Abstract
This study aimed to investigate the knowledge, attitudes, and practices of primary school teachers in Malaysia regarding the inclusion of deaf and hard-of-hearing (DHH) students in mainstream education with a particular focus on students who have developed oral communication abilities through using listening devices. These students are not adequately supported when they enter school, suggesting gaps in how teachers are prepared to meet their needs. A cross-sectional survey was conducted with 349 teachers from schools with Special Education Integrated Programme (SEIP) that had DHH students in mainstream classrooms. A validated questionnaire was used to assess their KAP across key domains. Results revealed that most teachers demonstrated limited knowledge (75.9%) and mostly low or ambivalent attitudes (56.7%) toward DHH inclusion. Item-level analysis highlighted specific gaps in technical knowledge, such as listening devices and optimizing classroom acoustics. Regression analyses identified knowledge as a key predictor of both attitudes and practices. Teachers with formal DHH training, experience teaching DHH students, or direct interaction with DHH individuals demonstrated significantly higher KAP scores. Furthermore, significant positive correlations were found among knowledge, attitudes, and practices, indicating that higher levels of knowledge are associated with more positive attitudes and better practices, with knowledge showing the strongest correlations. A comparison between teacher groups showed that SEIP teachers outperformed mainstream teachers across all domains. The findings emphasize the need for evidence-based, targeted professional development program and ongoing support for mainstream teachers to ensure the successful and equitable inclusion of DHH students using listening devices in mainstream education.
Plain Language Summary
This study examined how well primary school teachers in urban Malaysia are prepared to support deaf and hard-of-hearing (DHH) students who use listening devices like hearing aids or cochlear implants in mainstream classrooms. We surveyed 349 teachers from schools with special education program to assess their knowledge, attitudes, and teaching practices related to DHH inclusion. The majority of teachers showed significant gaps in their preparedness. Over three-quarters had limited knowledge about supporting DHH students, and more than half held uncertain or negative attitudes toward inclusion. Specific weaknesses included limited knowledge in assistive technology, specifically troubleshooting, cochlear implant function, and FM systems. Additionally, fewer than one in ten understood effective teaching strategies for DHH students, and only about one in five correctly understood what “inclusion” means. However, we found that knowledge is key. Teachers with better knowledge had more positive attitudes and better teaching practices. Those who received formal training on DHH topics or had direct experience with DHH students performed significantly better across all areas. Special education teachers consistently outperformed mainstream teachers, highlighting a critical training gap. These findings reveal an urgent need for targeted, evidence-based professional development for mainstream teachers. Without adequate knowledge and training, even teachers with positive attitudes struggle to implement effective inclusive practices. This study provides the foundation for developing specialized training programs to ensure DHH students receive equitable, high-quality education in Malaysian mainstream schools. Beyond Malaysia, these findings offer valuable insights for other low- and middle-income countries in similar educational contexts, where teachers face comparable challenges in preparing for DHH inclusion.
Introduction
Inclusive education has become an essential pillar of international education policy, based on the recognition that all learners, regardless of gender, ethnicity, ability, or linguistic background, have a fundamental right to a quality education in mainstream settings (Alnahdi & Yada, 2020; Khairuddin et al., 2018; UNESCO, 1994, 2009; United Nations, 2006). International frameworks such as the Salamanca Statement recognize education as a fundamental right for all children and emphasize the pivotal role of teachers (UNESCO, 1994). In line with these principles, the World Health Organization’s World Report on Hearing highlights the importance of strengthening the training of professionals, including teachers and social workers, on the effects of hearing loss and emphasizes their critical role in facilitating effective communication for individuals with hearing impairment (World Health Organization, 2021).
In recent decades, there has been a notable increase in the number of deaf and hard-of-hearing (DHH) children attending mainstream schools, a trend attributed to the global rise in childhood hearing loss and significant advances in audiological technology and support services (Khairuddin et al., 2018; Lissi et al., 2017; Pim et al., 2020; Silvestri & Hartman, 2022; World Health Organization, 2025). Improvements in early identification of hearing loss, access to appropriate amplification devices, and additional support within educational settings have contributed to improved developmental outcomes for DHH students, particularly those who use listening devices (Keerthan et al., 2025; Moeller & Tomblin, 2015; Pim et al., 2020). DHH students in mainstream schools have distinct communicational and educational needs that necessitate tailored accommodations and supports (Alanazi, 2021; Khairuddin et al., 2018; Lissi et al., 2017). For DHH students who communicate verbally and rely on listening devices such as hearing aids (HAs) and cochlear implants (CIs), optimal auditory access is critical, especially in the typically noisy environments of regular classrooms. These students benefit from strategies such as appropriate seating and the use of assistive listening devices (ALDs), including FM systems, which help mitigate the challenges of background noise and distance from teachers (Crandell & Smaldino, 2000; Zanin & Rance, 2016).
Verbal DHH students who use listening devices represent a distinct group in inclusive education settings. Early auditory intervention has enabled many of these children to develop spoken language and enter mainstream education (Khairuddin & Miles, 2020). However, their ability to communicate verbally often leads to the assumption that they can cope without additional support. In reality, they continue to face challenges related to listening fatigue, classroom acoustics, and limited teacher awareness of their specific needs (Keerthan et al., 2025; Todorov et al., 2021).
Drawing on inclusive education principles that emphasize welcoming diversity and removing barriers to participation (Ainscow, 2020; Ainscow & Sandill, 2010; Florian & Black-Hawkins, 2011; UNESCO, 1994), various evidence-based pedagogical frameworks have been developed to guide classroom implementation (Allman et al., 2019; Silvestri & Hartman, 2022). Among these, Universal Design for Learning (UDL) provides a comprehensive framework for defining and creating effective inclusive practice for DHH students (CAST, 2024; Hartman et al., 2023; Meyer et al., 2013; Silvestri & Hartman, 2022). UDL is a neuroscience- and learning science-based educational framework that facilitates flexible learning to support the diverse needs of learners (Gilleran Stephens et al., 2025). UDL acknowledges the fact that learner diversity is a norm and not an exception, which is why the flexibility of instructions is needed to meet the needs of every student, including those with disabilities (Sewell et al., 2022). This student-centered teaching model is structured around three fundamental principles that facilitate this flexibility: (1) multiple modes of representation, to ensure that all students can access the learning material; (2) multiple modes of action and expression, when students can show what they have learned in several ways; and (3) multiple modes of engagement, which help motivate students and encourage them to work hard by providing them with a variety of teaching methods (Meyer et al., 2013; Moriña et al., 2025).
