  National Center for Education Statistics (NCES) .

July is both Disability Pride Month and the anniversary of the Americans with Disabilities Act. To mark these occasions, Pew Research Center used federal education data from  the National Center for Education Statistics  to learn more about students who receive special education services in U.S. public schools.

In this analysis, students with disabilities include those ages 3 to 21 who are served under the federal  Individuals with Disabilities Education Act (IDEA) . Through IDEA, children with disabilities are guaranteed a “free appropriate public education,” including special education and related services.

The 7.3 million disabled students in the U.S. made up 15% of national public school enrollment during the 2021-22 school year. The population of students in prekindergarten through 12th grade who are served under IDEA has grown in both number and share over the last few decades. During the 2010-11 school year, for instance, there were 6.4 million students with disabilities in U.S. public schools, accounting for 13% of enrollment.

The number of students receiving special education services temporarily dropped during the coronavirus pandemic – the first decline in a decade. Between the 2019-20 and 2020-21 school years, the number of students receiving special education services decreased by 1%, from 7.3 million to 7.2 million. This was the first year-over-year drop in special education enrollment since 2011-12.

The decline in students receiving special education services was part of a 3% decline in the overall number of students enrolled in public schools between 2019-20 and 2020-21. While special education enrollment bounced back to pre-pandemic levels in the 2021-22 school year, overall public school enrollment remained flat.

These enrollment trends may reflect some of the learning difficulties and health concerns students with disabilities and their families faced during the height of the COVID-19 pandemic , which limited or paused special education services in many school districts.

Many school districts struggle to hire special education professionals. During the 2020-21 school year, 40% of public schools that had a special education teaching vacancy reported that they either found it very difficult to fill the position or were not able to do so.

Foreign languages (43%) and physical sciences (37%) were the only subjects with similarly large shares of hard-to-fill teaching vacancies at public schools that were looking to hire in those fields.

While the COVID-19 pandemic called attention to a nationwide teacher shortage , special education positions have long been among the most difficult for school districts to fill .

The most common type of disability for students in prekindergarten through 12th grade involves “specific learning disabilities,” such as dyslexia.  In 2021-22, about a third of students (32%) receiving services under IDEA had a specific learning disability. Some 19% had a speech or language impairment, while 15% had a chronic or acute health problem that adversely affected their educational performance. Chronic or acute health problems include ailments such as heart conditions, asthma, sickle cell anemia, epilepsy, leukemia and diabetes.

Students with autism made up 12% of the nation’s schoolchildren with disabilities in 2021-22, compared with 1.5% in 2000-01.  During those two decades, the share of disabled students with a specific learning disability, such as dyslexia, declined from 45% to 32%.

The percentage of students receiving special education services varies widely across states. New York serves the largest share of disabled students in the country at 20.5% of its overall public school enrollment. Pennsylvania (20.2%), Maine (20.1%) and Massachusetts (19.3%) serve the next-largest shares. The states serving the lowest shares of disabled students include Texas and Idaho (both 11.7%) and Hawaii (11.3%).

Between the 2000-01 and 2021-22 school years, all but 12 states experienced growth in their disabled student populations. The biggest increase occurred in Utah, where the disabled student population rose by 65%. Rhode Island saw the largest decline of 22%.

These differences by state are likely the result of inconsistencies in how states determine which students are eligible for special education services and challenges in identifying disabled children.

The racial and ethnic makeup of the nation’s special education students is similar to public school students overall, but there are differences by sex.  About two-thirds of disabled students (65%) are male, while 34% are female, according to data from the 2021-22 school year. Overall student enrollment is about evenly split between boys and girls.

Research has shown that decisions about whether to recommend a student for special education may be influenced by their school’s socioeconomic makeup, as well as by the school’s test scores and other academic markers.

Note: This is an update of a post originally published April 23, 2020.

Katherine Schaeffer is a research analyst at Pew Research Center

Most Americans think U.S. K-12 STEM education isn’t above average, but test results paint a mixed picture

About 1 in 4 u.s. teachers say their school went into a gun-related lockdown in the last school year, about half of americans say public k-12 education is going in the wrong direction, what public k-12 teachers want americans to know about teaching, what’s it like to be a teacher in america today, most popular.

1615 L St. NW, Suite 800 Washington, DC 20036 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Age & Generations
• Coronavirus (COVID-19)
• Economy & Work
• Family & Relationships
• Gender & LGBTQ
• Immigration & Migration
• International Affairs
• Internet & Technology
• Methodological Research
• News Habits & Media
• Non-U.S. Governments
• Other Topics
• Politics & Policy
• Race & Ethnicity
• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of  The Pew Charitable Trusts .

Copyright 2024 Pew Research Center

Terms & Conditions

Privacy Policy

Cookie Settings

Reprints, Permissions & Use Policy

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 33, Issue 5
• Equitable and accessible informed healthcare consent process for people with intellectual disability: a systematic literature review
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0002-8498-7329 Manjekah Dunn 1 , 2 ,
• Iva Strnadová 3 , 4 , 5 ,
• Jackie Leach Scully 4 ,
• Jennifer Hansen 3 ,
• Julie Loblinzk 3 , 5 ,
• Skie Sarfaraz 5 ,
• Chloe Molnar 1 ,
• Elizabeth Emma Palmer 1 , 2
• 1 Faculty of Medicine & Health , University of New South Wales , Sydney , New South Wales , Australia
• 2 The Sydney Children's Hospitals Network , Sydney , New South Wales , Australia
• 3 School of Education , University of New South Wales , Sydney , New South Wales , Australia
• 4 Disability Innovation Institute , University of New South Wales , Sydney , New South Wales , Australia
• 5 Self Advocacy Sydney , Sydney , New South Wales , Australia
• Correspondence to Dr Manjekah Dunn, Paediatrics & Child Health, University of New South Wales Medicine & Health, Sydney, New South Wales, Australia; manjekah.dunn{at}unsw.edu.au

Objective To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible.

