A Critical Examination of School-based Physiotherapists’ Perceived Aptitude and Willingness to Facilitate Health and Wellness Promotion

Placing value on the health and wellness of Children with Disabilities (CWD) should be a core societal value. Twenty percent of children with disabilities aged 10 to 17 are obese. Decreased access to developmentally appropriate recreational activities, and inexperienced instructors lack of knowledge to effectively support their inclusion are barriers to their participation. School-based Physical Therapists (SBPT) are in a distinctive position to provide appropriate and modified fitness programs for children with disabilities. The purpose of this basic qualitative design study was to determine SBPTs’ perspectives on their aptitude and willingness to facilitate fitness, health, and wellness promotion programs for CWD. Social cognitive theory was used as the theoretical grounding for the conceptual framework of this research. The conceptual framework that guided this research was constructed from a combination of the International Classification of Functioning, Disability, and Health for Children and Youth and the Comprehensive School Physical Activity Program conceptual framework. Purposive sampling yielded 12 participants who took part in semi-structured interviews. Data were analyzed through Colaizzi’s seven step method. Results showed that SBPTs felt capable and willing to provide fitness, health, and wellness programs for CWD. Results support findings from the literature that suggest SBPTs are underutilized in the school setting and are equipped to facilitate fitness, health, and wellness initiatives for CWD. Findings inform stakeholders on strategies to steer SBPTs’ role as healthcare professionals in an educational environment. This research brings increased awareness to the potential contribution of SBPTs to partner with schools and families to facilitate fitness, health, and wellness programs for CWD.

Recognizing the social determinants of health can help formulate goals for improving CWD's inclusion in fitness and wellness initiatives (ODPHP, 2018). Meaningful opportunities for inclusion in physical activity are necessary to promote CWD's health and wellness (ODPHP, 2018). While there is evidence and research on the role of the pediatric PTs role in fitness and health promotion, there is a gap in the research on SBPTs perceived aptitude and willingness to participate in this capacity for CWD. The American Physical Therapy Association's (APTA) guide to practice defined the scope of practice to incorporate fitness, health promotion, and wellness (APTA, 2016). The need for SBPTs to be more involved in health and wellness promotion in the schools is critical to developing a healthy lifestyle for CWD (Academy of Pediatric Physical Therapy [APPT], 2015). The APTA endorsed the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY) to inform physical therapy evidence-based practice at an individual and population level (APTA, 2016).
The problem was the underutilization of SBPTs related to their facilitation of fitness, health, and wellness initiatives for CWD. The American Physical Therapy Association's (APTA) Guide to Practice (2016) states that the scope of physical therapy practice includes diagnosis and treatment to optimize function, movement, quality of life, and well-being. School-based physical therapists are underutilized in the school setting in wellness and health promotion and implementing CWD exercise programs beyond the IEP (Jeffries et al., 2019). Further, CWD do not get the recommended amount of daily exercise and are at increased risk for obesity (CDC, 2020). There is a gap in the literature on the SBPTs perceived willingness and aptitude toward facilitating health and wellness promotion and exercise participation beyond the IEP among CWD. www.scholink.org/ojs/index.php/wjssr World Journal of Social Science Research Vol. 8, No. 4, 2021 4 Published by SCHOLINK INC.
School-based physical therapists have the training and skillset to promote health and wellness, provide specialized exercise intervention, facilitate participation in an adapted sports program, and to consult with other school staff on modifications and accommodations to improve the accessibility of the school setting (APTA, 2019a; Jeffries et al., 2019). School-based physical therapists' role in the school setting are limited to services prescribed on the IEP and often does not include health and wellness for CWD (APTA, 2019a). School-based physical therapists should advocate for "prevention, wellness, fitness, health promotion, and management of disease and disability" (APTA, 2019b, p. 2). School-based physical therapists should also support and advocate for inclusive physical education and reduce inequities of social determinants of health among (APTA, 2019b). The perception of SBPTs capability and willingness to engage in the promotion of fitness, health, and wellness programs was explored to support increased access to physical fitness programs for CWD to improve their quality of life.