While inclusive education principles and frameworks provide a foundation for effective practice, their successful implementation depends on teacher competencies. A pivotal role of teachers in fostering inclusive classrooms for DHH students is well established, as their professional competence, attitudes, and self-efficacy directly influence the quality of education and the success of inclusion initiatives (Alegre de la Rosa & Villar Angulo, 2024; Alsalem & Alzahrani, 2023; Pérez-Jorge et al., 2021). Core professional competencies include knowledge of hearing loss and its impact on learning, classroom management skills adapted for DHH learners, knowledge of differentiated instruction and assessment, familiarity with assistive listening technologies and their troubleshooting, and the ability to collaborate with families, colleagues, and audiologists, all of which are associated with more positive attitudes and reduced anxiety about inclusion (Alegre de la Rosa & Villar Angulo, 2024; Guardino, 2015; Khairuddin et al., 2018). Previous research has shown that teachers generally exhibit positive attitudes toward the inclusion of DHH students in mainstream classrooms, especially if they have received appropriate training or have prior experience working with these students (Charema, 2010; Eriks-Brophy & Whittingham, 2013; Prakash, 2012). However, a recurring challenge in the literature is that inclusive education may be hampered by a lack of adequate academic resources, specialized expertise, and insufficient training among general education teachers, particularly concerning the inclusion of DHH students who use listening devices and require specific support and accommodations (Keerthan et al., 2025; Khairuddin et al., 2018; Pérez-Jorge et al., 2021). It is also the concern predetermined by professional organizations, including the Council on Education of the Deaf (CED), which underlines that teachers who work with DHH students have to possess the special proficiencies and knowledge to meet their various educational and communicational needs (Guardino, 2015). To address these challenges, multidisciplinary teams often consist of specialist teachers, classroom teachers, and educational audiologists working with DHH students. Classroom teachers are among those professionals that have the most interaction with the students and are responsible for implementing necessary instructional adjustments, classroom modifications, and service delivery changes (Keerthan et al., 2025).
The analysis of teachers’ readiness to support the inclusion of DHH children can be contextualized using the Knowledge, Attitude, Practice (KAP) framework. The KAP framework is widely used in health and education to examine how what individuals know, believe, and do shapes their professional behavior (Andrade et al., 2020). It assumes knowledge informs attitudes and beliefs, which in turn influence classroom practices. However, the elements included in the structure may be harmonious or in conflicting patterns. Knowledge, attitudes, and beliefs may align to form practices, or knowledge and attitudes may conflict with beliefs (Launiala, 2009; Straughan & Xu, 2022). In the inclusive learning environment for DHH students, the attitude of teachers toward DHH inclusion will likely depend on their knowledge of hearing loss, assistive technologies, communication strategies, and classroom adaptations, which eventually would define their teaching practice and decision-making in the classroom (Alotaibi et al., 2020; Dsouza & Ranjan, 2024; Keerthan et al., 2025). This theoretical approach is in line with the available behavioral change theories, especially the Theory of Planned Behavior by Ajzen (1991), which asserts that attitudes, along with the subjective norms and perceived behavioral control, influence the behavioral intentions and action.
Many countries have adopted new educational strategies to advance inclusive education, and Malaysia is no exception. Malaysia’s commitment to inclusive education is evident through its ratification of the UN Convention on the Rights of Persons with Disabilities (CRPD; United Nations, 2006). The national policy has been influenced by these international frameworks, with the most notable one being the Malaysian Education Blueprint 2013–2025, which sets an ambitious target of enrolling 75% of students with special needs, including DHH students, in inclusive education programs, with the aim of equipping all teachers with at least basic knowledge of special education to better support diverse learning needs in mainstream educational settings (Ministry of Education Malaysia, 2013). The Malaysian education system provides three main pathways for DHH students: special education schools, the Special Education Integrated Programme (SEIP), and the Inclusive Education Programme (IEP). In SEIP schools, DHH students are placed on a continuum based on their readiness and abilities, including communication competence. Students may be placed fully in special education classrooms, partially integrated, attending both special education and mainstream classes, or fully in mainstream classrooms. All DHH students in SEIP schools receive ongoing support from special education teachers regardless of placement. In contrast, the IEP integrates these students directly into regular classrooms with support services (Khairuddin et al., 2018; Ministry of Education Malaysia, 2018). Although both the SEIP and IEP are designed to facilitate the integration of students with special needs into mainstream settings, significant disparities remain among DHH students, particularly those who communicate verbally and use listening devices, compounded by persistent gaps in teachers’ preparedness (Khairuddin et al., 2018).
While international studies have examined teachers’ competencies, including their knowledge, attitudes, and practices related to the inclusion of DHH students, critical gaps in evidence from low- and middle-income countries persist. This is particularly evident in the Asia-Pacific region, where systematic evidence on disability-inclusive teacher professional development remains scarce (Ahmed et al., 2022). Since Knowledge, Attitude, and Practice surveys (KAP) are context-specific and should be adjusted to the local setting, environment, and requirements of the target population (Andrade et al., 2020), investigating Malaysian teachers’ KAP will provide essential information to not only the local education authorities but also other countries that have the same landscape and limitations. More specifically, no existing research has examined teachers’ KAP regarding the inclusion of verbal DHH students using listening devices in mainstream primary schools. Given concerns about teacher’s preparedness to adequately support this group, this study aimed to investigate these domains among primary school teachers in Malaysian mainstream education, and to examine the underlying patterns, relationships, and contextual factors shaping these outcomes. To achieve these aims, the study addresses the following research questions:
What are the current levels of knowledge, attitudes, and practices among Malaysian primary school teachers regarding the inclusion of DHH students who use listening devices, and what specific gaps exist within each domain?
What are the interrelationships among knowledge, attitude, and practice domains in the context of supporting DHH students using listening devices in mainstream educational settings?
What demographic, professional, and experiential factors predict teachers’ knowledge, attitudes, and practices toward the inclusion of DHH students?
How do teachers working in SEIP schools differ from mainstream classroom teachers in their knowledge, attitudes, and practices toward DHH inclusion?
Answering these research questions will provide evidence-based direction for developing targeted professional development programs and will identify specific competency gaps that must be addressed to improve inclusive education quality for verbal DHH students who use listening devices in Malaysian primary schools and similar contexts across Southeast Asia and internationally.
Methods and Materials
Study Design and Setting
In this study, a cross-sectional survey design was used to measure the knowledge, attitudes, and practices (KAP) of the primary school teachers toward inclusion and education needs of the verbal DHH children using listening devices. The survey is a subset of a larger study to improve the integration of DHH students into general education, especially those who are verbal and use listening technologies like HAs or CIs. Data were collected from primary schools with special education integrated programs in the Klang Valley, Malaysia, between 20 November 2024 and 15 March 2025. These schools were selected because DHH students are enrolled across a range of placements, providing an appropriate context to assess mainstream teachers’ preparedness within supported inclusive setting. The study site, Klang Valley, comprising Kuala Lumpur, Putrajaya, and large urban areas in Selangor, was chosen because it is the most populous and diverse region in Malaysia.