Data sources Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals.

Eligibility criteria Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability.

Synthesis of results Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created.

Results Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals’ attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3).

Conclusions Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals’ attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability.

PROSPERO registration CRD42021290548.

• Decision making
• Healthcare quality improvement
• Patient-centred care
• Quality improvement
• Standards of care

Data availability statement

Data are available upon reasonable request. Additional data and materials such as data collection forms, data extraction and analysis templates and QualSyst assessment data can be obtained by contacting the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016113

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

What is already known on this topic

People with intellectual disability are frequently excluded from decision-making processes and not provided equal opportunity for informed consent, despite protections outlined in the United Nations Convention on the Rights of Persons with Disabilities.

People with intellectual disability have the capacity and desire to make informed medical decisions, which can improve their well-being, health satisfaction and health outcomes.

What this review study adds

Health professionals lack adequate training in valid informed consent and making reasonable adjustments for people with intellectual disability, and continue to perpetuate assumptions of incapacity.

Health information provided to people with intellectual disability is often inaccessible and insufficient for them to make informed decisions about healthcare.

The role of support people, systemic constraints, a person-centred approach and ineffective healthcare communication also affect informed consent.

How this review might affect research, practice or policy

Health professionals need additional training on how to provide a valid informed consent process for people with intellectual disability, specifically in using accessible health information, making reasonable adjustments (e.g., longer/multiple appointments, options of a support person attending or not, using plain English), involving the individual in discussions, and communicating effectively with them.

Inclusive research is needed to hear the voices and opinions of people with intellectual disability about healthcare decision-making and about informed consent practices in specific healthcare settings.

Introduction

Approximately 1% of the world’s population have intellectual disability. 1 Intellectual disability is medically defined as a group of neurodevelopmental conditions beginning in childhood, with below average cognitive functioning and adaptive behaviour, including limitations in conceptual, social and practical skills. 2 People with intellectual disability prefer an alternative strength-based definition, reflected in the comment by Robert Strike OAM (Order of Australia Medal): ‘We can learn if the way of teaching matches how the person learns’, 3 reinforcing the importance of providing information tailored to the needs of a person with intellectual disability. A diagnosis of intellectual disability is associated with significant disparities in health outcomes. 4–7 Person-centred decision-making and better communication have been shown to improve patient satisfaction, 8 9 the physician–patient relationship 10 and overall health outcomes 11 for the wider population. Ensuring people with intellectual disability experience informed decision-making and accessible healthcare can help address the ongoing health disparities and facilitate equal access to healthcare.

Bodily autonomy is an individual’s power and agency to make decisions about their own body. 12 Informed consent for healthcare enables a person to practice bodily autonomy and is protected, for example, by the National Safety and Quality Health Service Standards (Australia), 13 Mental Capacity Act (UK) 14 and the Joint Commission Standards (USA). 15 In this article, we define informed consent according to three requirements: (1) the person is provided with information they understand, (2) the decision is free of coercion and (3) the person must have capacity. 16 For informed consent to be valid, this process must be suited to the individual’s needs so that they can understand and communicate effectively. Capacity is the ability to give informed consent for a medical intervention, 17 18 and the Mental Capacity Act outlines that ‘a person must be assumed to have capacity unless it is established that he lacks capacity’ and that incapacity can only be established if ‘all practicable steps’ to support capacity have been attempted without success. 14 These assumptions of capacity are also decision-specific, meaning an individual’s ability to consent can change depending on the situation, the choice itself and other factors. 17

Systemic issues with healthcare delivery systems have resulted in access barriers for people with intellectual disability, 19 despite the disability discrimination legislation in many countries who are signatories to the United Nations (UN) Convention on the Rights of Persons with Disabilities. 20 Patients with intellectual disability are not provided the reasonable adjustments that would enable them to give informed consent for medical procedures or interventions, 21 22 despite evidence that many people with intellectual disability have both the capacity and the desire to make their own healthcare decisions. 21 23

To support people with intellectual disability to make independent health decisions, an equitable and accessible informed consent process is needed. 24 However, current health systems have consistently failed to provide this. 21 25 To address this gap, we must first understand the factors that contribute to inequitable and inaccessible consent. To the best of our knowledge, the only current review of informed consent for people with intellectual disability is an integrative review by Goldsmith et al . 26 Many of the included articles focused on assessment of capacity 27–29 and research consent. 30–32 The review’s conclusion supported the functional approach to assess capacity, with minimal focus on how the informed consent processes can be improved. More recently, there has been a move towards ensuring that the consent process is accessible for all individuals, including elderly patients 33 and people with aphasia. 34 However, there remains a paucity of literature about the informed consent process for people with intellectual disability, with no systematic reviews summarising the factors influencing the healthcare consent process for people with intellectual disability.

To identify barriers to and enablers of the informed healthcare consent process for people with intellectual disability, and to understand how this can be made equitable and accessible.

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) systematic literature review protocol. 35 The PRISMA 2020 checklist 36 and ENhancing Transparency in REporting the synthesis of Qualitative research (ENTREQ) reporting guidelines were also followed. 37 The full study protocol is included in online supplemental appendix 1 .

