Augmentative and alternative communication (AAC) is an umbrella term used to describe methods to support and supplement communication for individuals with complex communication needs (Iacono et al., 2016). It can be aided (e.g. picture communication boards or speech-generating devices) and/or unaided (e.g. signs, gestures or facial expressions) (Ganz et al., 2014; Handberg & Voss, 2018; Iacono et al., 2016; Pattison & Robertson, 2016). It is used in a wide variety of settings, including educational, vocational and social environments (Handberg & Voss, 2018; McNaughton et al., 2019). It can foster greater independence and community participation and also empower individuals to advocate for themselves, leading to more fulfilling lives (Tönsing & Dada, 2016; Waddington et al., 2017).

One multimodal, unaided AAC method, widely used by speech-language therapists (SLTs) internationally, is Makaton (Faiz et al., 2022). Makaton integrates signs, symbols and spoken language to support communication for individuals with communication difficulties, including those with intellectual disabilities and neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) (Makaton South Africa, n.d.). It is a total communication approach (Faiz et al., 2022) offering visual and physical means to facilitate improved understanding, expression of needs and desires, and social interaction for individuals with complex communication needs (Bednarski, 2016; Brignell et al., 2018; Faiz et al., 2022). Research indicates that Makaton supports the development of both language comprehension and expression (Bednarski, 2016; Faiz et al., 2022) and may also promote literacy in individuals with severe learning difficulties (Mistry & Barnes, 2013). Signs, one facet of Makaton, provide an alternative communication method that can reduce pressure and frustration by providing individuals with multiple ways to communicate and express themselves, rather than solely relying on verbal communication (Mistry & Barnes, 2013; Sheehy & Budiyanto, 2014). It is evident that Makaton, because of its adaptability, can be an invaluable method to address diverse communication challenges and could be a fundamental resource for all professionals working with individuals with complex communication needs, including SLTs.

As professionals with specialised expertise in language and communication, SLTs play a central role in supporting individuals with complex communication needs. The AAC, including systems such as Makaton, forms a recognised part of SLTs’ scope of practice (Chua & Gorgon, 2019; Dada et al., 2017) and is often integrated into multidisciplinary intervention approaches (Kathard et al., 2022). Given its potential to enhance communicative access, SLTs’ proficiency with Makaton is critical to ensuring effective and inclusive service delivery.

Despite the recognised role of SLTs in AAC service delivery, limited research has examined their proficiency in using systems such as Makaton, particularly within low- and middle-income contexts such as South Africa (Dada et al., 2017; Pillay et al., 2020). In South Africa, most AAC research has focused on aided systems (Tönsing & Dada, 2016; Tönsing et al., 2019). For example, Tönsing and Dada (2016) explored teachers’ perceptions of using aided AAC to support expressive communication in special schools. Their findings revealed that while aided AAC was utilised, its implementation was hindered by challenges such as limited teacher training, resource constraints and inconsistent support from stakeholders. Tönsing et al. (2019) explored the impact of multilingualism on AAC use in South Africa, highlighting challenges faced by individuals in accessing AAC systems that support multiple languages. The study emphasised the need for culturally and linguistically inclusive AAC interventions to enhance communication effectiveness. Dada et al. (2017) focused on the overall implementation of AAC by South African SLTs. Findings revealed that SLTs’ approaches were often shaped by prior experience rather than structured, evidence-based methods, highlighting a need for more training and support in AAC implementation (Dada et al., 2017). Challenges in AAC implementation are not unique to South Africa, as evidenced by a United Kingdom study in which SLTs reported lacking confidence in their AAC-related roles (Norburn et al., 2016).

In South Africa, however, AAC implementation is further complicated by contextual realities. Many SLTs work in education and health sectors where high caseloads, resource constraints, and diverse linguistic and cultural populations present ongoing challenges (Pillay et al., 2020; Tönsing et al., 2019). In the absence of standardised guidelines, dedicated AAC policies and limited AAC-specific training available to SLTs in South Africa, therapists often rely on informal strategies rather than structured systems such as Makaton (Dada et al., 2017).