Sampling
The research utilized a non-proportional judgmental quota sampling approach (Berndt, 2020; Morrow et al., 2007). Thirteen SEIP schools in the Klang Valley were purposively selected from a list provided by the Special Education Division of the Ministry of Education Malaysia, prioritizing schools with higher numbers of DHH children. Within these schools, questionnaires were distributed to eligible teachers, with the aim of maximizing the inclusion of teachers who had experience teaching verbal DHH children. The minimum sample size was calculated using Daniel’s (1999) formula for prevalence studies:
Participants
The study population was primary school teachers employed in special education integrated programme (SEIP) schools within the Klang Valley, Malaysia, including both teachers who taught in SEIP classes and those teaching in mainstream classrooms. Teachers in these settings have more opportunities not only to have personal experience working with DHH students but are also more likely to know about the inclusion practices and the challenges this group has to encounter. The eligible participants were all permanent teaching staff in these schools. Vernacular school teachers, in particular, from National-Type Schools (Chinese) and (Tamil), were excluded to guarantee methodological consistency in language and instructional practices.
A total of 349 primary school teachers participated in this study, including 160 SEIP teachers and 189 mainstream teachers recruited from schools implementing the SEIP program. Participants varied in demographic and professional characteristics, including teaching experience, subject specialization, and prior exposure to DHH individuals. Participants’ demographic and experience characteristics are presented in Table 1.
Participants’ Demographics.
Multiple-response item; percentages are based on n = 93.
Percentages for years and number of DHH students taught are calculated out of those with experience teaching DHH students (n = 159).
Survey Instrument
The research instrument that was applied in this study was the newly developed Teachers Questionnaire on Inclusion of DHH Students in Mainstream Education (TIDE-Q) that was designed, validated, and tested to assess the level of knowledge, attitudes, and practices of teachers on supporting the inclusion of DHH students who use listening devices in mainstream classes. The TIDE-Q has four sections with 52 items: demographics (11 items), knowledge (11 items), attitude (18 items), and practice (12 items). The complete TIDE-Q questionnaire is provided in the Supplemental Materials (Appendix A).
The TIDE-Q was constructed in a multi-phase process to ensure it accurately measured the constructs relevant to teacher preparedness, with attention to its cultural relevance and psychometric rigor. First, an initial literature search identified key areas needed to assess teacher preparedness for DHH inclusion. This was followed by expert consultations with specialists in audiology and education, ensuring alignment with the study objectives. The knowledge and practice items were formulated by the researchers, while the attitude items were translated and adapted, with permission, from the Opinions Relative to the Integration of Students with Disabilities (ORI) measuring instrument by Antonak and Larrivee (1995). The process resulted in a final pool of 18 items. The items were translated into Malay using forward and backward translations by bilingual professionals to ensure semantic equivalence and cultural relevance. The instrument underwent expert content and face validation, pilot testing with the target teacher population, and reliability testing.
The content validity of the questionnaire was evaluated by a panel of experts, with all items attaining a content validity index (CVI) of 1.0. In the pilot study, reliability analysis was done to determine internal consistency and temporal stability of the instrument. Results showed that the attitudes domain had strong internal consistency (Cronbach’s α = .86, 18 items), and the practice domain had acceptable internal consistency (Cronbach’s α = .78, 12 items). The test-retest reliability showed very high levels of stability with Intraclass Correlation Coefficients (ICC) of knowledge, attitude, and practice at .95, .88, and .79, respectively, with Cohen Kappa values of 0.67 to 1.00, indicating large to near-perfect agreement. In the present study, both the attitude and practice domains demonstrated strong internal consistency (Cronbach’s α for attitude = 0.84, n = 349; Cronbach’s α for practice = 0.82, n = 158).
The content of the questionnaire domains was informed by the UDL framework, with principles that align with key aspects of DHH inclusion, including classroom acoustics, listening technologies, and differentiated instructional strategies. Within this structure, the knowledge domain was designed to assess teachers’ understanding of core concepts relevant to including DHH students who use listening devices, such as the effects of hearing loss, principles of inclusive education, classroom acoustics, the use of assistive hearing technology, and effective instructional approaches for DHH learners. In addition to knowledge, the attitude domain captured belief-based dimensions reflecting teachers’ perceived efficacy and comfort in teaching DHH students. And finally, the practice domain addressed classroom management practices and techniques that support the successful inclusion of verbal DHH students using listening devices that may reflect how teachers apply their knowledge in practice.
In terms of item structure, the 11 items in the knowledge domain were in the true/false/not sure (8 items) and multiple responses (3 items) format. The 18 attitude and 12 practice items were rated on a six-point Likert scale from 1 (strongly disagree) to 6 (strongly agree). The questionnaire also contained questions that gathered demographic information, including age, gender, and level of education, along with questions about the experience and past training of the teachers in reference to DHH students (11 items).
Knowledge scores were computed dichotomously. For the true/false/not sure questions, a correct answer received a score of 1, and an incorrect or “not sure” answer received a score of 0. For the multiple-response questions, a score of 1 was awarded only when all correct options were selected; otherwise, the score was 0. This scoring method ensures comprehensive understanding of some knowledge aspects (Betts et al., 2022). For attitude and practice, raw scores were first adjusted by subtracting the minimum possible score to account for the scale’s lower bound. The adjusted scores were then converted into percentage scores by dividing each participant’s total by the maximum possible score for that section and multiplying by 100. The KAP levels were categorized according to modified Bloom’s cut-off points. For all three domains, scores of 80%–100%, 50%–79%, and less than 50% were designated as high, moderate, and low, respectively (Chand et al., 2022). Higher scores indicate greater knowledge, more positive attitudes toward the inclusion of DHH students, or more frequent implementation of targeted practices.
Ethical Considerations
This study received ethical approval from the institutional Health Research Ethics Committee, as well as permissions from the Ministry of Education Malaysia and the relevant state education departments, including those for the Federal Territory of Kuala Lumpur, the Federal Territory of Putrajaya, and Selangor State. Consent to conduct the research was first obtained from school principals, followed by written informed consent from participating teachers prior to data collection. The objectives and procedures of the study were explained to all participants, who were also informed about their rights of voluntary participation and withdrawal without any penalty at any time. Confidentiality of all responses was assured, and data were handled in accordance with institutional and national ethical guidelines.
Data Collection Procedure
The data collection followed a systematic process and consisted of five stages, as illustrated in Figure 1. After obtaining ethical approvals and institutional authorizations, the research team contacted the principals and the lead teacher at each participating school to explain the study’s objectives, procedures, and significance. Each principal received a formal letter of approval containing comprehensive research information, copies of all ethical and institutional approvals, and the researcher’s contact information.
Data collection procedure flowchart.