Supplemental material

No patients or members of the public were involved in this research for this manuscript.

Search strategy

A search strategy was developed to identify articles about intellectual disability, consent and healthcare interventions, described in online supplemental appendix 2 . Multiple databases were searched for articles published between January 1990 to January 2022 (Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL). These databases include healthcare and psychology databases that best capture relevant literature on this topic, including medical, nursing, social sciences and bioethical literature. The search was limited to studies published from 1990 as understandings of consent have changed since then. 38 39 This yielded 4853 unique papers which were imported into Covidence, a specialised programme for conducting systematic reviews. 40

Study selection

Citation screening by abstract and titles was completed by two independent researchers (MD and EEP). Included articles had to:

Examine the informed consent process for a healthcare intervention for people with intellectual disability.

Have collected more than 50% of its data from relevant stakeholders, including adults with intellectual disability, families or carers of a person with intellectual disability, and professionals who engage with people with intellectual disability.

Report empirical data from primary research methodology.

Be published in a peer-reviewed journal after January 1990.

Be available in English.

Full text screening was completed by two independent researchers (MD and EEP). Articles were excluded if consent was only briefly discussed or if it focused on consent for research, capacity assessment, or participant knowledge or comprehension. Any conflicts were resolved through discussion with an independent third researcher (IS).

Additional studies were identified through an ancestral search and by hand-searching three major journals relevant to intellectual disability research. Journals were selected if they had published more than one included article for this review or in previous literature reviews conducted by the research team.

Quality assessment

Two independent researchers (MD and IS) assessed study quality with the QualSyst tool, 41 which can assess both qualitative and quantitative research papers. After evaluating the distribution of scores, a threshold value of 55% was used, as suggested by QualSyst 41 to exclude poor-quality studies but capture enough studies overall. Any conflicts between the quality assessment scores were resolved by a third researcher (EEP). For mixed-method studies, both qualitative and quantitative quality scores were calculated, and the higher value used.

Data collection

Two independent researchers (MD and JH) reviewed each study and extracted relevant details, including study size, participant demographics, year, country of publication, study design, data analysis and major outcomes reported. Researchers used standardised data collection forms designed, with input from senior researchers with expertise in qualitative research (IS and EEP), to extract data relevant to the review’s research aims. The form was piloted on one study, and a second iteration made based on feedback. These forms captured data on study design, methods, participants, any factors affecting the process of informed consent and study limitations. Data included descriptions and paragraphs outlining key findings, the healthcare context, verbatim participant quotes and any quantitative analyses or statistics. Missing or unclear data were noted.

Data analysis

A pilot literature search showed significant heterogeneity in methodology of studies, limiting the applicability of traditional quantitative analysis (ie, meta-analysis). Instead, inductive thematic analysis was chosen as an alternative methodology 42 43 that has been used in recent systematic reviews examining barriers and enablers of other health processes. 44 45 The six-phase approach described by Braun and Clarke was used. 46 47 A researcher (MD) independently coded the extracted data of each study line-by-line, with subsequent data grouped into pre-existing codes or new concepts when necessary. Codes were reviewed iteratively and grouped into categories, subthemes and themes framed around the research question. Another independent researcher (JH) collated and analysed the data on study demographics, methods and limitations. The themes were reviewed by two senior researchers (EEP and IS).

Qualitative methods of effect size calculations have been described in the literature, 48 49 which was captured in this review by the number of studies that identified each subtheme, with an assigned frequency rating to compare their relative significance. Subthemes were given a frequency rating of A, B, C or D if they were identified by >10, 7–9, 4–6 or <3 articles, respectively. The overall significance of each theme was estimated by the number of studies that mentioned it and the GRADE framework, a stepwise approach to quality assessment using a four-tier rating system. Each study was evaluated for risk of bias, inconsistency, indirectness, imprecision and publication bias. 50 51 Study sensitivity was assessed by counting the number of distinct subthemes included. 52 The quality of findings was designated high, moderate or low depending on the frequency ratings, the QualSyst score and the GRADE scores of studies supporting the finding. Finally, the relative contributions of each study were evaluated by the number of subthemes described, guided by previously reported methods for qualitative reviews. 52

Co-research

The findings were reviewed by two co-researchers with intellectual disability (JL and SS), with over 30 years combined experience as members and employees of a self-advocacy organisation. Guidance on the findings and an easy read summary was produced in line with best-practice inclusive research 53 54 over multiple discussions. Input from two health professional researchers (MD and EEP) provided data triangulation and sense-checking of findings.

Twenty-three articles were identified ( figure 1 ): 14 qualitative, 6 quantitative and 3 mixed-methods. Two papers included the same population of study participants: McCarthy 55 and McCarthy, 56 but had different research questions. Fovargue et al 57 was excluded due to a quality score of 35%. Common quality limitations were a lack of verification procedures to establish credibility and limited researcher reflexivity. No studies were excluded due to language requirements (as all were in English) or age restrictions (all studies had majority adult participants).