Makaton’s simplicity, affordability and flexibility make it an ideal tool for use in low-resource and multilingual environments. Its formal integration into SLT practice, however, appears to be limited (Faiz et al., 2022; Norburn et al., 2016). This is concerning, given its potential to enhance accessibility, support inclusion, and foster more effective communication in the South African context (Faiz et al., 2022). Makaton has been adapted to the South African context in terms of vocabulary, signs and symbols that are used to be more contextually appropriate and relevant to South Africa. As Makaton is an additional course offered outside of the undergraduate SLT degree, formal training by Makaton South Africa is required to use the approach effectively in clinical practice. Training can be completed by anyone who is interested including but not limited to SLTs, parents or doctors. Makaton training consists of six levels with level one being the first and six the highest level. Additionally, after completing level six, one can become a tutor but is not required (Makaton South Africa, n.d.). There is currently limited understanding of how Makaton is used in SLT practice in South Africa, the barriers therapists face, and where support is most needed. To address this gap, the current study explores South African SLTs’ perceived competencies and use of Makaton. In this study, perceived competencies refer to SLTs’ self-judged levels of knowledge, confidence and preparedness to use Makaton. This includes their understanding of the programme, the extent of their exposure and training, and their experiences applying it in practice. By examining and exploring their experiences, confidence levels and implementation practices, this research seeks to contribute towards strengthening AAC service delivery, particularly through tools that are inclusive, cost-effective and appropriate for South Africa’s diverse population.

The two sections, ‘Understanding Makaton’ and ‘Perceived competences’, combined aimed to provide information on SLTs exposure, understanding and experiences with Makaton to be able to provide information on the perceptions SLTs have with Makaton.

There has been a notable lack of research investigating the perspectives and use of Makaton among South African SLTs. Previous research focused on aided AAC (Tönsing & Dada, 2016; Tönsing et al., 2019) with limited information about SLT’s perception of Makaton. Overall, the findings suggest a positive response to Makaton as a form of AAC. Participants showed a clear understanding of what Makaton is and recognised its value in supporting communication, despite reporting several challenges related to its implementation.

Research conducted in South Africa on the distribution of the SLT workforce indicates that the majority of SLTs are located in Gauteng and the Western Cape (Pillay et al., 2020). Similarly, in this study, more than half of the responses came from these provinces, with the majority of participants working in urban settings. Many were employed in private sector contexts, such as private preschools, while those in the public sector were often based at Learners with Special Educational Needs (LSEN) schools. This aligns with broader trends of SLTs working across diverse clinical and educational settings (Agaronnik et al., 2019; Berenguer et al., 2022; Biggs et al., 2018; Blackstone et al., 2021; Dada et al., 2017; Sigafoos & Gevarter, 2019). This context is important when interpreting the findings of this study, as SLTs working in urban, better-resourced, and private settings may have greater exposure to or access to training in tools such as Makaton. As such, the results may not fully reflect the challenges faced by SLTs in rural or under-resourced environments, highlighting the need for future research in those settings.

Although participants had varying years of professional experience, familiarity with Makaton did not seem to follow a clear pattern based on experience alone. This suggests that professional experience may not be the strongest predictor of AAC competence. Instead, as previous studies have found, SLTs’ use of AAC tools, such as Makaton, is often shaped by individual exposure, access to training, and clinical context rather than by structured, evidence-based preparation (Chua & Gorgon, 2019; Dada et al., 2017).

An important finding from this study is that participants perceived Makaton as an effective tool for supporting communication. However, more than half reported feeling only ‘moderately acquainted’ with it, and most had completed only Level 1 or 2 training. While higher-level training was limited, participants commonly cited lack of access rather than lack of interest or perceived value as the main barrier. This reflects similar findings in previous South African research, where SLTs identified limited AAC training opportunities as a challenge to service delivery (Dada et al., 2017). The fact that participants expressed strong interest in further training, despite limited access, underscores the profession’s readiness to engage more deeply with AAC. This interest, however, contrasts with the lack of accessible pathways to develop competence, pointing to a structural gap in professional preparation. Addressing this gap requires more than isolated training opportunities; it calls for a national framework that embeds AAC within curricula, ensures equitable access across provinces, and provides sustainable professional development routes. In this way, the findings highlight both the urgency and the opportunity for expanded, structured training, echoing broader international debates on AAC training equity (Fayyaz et al., 2024). It also adds to the growing body of evidence from South Africa (Dada et al., 2017) calling for improved national guidelines and training pathways to support SLTs in delivering AAC services to vulnerable populations.