Purpose
The purpose of this basic qualitative study was to determine SBPTs perspectives on their aptitude and willingness to facilitate fitness, health, and wellness promotion programs among CWD beyond the IEP.
There are many health benefits to physical activity among non-disabled children and those with a disability, including maintaining a healthy weight. There is an increased risk of obesity among children with intellectual disabilities compared to their non-disabled peers (Collins & Staples, 2017). The primary objectives for promoting exercise, health, and wellness in CWD are to maximize function, improve or sustain mobility, and to enhance the quality of life (Collins & Staples, 2017). Research has shown that physical activity benefits included improved aerobic capacity, maintenance of muscle strength and flexibility, and gross motor function (Kapsal et al., 2019). CWD are far less active than non-disabled children and encounter barriers in fitness participation due to the lack of instructor knowledge about effectively supporting their inclusion (McGarty & Melville, 2018).
School-based physical therapists are in the perfect position to facilitate increased physical activity, exercise design, peer modeling, and promote health and wellness (Jeffries et al., 2019). In addition to addressing school-related gross motor goals, the SBPTs are equipped to develop a physical activity program and facilitate health and wellness initiatives for CWD with a focus on common gross motor delays, such as balance, agility, strength, and coordination (Rowland et al., 2015).
The following research questions guided this study:

RQ1:
What are the school-based physical therapists' perception of their willingness to facilitate fitness, health, and wellness programs for children with disabilities?

RQ2:
What are the school-based physical therapists' perception of their ability to facilitate fitness, health, and wellness programs for children with disabilities? The target population well-suited for this study was licensed physical therapists working in the public-school setting for at least one year in the Northeast region of the United States of America. Their real-world experience with school-based physical therapy allowed them to adequately describe their perception of SBPTs role in schools, which fit the basic qualitative research design. The sample was a non-probability purposive sample. A non-probability purposive sample was appropriate for this research because it represents a typical subject within the larger population of SBPTs.

Research Design
A basic qualitative design best fit this study because it allowed for collecting descriptive accounts from the participants to better understand the phenomenon (Rudestam & Newton, 2015). This qualitative design allowed for salient, in-depth information to be gathered focused on the participants' perspectives (Rudestam & Newton, 2015). As data was collected, emerging categories and themes arose about SBPTs' perceptions and experiences. The data was categorized into themes using a priori, open, and axial codes for detailed data analysis.

Data Collection
The interviews took place over three weeks using a video conferencing platform. Semi-structured interviews provided flexibility to adjust to participants' knowledge and experience and to collect in-depth responses related to the phenomenon. Gray et al. (2020) reported that video conferencing for qualitative research saved money, time, allowed access to a larger population, and there was no difference in interview quality when in-person interviews were compared with video conferencing.
Participant technical abilities and computer savvy were considered when setting up video conferencing interviews (Gray et al., 2020). Zoom Meeting has been determined to be the most efficient video conferencing platform because the participants do not need an account, and there are screen-sharing abilities to review the interview protocol and informed consent (Gray et al., 2020). Most importantly, Zoom Meeting has a password protection feature to ensure the participant's confidentiality (Gray et al., 2020). Since there was no audio or video recording of the interviews, field notes were used as the primary method of data collection. Immediately after each interview, the typed field notes were reviewed for clarity and grammatical fluency. A reflective journal was used to document impressions before and after the interview. The reflective journal was used to reflect further on what was noticed before, during, and after the interviews. The handwritten notes taken in the reflective journal before and after the interviews allowed the research to reflect and compare information from the typed interviews.
To determine each transcription's accuracy, member checking was accomplished by emailing the template containing the participant's typed responses. Each participant had the opportunity to review the typed transcript of their interview to ensure the intent of their answers was accurately captured. One participant made some changes to the typed interview transcript, while the other 11 verified their transcripts' accuracy.

Results
The data analysis involved providing an overview of the themes and codes used in the data collection coding process. Table 1 shows the themes and categories that emerged and their alignment with the grounding framework and research questions. The eight themes identified were: making fitness, health, and wellness accessible to CWD; multidisciplinary collaboration; access to resources and continuing education opportunities; provide education on the role of SBPTs and fitness, health, and wellness; fitness, health and wellness is within SBPT's scope of practice; developing a fitness, health, and wellness committee for special education; support from administration, staff, and parents; and SBPT and student time constraints. The eight major themes address the problem in this study, considering the underutilization of SBPTs related to their facilitation of fitness, health, and wellness initiatives for CWD. These findings underpin the purpose of the study: to determine SBPTs' perspectives on their aptitude and willingness to facilitate fitness, health, and wellness promotion programs among CWD.