• Download figure
• Open in new tab
• Download powerpoint

PRISMA 2020 flowchart for the systematic review. 36

Studies were published from 1999 to 2020 and involved participant populations from the UK (n=18), USA (n=3), Sweden (n=1) and Ireland (n=1). Participant numbers ranged from 9 to 604 (median 21), and participants included people with intellectual disability (n=817), health professionals (n=272), carers and support people (n=48), and other professionals that work with people with intellectual disability (n=137, community service agency directors, social workers, administrative staff and care home staff). Ages of participants ranged from 8 to 84 years, though only Aman et al 58 included participants <18 years of age. This study was included as the article states very few children were included. Studies examined consent in different contexts, including contraception and sexual health (6/23 articles), 58–60 medications (5/23 articles), 58–62 emergency healthcare, 63 cervical screening, 64 community referrals, 58–61 65 mental health, 66 hydrotherapy, 64 blood collection 67 and broad decision-making consent without a specific context. 65 68–71 A detailed breakdown of each study is included in online supplemental appendix 3 .

Six major themes were identified from the studies, summarised in figure 2 . An overview of included studies showing study sensitivity, effect size, QualSyst and GRADE scores is given in online supplemental appendix 4 . Studies with higher QualSyst and GRADE scores contributed more to this review’s findings and tended to include more subthemes; specifically, Rogers et al , 66 Sowney and Barr, 63 Höglund and Larsson, 72 and McCarthy 55 and McCarthy. 56 Figure 3 gives the easy read version of theme 1, with the full easy read summary in online supplemental appendix 5 .

Summary of the identified six themes and subthemes.

Theme 1 of the easy read summary.

Theme 1—Health professionals’ attitudes and lack of education about informed consent

Health professionals’ attitudes and practices were frequently (18/21) identified as factors affecting the informed consent process, with substantial evidence supporting this theme. Studies noted the lack of training for health professionals in supporting informed consent for people with intellectual disability, their desire for further education, and stereotypes and discrimination perpetuated by health professionals.

Lack of health professional education on informed consent and disability discrimination legislation

Multiple studies reported inconsistent informed consent practices, for various reasons: some reported that health professionals ‘forgot’ to or ‘did not realise consent was necessary’, 63 73 but inconsistent consent practices were also attributed to healthcare providers’ unfamiliarity with consent guidelines and poor education on this topic. Carlson et al 73 reported that only 44% of general practitioners (GPs) were aware of consent guidelines, and there was the misconception that consent was unnecessary for people with intellectual disability. Similarly, studies of psychologists 66 and nurses 63 found that many were unfamiliar with their obligations to obtain consent, despite the existence of anti-discrimination legislation. People with intellectual disability describe feeling discriminated against by health professionals, reflected in comments such as ‘I can tell, my doctor just thinks I’m stupid – I'm nothing to him’. 74 Poor consent practices by health professionals were observed in Goldsmith et al , 67 while health professionals surveyed by McCarthy 56 were unaware of their responsibility to provide accessible health information to women with intellectual disability. Improving health professional education and training was suggested by multiple studies as a way to remove this barrier. 63 65–67 69 73

Lack of training on best practices for health professions caring for people with intellectual disability

A lack of training in caring for and communicating with people with intellectual disability was also described by midwives, 72 psychologists, 66 nurses, 63 pharmacists 61 and GPs. 56 72 75 Health professionals lacked knowledge about best practice approaches to providing equitable healthcare consent processes through reasonable adjustments such as accessible health information, 56 60 66 longer appointments times, 60 72 simple English 62 67 and flexible approaches to patient needs. 63 72

Health professionals’ stereotyping and assumptions of incapacity

Underlying stereotypes contributed to some health professionals’ (including nurses, 63 GPs 56 and physiotherapists 64 ) belief that people with intellectual disability lack capacity and therefore, do not require opportunities for informed consent. 56 64 In a survey of professionals referring people with intellectual disability to a disability service, the second most common reason for not obtaining consent was ‘patient unable to understand’. 73

Proxy consent as an inappropriate alternative

People with intellectual disability are rarely the final decision-maker in their medical choices, with many health providers seeking proxy consent from carers, support workers and family members, despite its legal invalidity. In McCarthy’s study (2010), 18/23 women with intellectual disability said the decision to start contraception was made by someone else. Many GPs appeared unaware that proxy consent is invalid in the UK. 56 Similar reports came from people with intellectual disability, 55 56 60 64 69 76 health professionals (nurses, doctors, allied health, psychologists), 56 63 64 66 77 support people 64 77 and non-medical professionals, 65 73 and capacity was rarely documented. 56 62 77

Exclusion of people with intellectual disability from decision-making discussions

Studies described instances where health professionals made decisions for their patients with intellectual disability or coerced patients into a choice. 55 72 74 76 77 In Ledger et al 77 , only 62% of women with intellectual disability were involved in the discussion about contraception, and only 38% made the final decision, and others stated in Wiseman and Ferrie 74 : ‘I was not given the opportunity to explore the different options. I was told what one I should take’. Three papers outlined instances where the choices of people with intellectual disability were ignored despite possessing capacity 65 66 69 and when a procedure continued despite them withdrawing consent. 69

Theme 2—Inadequate accessible health information

Lack of accessible health information.

The lack of accessible health information was the most frequently identified subtheme (16/23 studies). Some studies reported that health professionals provided information to carers instead, 60 avoided providing easy read information due to concerns about ‘offending’ patients 75 or only provided verbal information. 56 67 Informed consent was supported when health professionals recognised the importance of providing medical information 64 and when it was provided in an accessible format. 60 Alternative approaches to health information were explored, including virtual reality 68 and in-person education sessions, 59 with varying results. Overall, the need to provide information in different formats tailored to an individual’s communication needs, rather than a ‘one size fits all’ approach, was emphasised by both people with intellectual disability 60 and health professionals. 66

Insufficient information provided

Studies described situations where insufficient information was provided to people with intellectual disability to make informed decisions. For example, some people felt the information from their GP was often too basic to be helpful (Fish et al 60 ) and wanted additional information on consent forms (Rose et al 78 ).