A liaison teacher was assigned to each school to facilitate the distribution and follow-up of the questionnaire. Teachers received paper copies of the questionnaire in individually sealed envelopes, each containing a clear instruction page and a copy of the informed consent form. This was done to ensure confidentiality and participant comfort. Teachers had 2 weeks to complete the questionnaire. During this period, the researcher maintained regular contact with the liaison teachers at each school to monitor progress and provide reminders. This paper-based strategy was adopted to ensure equitable access by allowing teachers in schools with limited technological infrastructure to participate without barriers. Direct distribution and collection through liaison teachers within a defined 2-week timeframe increase response rates through direct facilitation and minimize school disruption by requiring only two researcher visits: one to distribute the questionnaires and another to collect them. At the end of the 2 weeks, all completed questionnaires were collected for subsequent quantitative analysis using appropriate statistical methods. Each participating teacher received a small incentive upon completion of the questionnaire as a token of appreciation.
Data Analysis
Raw data were entered, coded, and analyzed using IBM SPSS Statistics version 23.0. Data coding involved assigning numerical values to categorical responses to prepare the data for quantitative analysis. Prior to analysis, all items with negative wording in the attitudes and practice domains were reverse-coded to ensure that consistently higher scores reflected more positive attitudes or more frequent practices. Addressing the first research question (RQ1), descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to characterize the overall distribution of knowledge, attitude, and practice scores across the sample and to conduct an item-level analysis. Normality was confirmed before analyses (Knowledge: kurtosis z-score = −0.223; Attitude: kurtosis z-score = −0.135; Practice: Kolmogorov-Smirnov p = .096).
To address the second research question (RQ2) on interrelationships among KAP domains, Pearson correlation analysis was applied to examine the relationships between knowledge, attitudes, and practice scores. Multiple linear regression analyses were then conducted to examine the interrelationships between the three domains of knowledge, attitudes, and practices. For the third research question (RQ3), additional multiple linear regression analyses were applied to identify factors associated with each KAP domain. Knowledge, attitudes, and practices were the dependent variables in separate regression models. The regression assumptions were evaluated and confirmed.
Group comparisons of knowledge, attitudes, and practices scores were performed between SEIP teachers and mainstream classroom teachers using an independent t-test to address the fourth research question (RQ4). Statistical significance was set at p < .05 for independent t-test and regression and at p < .01 for Pearson correlation.
Results
Knowledge, Attitude, and Practice Results Among Primary Schools’ Teachers
Answering RQ1 on current levels and specific gaps in teachers’ knowledge, attitudes, and practices, the majority of teachers demonstrated low knowledge and attitude scores, with over three-quarters (75.9%) classified as having low knowledge and more than half showing low attitudes (56.7%). Practice scores among teachers with relevant experience (n = 158) were comparatively higher, with 70.3% of teachers showing a moderate level of practice. The mean percentage scores were 39.0 ± 16.9 for knowledge, 46.6 ± 12.6 for attitude, and 73.8 ± 11.2 for practice. The full score distributions are presented in Figure 2.
Levels of knowledge, attitude, and practice among teachers. Percentage distribution of KAP levels across the three domains: knowledge (n = 349), attitudes (n = 349), and practice (n = 158). Categories represent high, moderate, low proficiency based on established cut-off criteria: for all three domains, scores of 80%–100%, 50%–79%, and less than 50% were designated as high, moderate, and low, respectively.
Item-level analysis (Table 2) showed the proportion of teachers who answered each item correctly. While foundational concepts such as the impact of noise exposure on hearing and the school’s support role in inclusion were relatively well understood (78.5% and 93.7% of teachers, respectively), substantial gaps existed in practical, technical, and instructional knowledge. Notably, only 12% of teachers correctly answered the question on hearing aid troubleshooting, 8.9% correctly identified all instructional practices for DHH students, 9.2% recognized teachers’ roles in inclusive education, and 22.4% demonstrated an accurate understanding of the concept of “inclusion,” indicating limited familiarity with assistive technology and inclusive instructional practices. Knowledge was also limited regarding strategies to reduce classroom reverberation (41.6%), FM system benefits (39.8%), and cochlear implant function (22.1%).
Item-Level Analysis of Teachers’ Knowledge Related to the Inclusion of DHH Students Using Listening Devices.
Note. Data based on responses from 349 teachers across multiple schools.
Multiple-response item.
With respect to attitudes, teachers exhibited complex and sometimes contradictory views toward the inclusion of DHH students in mainstream classrooms (Figure 3). The attitude item most frequently endorsed, though still by less than half of the teachers, was the belief that most DHH students will try to complete their assignments similarly to their hearing peers (A1: 49.6%). While 47.9% agreed that DHH students can receive adequate support in mainstream schools (A4), a substantial 78.2% believed that teaching DHH students should be the responsibility of special education teachers (A16), reflecting reliance on a segregated education model. Similarly, 81.7% of teachers agreed that placement in special schools positively impacts the social-emotional development of DHH students (A17), representing the least favorable attitude toward inclusion.
Item-level analysis of teacher attitudes toward DHH student inclusion.
Notably, 67.3% of teachers felt mainstream educators lack adequate training to support DHH students (A13), and 35.5% worried about behavioral issues arising from inclusive environments (A3). However, 49% agreed that the presence of DHH students encourages peer acceptance of differences (A8), highlighting perceived social benefits. See Supplemental Material (Table A1) for item-level percentages and the corresponding item codes referenced in the text (e.g., A1, A4).
Regarding practice, teachers with direct experience teaching DHH students reported a range of classroom supports to facilitate the learning of students who use listening devices, with notable variability across specific strategies (Figure 4). The most widely adopted practice was giving feedback and reinforcement to help students understand the lesson (P12), with 76.6% of teachers indicating that they do this regularly. Other reported common practices included adjusting seating for effective communication (P1: 72.8%) and ensuring that students’ listening devices functioned properly (P7: 69.6%). However, certain recommended practices were less consistently implemented. Only 37.3% of teachers reported routinely checking that students’ listening devices were working (P8), and 44.3% made efforts to reduce auditory distractions in the classroom (P11), such as turning off unnecessary electronics. See Supplemental Material (Table A1) for the full item-level percentages and the corresponding item codes referenced in the text (e.g., P1, P7).
Item-level analysis of inclusive teaching practices for DHH students.
Association Among Knowledge, Attitude, Practice Domains
Pearson correlation analyses were conducted to examine the strength and direction of the association among the KAP domains. Table 3 presents the Pearson correlation coefficients (r), revealing significant positive correlations between all three domains. Knowledge showed moderate positive correlations with attitude (r = .394, p < .001) and practice (r = .399, p < .001). A weaker but still significant positive correlation was found between attitude and practice (r = .216, p = .007; Papageorgiou, 2022).
Pearson Correlations Between Knowledge, Attitude, and Practice Domains.