Research Question 1
The first research question addressed in this study was: What are SBPTs' perceptions of their willingness to facilitate fitness, health, and wellness programs for children with disabilities? Three themes emerged answering this research question: making fitness, health, and wellness accessible to CWD; multidisciplinary collaboration; and access to resources and continuing education. These themes were found to be factors that would improve SBPTs' willingness to facilitate programs for CWD.

Making Fitness, Health, and Wellness Accessible to CWD
Participants suggested strategies to make fitness, health, and wellness accessible to CWD. Five participants (42%) felt that these programs should be incorporated into the school day, and 25% of participants proposed implementing before and after school programs for CWD to engage in physical Disability (NCHDAP, 2017) posited that physical activity, health, and wellness programs should be modified to address CWD's individual needs.
Participants suggested before and after school programs as an excellent approach to support inclusion and promote a healthy lifestyle among CWD. Eleven out of twelve (92%) interviewed echoed that CWD do not get the recommended amount of physical activity and do not have access to programs that promote fitness. Bota et al. (2014) revealed that supporting inclusion through programs such as adapted sports in the school environment can enhance physical fitness and social acceptance levels. SBPTs are ideal candidates to facilitate and promote before and after-school programs for CWD.

Multidisciplinary Collaboration
Multidisciplinary collaboration was a common thread throughout many of the participant responses.
The participants felt strongly that the effectiveness of their services could be improved with better collaboration from school staff. It was revealed that 67% of participants felt that building a strong rapport with colleagues was critical in successful service delivery and the formation of new programs such as fitness, health, and wellness for CWD. This finding is consistent with Kolbe (2019), who reported that increasing alignment and collaboration between educators and health providers improved cognition, physical, social, and emotional skills for each child.
Participants' felt that multidisciplinary collaboration was crucial to their willingness to provide fitness, health, and wellness programs. Participants suggested that multidisciplinary collaboration be enhanced with a team-based approach through strong rapport with other staff members. Centeio et al. (2018) revealed that multidisciplinary collaboration positively affects the school's health and wellness culture.
This study corroborated that SBPTs would like to be more involved in collaboration with PE teachers and special educators to influence the school culture towards fitness positively. It was revealed that participants felt collaboration is essential to ensure CWD are looked at from a whole-child perspective.
This theme is consistent with NCHPAD's (2017) recommendations, which suggested CWD can get the recommended daily physical activity through better interprofessional collaboration between SBPTs and adaptive physical education teachers. Hutzler and Barak (2017) recommended that SBPTs are consulted on expected physical function and strategies to improve CWD inclusion in physical activity (Hutzler & Barak, 2017), consistent with the need for multidisciplinary collaboration.

Access to Resources and Continuing Education
A common response from the participants was that their school district did not offer appropriate continuing education opportunities, and they had limited access to resources such as equipment.
Seventy-five percent of participants interviewed felt that school districts did not offer SBPTs continuing education opportunities appropriate for their scope and breadth of practice within the schools. The participants reported that having access to non-educational resources and appropriate continuing education would improve their willingness to facilitate fitness, health, and wellness programs for CWD.
Access to professional development that teaches strategies to incorporate health and wellness into their treatment sessions could increase SBPTs self-efficacy and confidence. Perera et al. (2019) found that providing SBPTs with professional development geared toward incorporating health and wellness into their treatment sessions can increase their self-efficacy and confidence; furthermore, study participants agreed on the importance of appropriate professional development. Black et al. (2016) found that training and continuing education are necessary for PTs to feel competent to facilitate health and wellness promotion. Dauenhauer et al. (2018) recommended that school districts provide professional development opportunities to expand physical activity promotion programs and initiatives.