This study also explored South African SLTs’ perceptions of Makaton, focusing on its effectiveness and the challenges of implementation. Participants viewed Makaton as an effective AAC method, echoing international research that demonstrates the value of AAC systems in enabling individuals with complex communication needs to express themselves (Faiz et al., 2022; Mistry & Barnes, 2013; Sheehy & Budiyanto, 2014). Importantly, the reasons cited for Makaton’s effectiveness – its multimodality, versatility across contexts, and ability to support social inclusion – suggest that SLTs see it as a flexible tool that can be integrated into diverse clinical and educational settings. In addition, participants reported using Makaton with a wide range of populations, reinforcing its adaptability for multiple conditions and aligning with its design as a multimodal, accessible communication approach (Bednarski, 2016; Brignell et al., 2018; Faiz et al., 2022). This broad application strengthens the argument that Makaton is not only comparable to other AAC approaches but particularly well-suited for low-resource and multilingual environments such as South Africa, where simplicity, affordability and flexibility are essential. These findings therefore align with broader AAC literature emphasising participation across environments (Handberg & Voss, 2018; McNaughton et al., 2019; Waddington et al., 2017), while also highlighting the unique potential of Makaton to address systemic barriers in the South African context.

Participants identified several challenges with the implementation of Makaton, including a lack of awareness and training, resource and time constraints, difficulties with consistency and carryover, and cultural and regional barriers. These challenges were consistent with findings from both South African and international research (Dada et al., 2017; Norburn et al., 2016; Tönsing & Dada, 2016; Tönsing et al., 2019). These challenges point to the need for improved awareness campaigns, greater access to affordable training, and the development of culturally responsive resources that support consistency and carryover across South Africa’s diverse setting. The fact that SLTs continued to recommend Makaton to parents and team members, and expressed confidence about who could be trained, suggests a shift from relying primarily on informal AAC strategies (as previously reported by Dada et al., 2017) towards recognising the value of structured systems like Makaton. This reflects growing professional openness to integrating formal AAC into service delivery, even in resource-constrained contexts and strengthens the case for national strategies that prioritise equitable AAC training and culturally relevant implementation guidelines (Dada et al., 2017; Norburn et al., 2016; Tönsing & Dada, 2016; Tönsing et al., 2019).

Participants offered practical suggestions for improving Makaton training and implementation. These suggestions point to a broader need for more accessible and contextually relevant training in South Africa. The emphasis on embedding Makaton in daily routines and across environments reflects a growing recognition of the importance of ecological and inclusive approaches to AAC intervention as suggested by Tönsing et al. (2019) as well as Dada et al. (2017). These insights reinforce calls for stronger integration of AAC, including Makaton, into both pre-service education and ongoing professional development. Importantly, they highlight the value of moving beyond clinic-based training models towards more functional, community-based applications that support real-world carryover and inclusion.

This study provides valuable insight into how South African SLTs perceive and use Makaton as an AAC method. It highlights Makaton’s relevance in supporting individuals with complex communication needs and raises awareness of its use within the South African context. The qualitative data offered a deeper understanding of both the value SLTs associate with Makaton and the challenges they face in implementing it effectively.

Participants also shared practical suggestions for improving training, access and integration. These findings can inform the development of locally relevant AAC guidelines and support the inclusion of Makaton in undergraduate curricula. While the sample was limited, the study contributes to a growing evidence base and emphasises the need for further research to support AAC implementation in diverse South African settings.

The results from this study may help improve SLTs’ confidence, consistency, and effectiveness in using AAC strategies in diverse clinical settings. These changes have the potential to enhance South African SLTs’ engagement with Makaton as a tool to support communication (Bednarski, 2016; Faiz et al., 2022).