Note. p-Value <0.01 considered as significant. Knowledge and attitude correlations are based on data from 349 teachers; practice correlations are based on data from 158 teachers with relevant teaching experience.
To further examine the predictive relationships and determine the unique contribution of each domain to another, multiple linear regression analyses were conducted (Table 4). Attitude (β = .298, p < .001) and practice (β = .314, p < .001) were found to be significant predictors for knowledge domain. While knowledge was also found as a significant predictor for both attitude (β = .329, p < .001) and practice (β = .343, p < .001). Together, the correlation and regression analyses address RQ2 by confirming significant interrelationships among all three KAP domains.
Linear Regression Analysis Among KAP Domains.
Note. p-Value <.05 considered as significant. Model statistics: Knowledge (R2 = .236, F(2,154) = 23.768, p < .001); Attitude (R2 = .158, F(2,154) = 14.396, p < .001); Practice (R2 = .167, F(2,154) = 15.392, p < .001). B = unstandardized coefficient; β = standardized coefficient; CI = confidence interval.
Following the domain-level correlations, an analysis was conducted to identify the predictors of teachers’ knowledge, attitudes, and practices that address RQ3. Prior to modeling, variables with minimal variance, including ethnicity and level of education, were removed to ensure model stability. Factors associated with knowledge included formal DHH training (β = .412, p < .001), DHH teaching experience (β = .219, p = .001) and general prior DHH individual experience (β = .106, p = .047). Similarly, for attitude, significant factors were DHH teaching experience (β = .281, p < .001), prior DHH individual experience (β = .233, p < .001), and formal training (β = .152, p = .009). Teacher type (SEIP; β = .231, p = .003) and formal training (β = .385, p < .001) were found as significant predictors for practice. All tested demographic variables and general teaching experience were nonsignificant in all domains (p > .05). Detailed results are presented in Table 5.
Linear Regression Analysis Results of KAP-Associated Factors.
Note. p-value <.05 considered as significant. Model statistics: Knowledge (R2 = 0.397, F(9,339) = 24.782, p < .001); Attitude (R2 = 0.247, F(9,339) = 12.348, p < .001); Practice (R2 = 0.263, F(7,150) = 7.665, p < .001). Reference categories: Gender (male), Age (≤40), years of teaching experience (<4), all training and experience variables (no), teacher type (mainstream teachers). Experience teaching DHH factor was excluded from the practice model, as all participants had teaching experience, and prior experience with DHH individual factor was excluded to meet regression assumptions. B = unstandardized coefficient; β = standardized coefficient; CI = confidence interval.
Comparison of KAP Scores Between SEIP and Mainstream Classroom Teachers
To answer RQ4 on differences between the two teacher groups, an independent t-tests were conducted. Comparing knowledge, attitude, and practice between SEIP teachers and mainstream teachers, as shown in Table 6, the independent t-test results indicated that SEIP teachers scored significantly higher than mainstream teachers across all domains (p < .001). These differences were characterized by medium to large effect sizes across all domains according to Cohen (1988) criteria. The largest mean difference was observed in the knowledge domain (15.1), while the smallest mean difference was in the attitude domain (8.3).
Comparison of Knowledge, Attitude, Practice Scores Between SEIP and Mainstream Teachers.
Note. p-Value < 0.05 considered as significant. p-Value was obtained by Independent t-test. Data based on responses from 349 teachers for knowledge and attitude domains, and 158 teachers for the practice domain.
Discussion
This study aimed to assess the knowledge, attitudes, and practices of primary school teachers regarding the inclusion of verbal DHH students in mainstream education, as well as to examine the interrelationships among the KAP domains and identify key indicators within each domain. The focus on verbal DHH students who use listening devices reflects the reality of prevailing spoken language mainstream environments, where children rely on amplification technology with verbal or bilingual communication modes. This study gathered information from both mainstream and special education teachers working in schools with SEIP in Malaysian public schools, who operate in separate classrooms within the SEIP framework (Khairuddin et al., 2016).
This study addresses a critical evidence gap in teacher preparedness for DHH inclusion in Malaysia, a middle-income country in the Asia-Pacific region. A recent systematic review has emphasized the need to conduct more primary research on disability-inclusive teacher professional development interventions across the Asia-Pacific region, identifying only 50 studies across 41 low- and middle-income countries over two decades (2000–2021), with no research examining teachers’ knowledge, attitudes, and practices for supporting DHH students using listening devices (Ahmed et al., 2022). The present study makes three key contributions to the field of inclusive education for DHH students. First, it provides the first empirical evidence of Malaysian teachers’ preparedness to support DHH students using listening devices, revealing substantial gaps in knowledge and attitudes, in addition to identifying specific competency deficits that have direct implications for DHH students in mainstream settings. Second, it demonstrates that knowledge functions as a central mediating mechanism between attitudes and practices, providing critical guidance for designing professional development interventions. Third, it establishes that DHH-specific training and experience, rather than general demographic or professional characteristics, predict teacher preparedness, providing clear direction for resource allocation in teacher education programs. These findings are particularly significant for low- and middle-income countries in Southeast Asia, where systematic evidence on DHH inclusion remains scarce despite policy commitments to inclusive education.
While previous research from other countries has explored teachers’ KAP concerning DHH inclusion, evidence remains limited on how teachers support the specific needs of verbal DHH students, particularly in regions such as Southeast Asia. Findings from the present study highlight several important aspects of teachers’ KAP within mainstream education settings.
KAP Interrelationship in DHH Inclusive Practices
Generally, teachers in this study demonstrated low levels of knowledge and attitude toward supporting verbal DHH learners using listening devices, even when teachers were recruited from schools with SEIP where DHH students have the opportunity to learn together or participate in class together with their hearing peers. Teachers having low knowledge about inclusion is not uncommon, especially in low- and middle-income countries in the Asia-Pacific region, where teachers often lack the knowledge and skills for recognizing and supporting students with disabilities (Ahmed et al., 2022). This is significant because teachers’ knowledge and attitude are the most essential components for the successful inclusion of DHH students in mainstream education (Keerthan et al., 2025), especially in countries where resources and infrastructure tend to be scarce (Ahmed et al., 2022; Khairuddin & Miles, 2020).
Knowledge is closely intertwined with attitude and practice, as we have found in this study, where knowledge acts as an enabling factor that supports both positive attitudes and effective practices for DHH inclusion. This finding aligns with evidence from regional and international studies, which indicate that insufficient teacher training and a lack of specialized knowledge are major barriers to effective inclusion that contribute to teachers’ uncertainty and concerns about inclusion in supporting DHH students (Alegre de la Rosa & Villar Angulo, 2024; Dsouza & Ranjan, 2024; Keerthan et al., 2025; Khairuddin et al., 2018; Pérez-Jorge et al., 2021).