Research Question 2
The second research question addressed in this study was: What are SBPTs' perceptions of their ability to facilitate fitness, health, and wellness programs for children with disabilities? The themes that emerged answering this research question were provide education on the role of SBPTs and fitness, health, and wellness; and fitness, health, and wellness are within SBPT's scope of practice. These two themes were discovered to be essential components of SBPTs' perceived self-efficacy in providing fitness, health, and wellness programs for CWD. Participants indicated that addressing these needs by providing education and increasing awareness of the SBPT's scope of practice would improve their ability to facilitate programs for CWD.

Provide Education on the Role of SBPTs and Fitness, Health, and Wellness
All participants (100%) interviewed felt they had the ability, knowledge, and background to provide fitness, health, and wellness programs for CWD. They suggested a significant barrier was the lack of knowledge of academic staff regarding their role and scope. Providing education to administration and staff was an overarching recommendation to change the school's culture of health and wellness and the staff's perception of SBPTs. The SBPTs echoed that many staff members did not understand their knowledge and training breadth and depth.
In this study, participants felt they were not seen as a resource in health and wellness within the school environment. Most participants (92%) felt that physical therapy was not viewed as a priority in the schools. Providing education to administration and staff was suggested to inform and clarify SBPT's role and improve their willingness to provide these programs for CWD. Lee and Welk (2019) found that a principal's beliefs and attitudes toward special education were critical to the successful implementation of inclusion within schools, particularly in promoting physical activity participation among CWD. Templeton (2017) reported that knowledgeable school administrators who supported special education services could positively support and motivate the special education staff.

Fitness, Health, and Wellness is Within SBPTs Scope of Practice
Eleven participants (92%) indicated they had the knowledge, skills, and training necessary to facilitate www.scholink.org/ojs/index.php/wjssr World Journal of Social Science Research Vol. 8, No. 4, 2021 10 Published by SCHOLINK INC. these programs. All participants (100%) reported feeling high self-efficacy about utilizing their scope of knowledge, depth, and breadth of practice to appropriately deliver fitness, health, and wellness programs for CWD. This positive self-efficacy contributed to participants' perceived capability to provide fitness, health, and wellness programs for CWD. Queralt et al. (2016) found that SBPTs had the skills and knowledge to facilitate the transition from receiving school-based therapy services to participate in an adapted sports program. However, the Black et al. (2016) study results were inconsistent with the findings of this research. While the results of this study indicated that all the participants felt facilitating fitness, health, and wellness for CWD were within their scope, Black et al. (2016) found that many PTs reported they hesitated to facilitate health and wellness promotion due to a lack of confidence. In the current study, all the participants interviewed indicated they felt they had the skills and training to facilitate fitness, health, and wellness for CWD. This discrepancy could be due to the participant work setting in a school district.

Research Question 3
The third research question addressed in this study was: What are SBPTs' perceptions about the key determinants for physical therapists' involvement in fitness, health, and wellness promotion for children with disabilities? Three themes emerged answering this research question: instituting a fitness, health, and wellness committee for special education; support from administration, staff, and parents; and SBPT and student time constraints. These themes were discovered to be key determinants that may influence SBPTs involvement in facilitating programs for CWD.

Fitness, Health, and Wellness Committee for Special Education
The development of a fitness, health, and wellness committee for special education with support from administration, staff, and parents was a key determinant in SBPTs involvement in these programs for CWD. Many school districts had health and wellness committees, but 92% of participants suggested that a health and wellness committee specifically addressing special education students should be formed with SBPTs as active committee members. This aligned with results from studies by Jeffries et al. (2019) reported that while SBPTs were a part of the planning and placement team, they were often not utilized to an extent commensurate with their training and knowledge.
Participants indicated that a special education-focused committee would help to advance the health agenda of CWD within the school environment. Further, they recommended that SBPTs should be key players, given their scope of practice and knowledge. This theme arose from the lack of health and wellness committees specific to special education. None (0%) of the participants interviewed were members of their school district's general health and wellness committee.
Multidisciplinary collaboration was suggested as a critical component to the development of a successful committee. Eleven participants (92%) proposed that sharing knowledge and ideas between different disciplines on a special education health and wellness committee would support CWD by www.scholink.org/ojs/index.php/wjssr World Journal of Social Science Research Vol. 8, No. 4, 2021 11 Published by SCHOLINK INC. encouraging a healthy lifestyle and an improved quality of life. This belief was consistent with the APTA (2019a) position statement that SBPTs should support and advocate for inclusive physical education and reduce inequities of social determinants of health among CWDs.