Theme 3—The involvement of support people

Support people (including carers, family members and group home staff) were identified in 11 articles as both enablers of and barriers to informed consent. The antagonistic nature of these findings and lower frequency of subthemes are reflected in the lower quality assessments of evidence.

Support people facilitated communication with health professionals

Some studies reported carers bridging communication barriers with health to support informed consent. 63 64 McCarthy 56 found 21/23 of women with intellectual disability preferred to see doctors with a support person due to perceived benefits: ‘Sometimes I don’t understand it, so they have to explain it to my carer, so they can explain it to me easier’. Most GPs in this study (93%) also agreed that support people aided communication.

Support people helped people with intellectual disability make decisions

By advocating for people with intellectual disability, carers encouraged decision-making, 64 74 provided health information, 74 77 emotional support 76 and assisted with reading or remembering health information. 55 58 76 Some people with intellectual disability explicitly appreciated their support person’s involvement, 60 such as in McCarthy’s 55 study where 18/23 participants felt supported and safer when a support person was involved.

Support people impeded individual autonomy

The study by Wiseman and Ferrie 74 found that while younger participants with intellectual disability felt family members empowered their decision-making, older women felt family members impaired their ability to give informed consent. This was reflected in interviews with carers who questioned the capacity of the person with intellectual disability they supported and stated they would guide them to pick the ‘best choice’ or even over-ride their choices. 64 Studies of psychologists and community service directors described instances where the decision of family or carers was prioritised over the wishes of the person with intellectual disability. 65 66 Some women with intellectual disability in McCarthy’s studies (2010, 2009) 55 56 appeared to have been coerced into using contraception by parental pressures or fear of losing group home support.

Theme 4—Systemic constraints within healthcare systems

Time restraints affect informed consent and accessible healthcare.

Resource limitations create time constraints that impair the consent process and have been identified as a barrier by psychologists, 66 GPs, 56 hospital nurses 63 and community disability workers. 73 Rogers et al 66 highlighted that a personalised approach that could improve informed decision-making is restricted by inflexible medical models. Only two studies described flexible patient-centred approaches to consent. 60 72 A survey of primary care practices in 2007 reported that most did not modify their cervical screening information for patients with intellectual disability because it was not practical. 75

Inflexible models of consent

Both people with intellectual disability 76 and health professionals 66 recognised that consent is traditionally obtained through one-off interactions prior to an intervention. Yet, for people with intellectual disability, consent should ideally be an ongoing process that begins before an appointment and continues between subsequent ones. Other studies have tended to describe one-off interactions where decision-making was not revisited at subsequent appointments. 56 60 72 76

Lack of systemic supports

In one survey, self-advocates highlighted a lack of information on medication for people with intellectual disability and suggested a telephone helpline and a centralised source of information to support consent. 60 Health professionals also want greater systemic support, such as a health professional specialised in intellectual disability care to support other staff, 72 or a pharmacist specifically to help patients with intellectual disability. 61 Studies highlighted a lack of guidelines about healthcare needs of people with intellectual disabilities such as contraceptive counselling 72 or primary care. 75

Theme 5—Person-centred informed consent

Ten studies identified factors related to a person-centred approach to informed consent, grouped below into three subthemes. Health professionals should tailor their practice when obtaining informed consent from people with intellectual disability by considering how these subthemes relate to the individual. Each subtheme was described five times in the literature with a relative frequency rating of ‘C’, contributing to overall lower quality scores.

Previous experience with decision-making

Arscott et al 71 found that the ability of people with intellectual disability to consent changed with their verbal and memory skills and in different clinical vignettes, supporting the view of ‘functional’ capacity specific to the context of the medical decision. Although previous experiences with decision-making did not influence informed consent in this paper, other studies suggest that people with intellectual disability accustomed to independent decision-making were more able to make informed medical decisions, 66 70 and those who live independently were more likely to make independent healthcare decisions. 56 Health professionals should be aware that their patients with intellectual disability will have variable experience with decision-making and provide individualised support to meet their needs.

Variable awareness about healthcare rights

Consent processes should be tailored to the health literacy of patients, including emphasising available choices and the option to refuse treatment. In some studies, medical decisions were not presented to people with intellectual disability as a choice, 64 and people with intellectual disability were not informed of their legal right to accessible health information. 56

Power differences and acquiescence

Acquiescence by people with intellectual disability due to common and repeated experiences of trauma—that is, their tendency to agree with suggestions made by carers and health professionals, often to avoid upsetting others—was identified as an ongoing barrier. In McCarthy’s (2009) interviews with women with intellectual disability, some participants implicitly rejected the idea that they might make their own healthcare decisions: ‘They’re the carers, they have responsibility for me’. Others appeared to have made decisions to appease their carers: ‘I have the jab (contraceptive injection) so I can’t be blamed for getting pregnant’. 55 Two studies highlighted that health professionals need to be mindful of power imbalances when discussing consent with people with intellectual disability to ensure the choices are truly autonomous. 61 66

Theme 6—Effective communication between health professionals and patients

Implementation of reasonable adjustments for verbal and written information.