The close relationship between knowledge, attitudes, and practice has been well established in the literature, with numerous studies demonstrating that teachers’ preparedness and confidence in inclusive education are strengthened through targeted professional development and direct experience with DHH students (Alegre de la Rosa & Villar Angulo, 2024; Alotaibi et al., 2020; Keerthan et al., 2025; Pérez-Jorge et al., 2021). In the present study, this interconnection was confirmed through significant positive associations between all three domains. These results suggest that enhancing teacher knowledge and attitudes through evidence-based training and experiential learning can yield measurable improvements in inclusive educational practices for DHH students using listening devices. Supporting this, prior DHH teaching experience and direct contact with DHH individuals predicted more positive attitudes, whereas formal training showed weaker effects on attitudes compared to its effects on knowledge and practice. Within the KAP framework, this indicates that while knowledge can be improved through structured training, attitudes require experiential exposure and supportive social contexts to improve.
Examining the directionality of these relationships, analyses revealed knowledge as the central mechanism in the framework. Knowledge correlated with both attitude and practice in a bidirectional way. This bidirectional relationship suggests a reinforcing cycle. Knowledge shapes beliefs and behaviors (Ajzen, 1991; Andrade et al., 2020; Launiala, 2009), while active engagement in inclusive practices and holding positive attitudes conversely deepen knowledge through experiential and motivated learning. Nevertheless, attitude and practice did not significantly predict each other when controlling for knowledge, despite their bivariate correlation. This indicates that knowledge mediates the attitude-practice relationship, where positive attitudes toward DHH inclusion do not translate to adequate classroom practices when teachers lack knowledge of how to implement appropriate strategies. This also justifies why the association between attitude and practice was the weakest among the three domains. External constraints, including limited resources, time, or institutional support, can hinder teachers from implementing inclusive strategies, even if they hold favorable attitudes (Ahmed et al., 2022; Keerthan et al., 2025; Rajkumari, 2023).
These findings on the interrelationships among knowledge, attitudes, and practices have important implications for the design of teacher professional development interventions in inclusive education. Identifying knowledge as the central mediating mechanism indicates that effective training programs should incorporate both theoretical content delivery and structured opportunities for practical application. Research demonstrates that combining instructional input with practical training phases enhances learning outcomes and supports transfer to classroom implementation (Donath et al., 2023). Lately, there is growing international recognition that teacher professional development programs are critical mechanisms for advancing inclusive education and improving outcomes for students with disabilities (Ahmed et al., 2022).
Areas of Strengths and Gaps in Teachers Knowledge
Closer examination of individual knowledge items revealed specific areas of concern within this competency. While teachers understood foundational concepts such as the impact of noise exposure, the impact of hearing loss on psychosocial development, and the school’s supportive role in inclusion, considerable gaps emerged in practical, technical, and instructional knowledge. Teachers demonstrated limited knowledge in assistive technology, specifically troubleshooting, cochlear implant function, and FM systems. This limitation was evident among both mainstream and special education teachers in SEIP schools, likely because SEIP teachers may lack formal training in deaf education despite having trained in other areas of special education, and thus may not receive specific training in the technical aspects of assistive technologies. In addition, understanding of echo and noise reduction strategies, a crucial element of accessible learning environments, was limited. These aspects represent important components of the technical knowledge required to successfully support DHH students using listening devices (Todorov et al., 2021; Zanin & Rance, 2016). A similar gap emerged in instructional knowledge, with fewer than one in ten teachers identifying all targeted instructional practices for DHH students who use listening devices and accurately recognizing teachers’ responsibilities in inclusive education. Only about one in five of the teachers demonstrated accurate understanding of the concept of “inclusion,” revealing a fundamental gap that may hinder implementation of inclusive practices. Most teachers believed that students should adapt to the school, rather than understanding that inclusive education requires adapting the school environment, curriculum, and teaching practices to meet the diverse needs of all students. Several factors may explain why teachers have misconceptions about inclusion. Teachers may be reflecting on the institutional reality they experience rather than the theoretical ideals stated in policy documents. There appears to be a gap between policies and practices, with inclusive education policies being imposed without corresponding systemic changes to support their implementation. This has also been reflected in teachers’ attitudes in our results, as a good proportion of teachers agreed that the inclusion of DHH students in mainstream schools would require significant changes to existing school procedures. These findings closely mirror those of Dsouza and Ranjan (2024), who found similar knowledge gaps among Indian primary school teachers, particularly regarding amplification device management and troubleshooting, congenital hearing loss causes, the audiology profession and its services, identification and management of hearing impairments, and preventive measures.
Identifying these specific knowledge gaps is crucial for developing professional development content that removes learning barriers for DHH students who use listening devices. These areas of knowledge become essential for the effective application of UDL principles, which provide systematic frameworks for creating accessible learning environments that address both auditory and visual access needs while recognizing communication diversity for DHH students using listening devices (Allman et al., 2019; Hartman et al., 2023; Silvestri & Hartman, 2022). Applying the principles of UDL to ensure the effective inclusion of DHH students requires teachers to consider accessibility across auditory, visual, and multimodal dimensions (Silvestri & Hartman, 2022). Without knowledge of assistive technology function and acoustic environmental optimization, teachers cannot achieve the environmental optimization for both spoken and visual accessibility that UDL principles require.
These knowledge gaps are potentially addressable through modifiable factors. Formal DHH training emerged as the strongest predictor of knowledge, substantially outperforming prior DHH teaching experience and one-on-one interaction with DHH students. Research further emphasizes the critical importance of specialized preparation in assistive technology and inclusive practices for equipping teachers with the knowledge and skills needed to effectively support DHH students in inclusive settings (Alegre de la Rosa & Villar Angulo, 2024; Keerthan et al., 2025). The disparity in teacher readiness is also reported in Malaysia, where teachers were found to lack the specialized training and technical skills necessary to sustain and support the use of listening devices, a problem exacerbated by the shortage of professional growth opportunities for mainstream teachers (Khairuddin et al., 2018).
Beliefs About Readiness for DHH Inclusion
More than half of the teachers surveyed exhibited unfavorable views toward the inclusion of DHH students. One prominent theme underpinning these beliefs is perceived insufficiencies in teacher preparation and training. Teachers commonly express similar reservations, reporting concerns about their practical efficacy (Bakar & Nordin, 2024; Moberg et al., 2020; Pérez-Jorge et al., 2021). Multiple studies highlighted that teacher attitudes function as critical mediators of inclusive education implementation (Keerthan et al., 2025). When teachers doubt their capacity to support DHH students, they are less likely to implement inclusive practices regardless of policy mandates or available resources, which can ultimately hinder the educational progress and social integration of these students (Keerthan et al., 2025; Pérez-Jorge et al., 2021).