Support from Administration, Staff, and Parents
The participants revealed that support from school administration, staff, and parents were key determinants to their successful implementation of any fitness, health, and wellness program for CWD.
Eight participants (67%) felt that administration support was a key determinant to their successful facilitation of fitness, health, and wellness programs for CWD. This theme was consistent with much of the reviewed literature. Burić and Moè (2020) found that creating a supportive and positive work environment led to higher employee self-efficacy levels, which improved job satisfaction. Carson et al. (2020) posited that administrative support of efforts to promote physical activity facilitated a positive image among other school staff and improved the effectiveness of SBPTs.
Ten participants (83%) indicated that support from the teachers and parents were key determinants.
McGarty and Melville (2018) found that parents played a critical role in encouraging physical activity among CWD. Thomason and Wilmarth (2015) reported a lack of parental understanding of the role of SBPTs. These findings corroborate the need for SBPTs to educate administration, staff, and parents on their role and scope of practice. As related service providers, SBPTs need administration, teachers, and parents to advocate for the benefits of their services and repertoire of skills.

SBPT and Student Time Constraints
All 12 participants (100%) suggested that time was a significant barrier to implementing a fitness, health, and wellness program for CWD. Participants felt that there was not enough time in the school day to deliver services that were outside of the IEP. Lack of time in participants' and students' daily schedules was determined to be decisive factors in developing these programs. Thomason and Wilmarth (2015) revealed barriers for SBPTs to provide integrated services included unmanageable caseloads, scheduling challenges, travel time between schools within a school district, and differing school schedules.

Research Discussion
The results of this study added to the literature and body of knowledge of SBPTs by analyzing their perceived willingness and ability to provide fitness, health, and wellness for CWD. These results suggest an opportunity for SBPTs to be more involved in fitness, health, and wellness promotion for CWD. These results contribute to the existing literature that implies SBPTs are in the perfect position to facilitate increased physical activity, exercise design, peer modeling, health, and wellness (Jeffries et al.,

Conclusion
The purpose of this basic qualitative study was to examine SBPTs' perceived willingness and capability to facilitate fitness, health, and wellness programs for CWD. Scholarly literature was examined within school-based physical therapy and fitness, health, and wellness among CWD. This study captured the perspectives of 12 participants. The findings revealed that participants felt they had the knowledge and training to provide fitness, health, and wellness programs for CWD. Participants shared strategies that would increase their willingness and capability to engage in these programs in the schools. Participants suggested that providing education on the role and scope of practice of SBPTs and the benefits of fitness, health, and wellness for CWD would ensure key educational staff understood SBPTs' depth and breadth of practice. Eliminating confusion about their capabilities would lead to the inclusion of SBPTs in program development for CWD.
Additional facilitators to participants' involvement included increased support from administration, staff, and parents; access to non-educational resources and continuing education; and having more time in the school day to conduct this type of programming. Support for SBPTs can be accomplished in several ways: disseminating literature on SBPTs; participating in professional development to educate administration, staff, and parents on the breadth of SBPTs practice; and providing strategies for teachers and parents to collaborate with SBPTs to encourage fitness activities for CWD.
A final recommendation to facilitate multidisciplinary collaboration was developing health and wellness committees that specifically addressed CWD. It is recommended that SBPTs pursue an active role as collaborative leaders on their school's health and wellness committee to advocate for CWD, ensure inclusion, and address their unique needs. This goal can be achieved by providing education to school administration on SBPTs' knowledge and impactful contribution as members of the health and wellness committee.
This study, which examined SBPTs' perceived willingness and capabilities to facilitate fitness, health, and wellness programs for CWD, provided insight into what is necessary for SBPTs to feel more equipped to provide these services. The study results contribute to the knowledge base of SBPTs and their role in fitness, health, and wellness programs for CWD. It is the hope that this study encourages SBPTs to advocate for their unique capacity as a related service provider in the schools and seek an expanded role in fitness, health, and wellness programs for CWD.