Simple language was always preferred by people with intellectual disability. 60 67 Other communication aids used in decision-making included repetition, short sentences, models, pictures and easy read brochures. 72 Another reasonable adjustment is providing the opportunity to ask questions, which women with intellectual disability in McCarthy’s (2009) study reported did not occur. 55

Tailored communication methods including non-verbal communication

Midwives noted that continuity of care allows them to develop rapport and understand the communication preferences of people with intellectual disability. 72 This is not always possible; for emergency nurses, the lack of background information about patients with intellectual disability made it challenging to understand their communication preferences. 63 The use of non-verbal communication, such as body language, was noted as underutilised 62 66 and people with intellectual disability supported the use of hearing loops, braille and sign language. 60

To the best of our knowledge, this is the first systematic review investigating the barriers and enablers of the informed consent process for healthcare procedures for people with intellectual disability. The integrative review by Goldsmith et al 26 examined capacity assessment and shares only three articles with this systematic review. 69 71 73 Since the 2000s, there has been a paradigm shift in which capacity is no longer considered a fixed ability that only some individuals possess 38 39 but instead as ‘functional’: a flexible ability that changes over time and in different contexts, 79 reflected in Goldsmith’s review. An individual’s capacity can be supported through various measures, including how information is communicated and how the decision-making process is approached. 18 80 By recognising the barriers and enablers identified in this review, physicians can help ensure the consent process for their patients with intellectual disability is both valid and truly informed. This review has highlighted the problems of inaccessible health information, insufficient clinical education on how to make reasonable adjustments and lack of person-centred trauma-informed care.

Recommendations

Health professionals require training in the informed consent process for people with intellectual disability, particularly in effective and respectful communication, reasonable adjustments and trauma-informed care. Reasonable adjustments include offering longer or multiple appointments, using accessible resources (such as easy read information or shared decision-making tools) and allowing patient choices (such as to record a consultation or involve a support person). Co-researchers reported that many people with intellectual disability prefer to go without a support person because they find it difficult to challenge their decisions and feel ignored if the health professional only talks to the support person. People with intellectual disability also feel they cannot seek second opinions before making medical decisions or feel pressured to provide consent, raising the possibility of coercion. These experiences contribute to healthcare trauma. Co-researchers raised the importance of building rapport with the person with intellectual disability and of making reasonable adjustments, such as actively advocating for the person’s autonomy, clearly stating all options including the choice to refuse treatment, providing opportunities to contribute to discussions and multiple appointments to ask questions and understand information. They felt that without these efforts to support consent, health professionals can reinforce traumatic healthcare experiences for people with intellectual disability. Co-researchers noted instances where choices were made by doctors without discussion and where they were only given a choice after requesting one and expressed concern that these barriers are greater for those with higher support needs.

Co-researchers showed how these experiences contributed to mistrust of health professionals and poorer health outcomes. In one situation, a co-researcher was not informed of a medication’s withdrawal effects, resulting in significant side-effects when it was ceased. Many people with intellectual disability describe a poor relationship with their health professionals, finding it difficult to trust health information provided due to previous traumatic experiences of disrespect, coercion, lack of choice and inadequate support. Many feel they cannot speak up due to the power imbalance and fear of retaliation. Poor consent practices and lack of reasonable adjustments directly harm therapeutic alliances by reducing trust, contribute to healthcare trauma and lead to poorer health outcomes for people with intellectual disability.

Additional education and training for health professionals is urgently needed in the areas of informed consent, reasonable adjustments and effective communication with people with intellectual disability. The experiences of health professionals within the research team confirmed that there is limited training in providing high-quality healthcare for people with intellectual disability, including reasonable adjustments and accessible health information. Co-researchers also suggested that education should be provided to carers and support people to help them better advocate for people with intellectual disability.

Health information should be provided in a multimodal format, including written easy read information. Many countries have regulation protecting the right to accessible health information and communication support to make an informed choice, such as UK’s Accessible Information Standard, 81 and Australia’s Charter of Health Care Rights, 24 yet these are rarely observed. Steps to facilitate this include routinely asking patients about information requirements, system alerts for an individual’s needs or routinely providing reasonable adjustments. 82 Co-researchers agreed that there is a lack of accessible health information, particularly about medications, and that diagrams and illustrations are underutilised. There is a critical need for more inclusive and accessible resources to help health professionals support informed consent in a safe and high-quality health system. These resources should be created through methods of inclusive research, such as co-production, actively involving people with intellectual disability in the planning, creation, and feedback process. 53

Strengths and limitations

This systematic review involved two co-researchers with intellectual disability in sense-checking findings and co-creating the easy read summary. Two co-authors who are health professionals provided additional sense-checking of findings from a different stakeholder perspective. In future research, this could be extended by involving people with intellectual disability in the design and planning of the study as per recommendations for best-practice inclusive research. 53 83

The current literature is limited by low use of inclusive research practices in research involving people with intellectual disability, increasing vulnerability to external biases (eg, inaccessible questionnaires, involvement of carers in data collection, overcompliance or acquiescence and absence of researcher reflexivity). Advisory groups or co-research with people with intellectual disability were only used in five studies. 58 60 68 74 76 Other limitations include unclear selection criteria, low sample sizes, missing data, using gatekeepers in patient selection and predominance of UK-based studies—increasing the risk of bias and reducing transferability. Nine studies (out of 15 involving people with intellectual disability) explicitly excluded those with severe or profound intellectual disability, reflecting a selection bias; only one study specifically focused on people with intellectual disability with higher support needs. Studies were limited to a few healthcare contexts, with a focus on consent about sexual health, contraception and medications.