Most teachers believed that teaching DHH students is better suited to special education teachers. This perception may be related to their belief that mainstream teachers require comprehensive retraining and the worry of their inability to adequately support DHH students’ learning in mainstream classrooms, as has been reported in other studies (Pérez-Jorge et al., 2021). It also may stem from the belief that supporting DHH students in mainstream settings would require a fundamental overhaul of the educational system. Such apprehension may explain their preference for a separate education model. Understanding these attitudinal barriers requires examining the broader context in which teachers work. Teacher attitudes toward inclusion have consistently emerged as critical determinants of implementation success, but these attitudes must be understood within the systemic constraints teachers face (Ahmed et al., 2022). In settings such as Malaysia, where infrastructure and resources are limited, teachers’ preferences for segregated education may reflect rational responses to real barriers. According to the GEM 2020 Inclusion and Education report, these barriers include large student-to-teacher ratios, insufficient educational support services, weak professional development networks, and limited autonomy over instructional content (UNESCO, 2020). The separated education model contradicts international and national frameworks promoting inclusive education, which support DHH children learning alongside their hearing peers to maximize both academic and social development, facilitate peer interaction, and participation within the school environment (United Nations, 2006). Thus, moving beyond the segregated approach, supported by appropriate systemic structure that address both practical and attitudinal barriers, is critical for fostering equitable, collaborative, and effective educational environments for DHH learners, particularly those with sufficient auditory access and oral language fluency.
Moderate responses across many attitude items indicate ambivalence regarding the inclusion of DHH students. Teachers expressed varying opinions regarding the behavioral, academic, and socio-emotional development of these students in mainstream settings. They also expressed uncertainty about managing inclusive school environments, the perceived impact of inclusivity on other students, and the need for systemic or procedural changes to support inclusion. Despite these reservations, nearly half of the teachers agreed that DHH students should participate in mainstream settings and can receive adequate support in mainstream schools. This suggests that many teachers hold positive attitudes toward the principle of inclusion, even though they lack confidence in their own current capacity to implement it. International studies have supported and perhaps justified these results, showing that teacher attitudes are shaped by historical and cultural norms regarding disability placement within educational systems, policy endorsement of inclusion, professional preparation, and direct exposure to DHH students (Bakar & Nordin, 2024; Khairuddin et al., 2018; Khairuddin & Miles, 2020; Moberg et al., 2020). For example, Moberg et al. (2020) showed that Finnish teachers reported greater acceptance of including children with disabilities, including hearing impairments, than Japanese teachers, reflecting Finland’s longer-standing integration of sensory disabilities into mainstream education and more established teacher preparation in inclusive education.
Contextual Differences in Teachers’ Preparedness for DHH Inclusion
Differences in teacher preparedness became evident when considering educational context and program placement. The favorable outcomes of practice in the SEIP context reflect the specialized training and experience of the teachers, and indeed both formal training and SEIP teacher status emerged as significant predictors of practice, with training exhibiting stronger effects. The relatively higher practice scores observed in this study should be interpreted within the specific context of SEIP, where the majority of respondents were special education teachers. Their reported practices are likely attributable to formal training and assignment within SEIP classrooms, where adherence to established standard operating procedures guides the use of communication strategies, environmental accommodations, and educational modifications for DHH students using listening devices. These results align with prior research confirming the importance of expanding specialized training for all teachers in inclusive education settings, including technical skills and structured implementation of inclusive practices, to achieve successful and equitable inclusion of DHH students (Alsalem & Alzahrani, 2023; Dsouza & Ranjan, 2024). Given that the practice was completed primarily by SEIP teachers, the generalizability of these results to all mainstream teachers is limited.
Furthermore, although teacher type (SEIP vs. mainstream) did not emerge as a significant predictor in the regression models for knowledge and attitude, significant differences between the two groups have been shown through direct statistical comparisons. SEIP teachers scored significantly higher than mainstream teachers across all domains with effect sizes ranging from medium to large (Cohen, 1988), with the most pronounced difference in knowledge. These substantial effect sizes indicate practically meaningful differences between SEIP and mainstream teachers. This is consistent with the findings of Alotaibi et al. (2020), who reported that teachers with a degree in special education and those with experience teaching DHH students were significantly more knowledgeable and exhibited more positive attitudes toward DHH inclusion than their counterparts without such specialization and experience.
The apparent disparity between SEIP and mainstream teachers carries important implications for intervention design. Rather than viewing these groups as entirely separate, the substantial expertise within the SEIP teacher population represents a valuable resource that could be leveraged through collaborative professional development models. Establishing structured collaboration between special education teachers and mainstream teachers could facilitate knowledge transfer and provide mainstream teachers with direct access to specialized expertise in DHH inclusion. Research has consistently identified collaboration between special and mainstream educators as a critical factor affecting successful inclusive education implementation, with lack of collaboration emerging as a significant barrier and strong collaborative practices serving as key facilitators (Alsayed, 2024; Khairuddin & Miles, 2020; Salter et al., 2017; Swanwick et al., 2021). These group differences further highlight the urgent need to extend the specialized training to broader mainstream teachers.
Notably, demographic variables such as age, gender, and years of teaching experience were not identified as predictors of any KAP domain in this study. This finding contrasts with multiple studies where demographic characteristics often function as determinants of knowledge, attitudes, and practice in various educational and health contexts (Straughan & Xu, 2022). This may indicate that general teaching experience does not necessarily equate to appropriate experience in supporting DHH students. Furthermore, structural and contextual factors, such as educational placement programs, influenced KAP levels. Taken together, these findings suggest that knowledge, attitudes, and practices related to the inclusion of DHH students using listening devices are more significantly influenced by contextual and training factors than by teachers’ demographic characteristics. This finding is highly encouraging from an intervention perspective, as it indicates that all teachers can benefit equally from targeted professional development in the field of DHH inclusion. The prioritization of training and context over demographic factors suggests that systematic investment in specialized preparation can effectively equip general teaching staff to implement inclusive education.
Collectively, our findings illustrate how knowledge, attitudes, and practice function as an interconnected system that shapes teachers’ capacity to support the inclusion of verbal DHH students using listening devices. In addition, the results highlight the critical importance of evidence-based professional development that integrates specific knowledge of DHH, experiential learning, and instructional design for all teachers, not only specialists, aligning with UDL instructional design. Addressing these challenges at both the systemic and classroom levels is essential for achieving inclusive education goals in Malaysia and aligning with international best practices.
Recommendations and Practical Implications
Specific knowledge related to the inclusion of DHH students requires specialized and targeted training, as our findings have revealed. These precise gaps define the priorities for future professional development training, including instructional strategies, technical device competencies related to troubleshooting and assistive listening devices (FM systems), and environmental adaptation strategies. These areas align directly with the principles of the UDL framework, which emphasizes proactive instructional planning, multiple modes of representation, and the removal of environmental barriers to develop inclusive and accessible curricula (Sewell et al., 2022; Silvestri & Hartman, 2022).
The analytical findings suggest that it is essential to address gaps in teachers’ knowledge, attitudes, and practices through a multifaceted approach to achieve successful and equitable inclusion of DHH students in mainstream classrooms.
Provide targeted training for all teachers (mainstream and SEIP) in inclusive settings, both pre-service and in-service, to address identified gaps. Knowledge was identified as a central mechanism, indicating that enhancing knowledge improves attitudes and practices simultaneously.
Integrate experiential activities and practice-based learning that address misconceptions and foster self-efficacy to enhance teacher confidence and attitudes toward inclusion of DHH students.
Promote collaboration and mentorship between SEIP and mainstream teachers to facilitate the exchange of expertise and the joint development of inclusive practices for DHH students using listening devices. KAP domains develop primarily through teaching experience and prior interaction with DHH children.
Conduct regular practical workshops focusing on instructional adaptations (adapting lesson plans, utilizing assistive technology, including visual supports and FM systems) and communication strategies tailored to DHH students using listening devices.
Establish systematic monitoring and feedback mechanisms to assess and improve all teachers’ knowledge, attitudes, and practices regarding DHH inclusion. TIDE-Q provides the first psychometrically validated tool developed to assess teachers’ knowledge, attitudes, and practices related to the inclusion of verbal DHH students.
Limitations of the Study
Several limitations should be considered when interpreting these findings. First, the cross-sectional design limits causal inference regarding the relationships among knowledge, attitudes, and practices. While the data reveal significant associations and suggest that knowledge mediates the attitude-practice relationship, the study cannot definitively establish temporal precedence or rule out alternative causal pathways. Longitudinal research would be necessary to confirm whether improvements in knowledge actually lead to changes in attitudes and practices over time. Second, reliance on subjective data may lead to response bias, particularly in the practice section, where teachers might overestimate their actual classroom practices. Future research incorporating classroom observations would provide more robust evidence of actual teaching practices. Third, the practice was completed primarily by SEIP teachers with specialized training and experience, limiting the generalizability of these results to all mainstream teachers. Fourth, the study was conducted exclusively in the Klang Valley, an urban region with relatively greater access to educational resources and specialized services compared to rural areas of Malaysia. Future research should extend this investigation to rural and remote regions to examine whether similar patterns emerge across diverse educational contexts and resource settings.
Conclusion
Drawing on data from Malaysian primary schools. This study highlights significant gaps in the knowledge and attitudes of school teachers toward the inclusion of verbal DHH students using listening devices, with possible implications in the global educational context. Most teachers demonstrated limited understanding and often low or ambivalent attitudes. The findings revealed that knowledge was the central mediating mechanism, strongly predicting both attitude and practice, while attitudes and practices did not predict each other when controlling for knowledge. This demonstrates that improving teacher preparedness requires specialized knowledge enhancement, as positive attitudes alone do not translate into adequate practices. Teachers in the SEIP program with specialized training and experience consistently outperformed their counterparts in mainstream classrooms across the domains of knowledge, attitude, and practice. There is a critical need for comprehensive and targeted professional development for mainstream school teachers to ensure equitable and effective inclusion. As part of an analytical phase in a broader initiative to develop a teacher training module, these results provide a vital foundation for designing evidence-based training programs that address current gaps and support the successful inclusion of DHH students who use listening devices in Malaysian schools. It is essential to assess teachers’ preparedness and identify areas for improvement to ensure that early investments in identification, intervention, and rehabilitation are matched by adequate support within educational systems.
Supplemental Material
sj-docx-1-sgo-10.1177_21582440261463087 – Supplemental material for Knowledge Gaps and Barriers to Inclusive Practice: A Cross-Sectional Study of Primary School Teachers on Supporting Verbal Deaf and Hard-of-Hearing Students in an Urban Malaysian Context
Supplemental material, sj-docx-1-sgo-10.1177_21582440261463087 for Knowledge Gaps and Barriers to Inclusive Practice: A Cross-Sectional Study of Primary School Teachers on Supporting Verbal Deaf and Hard-of-Hearing Students in an Urban Malaysian Context by Sondos Ahmad Al-Ghanim, Nashrah Maamor, Khairul Farhah Khairuddin and Aisyah Farhanah Hisam in SAGE Open
Supplemental Material
sj-docx-2-sgo-10.1177_21582440261463087 – Supplemental material for Knowledge Gaps and Barriers to Inclusive Practice: A Cross-Sectional Study of Primary School Teachers on Supporting Verbal Deaf and Hard-of-Hearing Students in an Urban Malaysian Context
Supplemental material, sj-docx-2-sgo-10.1177_21582440261463087 for Knowledge Gaps and Barriers to Inclusive Practice: A Cross-Sectional Study of Primary School Teachers on Supporting Verbal Deaf and Hard-of-Hearing Students in an Urban Malaysian Context by Sondos Ahmad Al-Ghanim, Nashrah Maamor, Khairul Farhah Khairuddin and Aisyah Farhanah Hisam in SAGE Open
Footnotes
Acknowledgements
The authors gratefully acknowledge the principals and teachers of the participating schools for their cooperation and support during the data collection phase.
Ethical Considerations
This study received ethical approval from the Health Research Ethics Committee, Faculty of Health Sciences, Universiti Kebangsaan Malaysia (UKM; UKM PPI/111/8/JEP-2024-657), as well as permissions from the Ministry of Education Malaysia (KPM.600-3/2/3-eras(21743)) and the relevant state education departments, including those for the Federal Territory of Kuala Lumpur (JPWPKL.600-9/1/5Jld. 16(30)), the Federal Territory of Putrajaya (JPWPP.100-6/2/1 Jld 13(3)), and Selangor State (JPNS.SPD 600-1/1/2 JLD. 45(43)).
Consent to Participate
Consent to conduct the research was first obtained from school principals, followed by written informed consent from participating teachers prior to data collection. All participants were informed about the study’s objectives, procedures, and their rights, including voluntary participation and the right to withdraw at any time without penalty. Confidentiality of all responses was assured, and data were handled in accordance with institutional and national ethical guidelines. A copy of the informed consent form used in this study is attached as supporting documentation below.
Author Contributions
Sondos Al-Ghanim: Conceptualization, Writing – original draft, Writing – review & editing, Methodology, Formal analysis, Resources, Visualization. Nashrah Maamor: Conceptualization, Supervision, Writing – review & editing, Methodology, Funding acquisition. Khairul Khairuddin: Writing – review & editing, Supervision. Aisyah Farhanah: Methodology, Formal analysis.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Ministry of Higher Education, Malaysia (FRGS/1/2024/SS05/UKM/02/2). The URL of the funder website is 
. The sponsors/funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
All data are fully available without restriction and upon request.*
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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