The heterogeneity and qualitative nature of studies made it challenging to apply traditional meta-analysis. However, to promote consistency in qualitative research, the PRISMA and ENTREQ guidelines were followed. 36 37 Although no meta-analyses occurred, the duplication of study populations in McCarthy 2009 and 2010 likely contributed to increased significance of findings reported in both studies. Most included studies (13/23) were published over 10 years ago, reducing the current relevance of this review’s findings. Nonetheless, the major findings reflect underlying systemic issues within the health system, which are unlikely to have been resolved since the articles were published, as the just-released final report of the Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability highlights. 84 There is an urgent need for more inclusive studies to explore the recommendations and preferences of people with intellectual disability about healthcare choices.

Informed consent processes for people with intellectual disability should include accessible information and reasonable adjustments, be tailored to individuals’ needs and comply with consent and disability legislation. Resources, guidelines and healthcare education are needed and should cover how to involve carers and support people, address systemic healthcare problems, promote a person-centred approach and ensure effective communication. These resources and future research must use principles of inclusive co-production—involving people with intellectual disability at all stages. Additionally, research is needed on people with higher support needs and in specific contexts where informed consent is vital but under-researched, such as cancer screening, palliative care, prenatal and newborn screening, surgical procedures, genetic medicine and advanced therapeutics such as gene-based therapies.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

• Maulik PK ,
• Mascarenhas MN ,
• Mathers CD , et al
• World Health Organisation
• Council for Intellectual Disability
• Emerson E ,
• Shogren KA ,
• Wehmeyer ML ,
• Reese RM , et al
• Cordasco KM
• Hallock JL ,
• Jordens CFC ,
• McGrath C , et al
• Brenner LH ,
• Brenner AT ,
• United Nations Population Fund
• Australian Commission on Safety and Quality in Health Care
• The Joint Commission
• Beauchamp TL ,
• Childress JF
• New South Wales Attorney General
• United Nations General Assembly
• Strnadová I ,
• Loblinzk J ,
• Scully JL , et al
• MacPhail C ,
• McKay K , et al
• Keywood K ,
• Fovargue S ,
• Goldsmith L ,
• Skirton H ,
• Cash J , et al
• Morris CD ,
• Niederbuhl JM ,
• Arscott K ,
• Fisher CB ,
• Davidson PW , et al
• Giampieri M
• Shamseer L ,
• Clarke M , et al
• McKenzie JE ,
• Bossuyt PM , et al
• Flemming K ,
• McInnes E , et al
• Appelbaum PS
• ↵ Covidence systematic review software . Melbourne, Australia ,
• Proudfoot K
• Papadopoulos I ,
• Koulouglioti C ,
• Lazzarino R , et al
• Onwuegbuzie AJ
• BMJ Best Practice
• Guyatt GH ,
• Vist GE , et al
• Garcia-Lee B
• Brimblecombe J , et al
• Benson BA ,
• Farmer CA , et al
• Ferguson L ,
• Graham YNH ,
• Gerrard D ,
• Laight S , et al
• Huneke NTM ,
• Halder N , et al
• Ferguson M ,
• Jarrett D ,
• McGuire BE , et al
• Woodward V ,
• Jackson L , et al
• Conboy-Hill S ,
• Leafman J ,
• Nehrenz GM , et al
• Höglund B ,
• Carlson T ,
• English S , et al
• Wiseman P ,
• Walmsley J ,
• Tilley E , et al
• Khatkar HS , et al
• Holland AJ , et al
• Beauchamp TL
• England National Health Service
• National Health Service England
• Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3
• Data supplement 4
• Data supplement 5

Contributors MD, EEP and IS conceived the idea for the systematic review. MD drafted the search strategy which was refined by EEP and IS. MD and EEP completed article screening. MD and IS completed quality assessments of included articles. MD and JH completed data extraction. MD drafted the original manuscript. JL and SS were co-researchers who sense-checked findings and were consulted to formulate dissemination plans. JL and SS co-produced the easy read summary with MD, CM, JH, EEP and IS. MD, JLS, EEP and IS reviewed manuscript wording. All authors critically reviewed the manuscript and approved it for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MD is the guarantor responsible for the overall content of this manuscript.

Funding This systematic literature review was funded by the National Health & Medical Research Council (NHMRC), Targeted Call for Research (TCR) into Improving health of people with intellectual disability. Research grant title "GeneEQUAL: equitable and accessible genomic healthcare for people with intellectual disability". NHMRC application ID: 2022/GNT2015753.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles

• Editorial It is up to healthcare professionals to talk to us in a way that we can understand: informed consent processes in people with an intellectual disability Jonathon Ding Richard Keagan-Bull Irene Tuffrey-Wijne BMJ Quality & Safety 2024; 33 277-279 Published Online First: 30 Jan 2024. doi: 10.1136/bmjqs-2023-016830

Read the full text or download the PDF:

• Dean’s Office
• External Advisory Council
• Computing Council
• Extended Computing Council
• Undergraduate Advisory Group
• Break Through Tech AI
• Building 45 Event Space
• Infinite Mile Awards: Past Winners
• Frequently Asked Questions
• Undergraduate Programs
• Graduate Programs
• Educating Computing Bilinguals
• Online Learning
• Industry Programs
• AI Policy Briefs
• Envisioning the Future of Computing Prize
• SERC Symposium 2023
• SERC Case Studies
• SERC Scholars Program
• SERC Postdocs
• Common Ground Subjects
• For First-Year Students and Advisors
• For Instructors: About Common Ground Subjects
• Common Ground Award for Excellence in Teaching
• New and Incoming Faculty
• Faculty Resources
• Faculty Openings
• Search for: Search
• MIT Homepage

Study demonstrates efficacy of MIT-led Brave Behind Bars program

Programming course for incarcerated people boosts digital literacy and self-efficacy, highlighting potential for reduced recidivism.

Several years ago, a team of scientists from MIT and the University of Massachusetts at Lowell designed and deployed a first-of-its-kind web programming course for incarcerated individuals across multiple correctional facilities. The program, Brave Behind Bars , uses virtual classroom technology to deliver web design training to students behind prison walls. The program brought together men and women from gender-segregated facilities to learn fundamentals in HTML, CSS, and JavaScript, helping them to create websites addressing social issues of their own choosing.

The program is accredited through three collaborating universities: Georgetown University, Benjamin Franklin Institute of Technology, and Washington County Community College. In a new open-access paper about the project, the team analyzed its impact: They used a multi-pronged approach, gathering insights through comprehensive surveys with participants from dichotomous and open-ended questions. The results painted a powerful narrative of increased self-efficacy — a crucial marker for successful reentry into the workforce and society — among incarcerated learners.

“Education has long been recognized as a pivotal factor in reducing recidivism and fostering successful reentry,” says Martin Nisser, an MIT PhD candidate in electrical engineering and computer science (EECS), affiliate of the MIT Computer Science and Artificial Intelligence Laboratory (CSAIL), and lead author of the paper. “By equipping incarcerated learners with invaluable digital literacy skills and boosting their self-efficacy, our program aims to foster the skills necessary to thrive in today’s technology-driven world.”

The strength of Brave Behind Bars is manifested vividly through the impactful websites created by the students. One project, “End Homelessness Statewide,” provided vital resources to help unhoused individuals find temporary and permanent shelter. Another website, “The PinkPrint,” addressed the unique challenges incarcerated women face, serving as a “blueprint” with educational resources and gender-responsive support. Equally remarkable was “No Excuse for Domestic Abuse,” which raised awareness about the prevalence of domestic violence while offering a lifeline to victims seeking help.

A mixed-methods research study evaluated how the 12-week, college-accredited course was faring. “Our qualitative study in 2022 involving thematic analyses of post-course surveys from 34 students revealed overwhelmingly positive feedback, with students reporting increased self-confidence, motivation, and a sense of empowerment from learning web programming skills. The themes we uncovered highlighted the powerful effect of the program on students’ self-beliefs,” says Nisser.

The urgency of such work cannot be understated, as underscored by the alarmingly high rates of recidivism, the rate at which formerly incarcerated individuals are rearrested leading to re-conviction. A central cause of mass incarceration, data shows that an estimated 68 percent of people released from U.S. jails or prisons were arrested within three years between 2005 and 2014, rising to 83 percent within nine years. However, a meta-analysis spanning 37 years of research (1980-2017) revealed a promising trend: Incarcerated individuals who participate in post-secondary educational programs are 28 percent less likely to return to prison.

Joblessness among the formerly incarcerated can be as high as 60 percent a year after release. Almost two-thirds of those who secure employment enter jobs typically available to people with little or no education, such as waste management, manufacturing, and construction — jobs increasingly being automated or outsourced.

While both the demand and supply of AI curricula in higher education have sky-rocketed, these have not typically served disadvantaged people, who must be caught up in foundational digital literacy. The ability to skillfully navigate computers and the internet is becoming essential for post-release employment in the modern workplace, as well as to navigate the economic, social, and health-related resources that are now embedded in our digital technologies.

The other part was a quantitative study in 2023, with 37 participants measuring general computer programming self-efficacy using validated scales before and after the course. The authors saw an increase in mean scores for general self-efficacy and digital literacy after the course, but the pre- and post-course measures of self-efficacy were not statistically significantly different. This challenge, the team says, is common in carceral environments, where meta-analyses of multiple studies with less significant results are often needed to achieve statistical significance and draw meaningful conclusions. The authors also acknowledge that their quantitative study contributes to this data pool, and they are conducting new courses to gather more data for future comprehensive statistical analyses.

“By providing incarcerated individuals with an opportunity to develop digital literacy, the Brave Behind Bars program facilitates self-efficacy through a novel education model designed not only to expand access to the internet for individuals but also to teach them the navigation and web design skills needed to connect and engage with the communities to which they will return,” says UMass Lowell professor and chair of the School of Criminology and Justice Studies April Pattavina, who was not involved in the research. “I applaud the team’s dedication in implementing the program and look forward to longer-term evaluations on graduates when they leave prison so we can learn about the extent to which the program transforms lives on the outside.”

One student, reflecting on the impact of the Brave Behind Bars program, says, “This class has shown me that I am human again, and I deserve to have a better quality of life post-incarceration.” In an environment where individuals can too often be made to feel like numbers, a program is underway to demonstrate that these individuals can be seen once more as people.

The research was conducted by a team of experts from MIT and UMass Lowell. Leading the team was Martin Nisser, who wrote the paper alongside Marisa Gaetz, a PhD student in the MIT Department of Mathematics; Andrew Fishberg, a PhD student in the MIT Department of Aeronautics and Astronautics; and Raechel Soicher, assistant director of research and evaluation at the MIT Teaching and Learning Laboratory. Faraz Faruqi, an MIT PhD student in EECS and CSAIL affiliate, contributed significantly to the project. Completing the team, Joshua Long brought his expertise from UMass Lowell, adding a unique perspective to the collaborative effort.

Related Stories