Augmentative and Alternative Communication Strategies for Learners with Diverse Educational Needs in African Schools: A Qualitative Literature Review

Abstract

Augmentative and Alternative Communication (AAC) research highlights the critical role of collaborative efforts among communication partners in supporting children with diverse educational needs in the school setting. This study aims to describe AAC strategies and systems employed in African schools to facilitate participation for learners with diverse educational needs. A qualitative literature review was employed to describe 18 studies involving 659 participants across special schools and inclusive classrooms. The participants included 488 learners with diverse educational needs and 171 teachers. The research designs predominantly featured quantitative approaches, with some mixed-methods studies. This study found that reviewing classroom instruction strategies, learning processes, participant proficiency, and AAC strategies is cardinal for communication participation within the classroom. However, outcomes varied widely due to factors including learner characteristics and contextual familiarity. Key outcomes included improved use of the AAC system labeling and the identification of different symbols. Recommendations for further research include increased professional training and the development of collaborative AAC services. The findings underscore the need for a collaborative approach to AAC implementation, further research, and enhanced training to address the diverse needs of learners and promote the sustainability of AAC use.

1. Introduction

Learners with diverse educational needs include learners with heterogeneous health conditions. Health conditions can include physical impairments (cerebral palsy (CP) and neuromuscular diseases), sensory impairments (vision and hearing impairments and sensory integration difficulties), and neurodiversity (autism spectrum disorder; Attention Deficit and Hyperactivity Disorder (ADHD); and intellectual, behavioral, and learning impairments (dyslexia)) [1]. These learners may present with complex communication needs (CCN) and may experience challenges that affect their speech production and communication participation [2]. The inability of such learners to communicate efficiently may hinder their ability to make friends, fully participate in school, and engage in academic activities [3]. Although communication impairments are not the sole cause of educational challenges, they may contribute to difficulties in social interactions and learning; they also impact the acquisition of fundamental skills like writing and reading, which are essential to access the school curriculum [4]. These learners may benefit from Augmentative and Alternative Communication (AAC) to improve their engagement in the learning process, as well as social and educational dialogue [5].

AAC refers to methods to support or augment oral communication and can be divided into aided and unaided communication [6]. Unaided systems convey messages using natural nonverbal communication such as eye movement, facial expressions, vocalizations, gestures, signs, and body movements [7]. Aided AAC involves external communication supports, including non-speech-generating technology (i.e., real or miniature objects, photographs, graphic symbols, and communication boards) and speech-generating technology [6,8]. These strategies may enhance the receptive communication (comprehension of information) and expressive communication (sharing their thoughts, information, and interests) of learners with diverse educational needs [9].

In South Africa, learners with diverse educational needs are often segregated into special schools that focus on providing intensive educational support [5]. Although policies to promote inclusive education have been developed, the application thereof remains challenging [5]. This may be due to poor policy directives, limited resources (funding), lack of school and teacher support, and the large number of learners in the class [10]. Additionally, South Africa has official language policies that allow schools to select any of the 12 official languages for teaching and learning [11]. Various challenges may hinder the provision of services (education and AAC) in this multilingual context, such as limited resources in all African languages and mismatches between the languages of the professional providing services and the client/their family [11]. According to Terblanche et al. [11], 70% of children with disabilities are not attending school. These factors impact the implementation of AAC, with strategies suggested in high-income countries not necessarily applicable to the African context (low-to-middle-income countries).

Moreover, the limited access to AAC makes it challenging for teachers to accurately evaluate the capabilities of learners with diverse educational needs, thereby further marginalizing them from active participation in the school setting [12]. Teachers’ reports on the use of AAC may also not be a true reflection of the strengths of learners with diverse educational needs. To address this, Dada et al. [13] suggest that teacher training may positively impact the attitudes of teachers working with learners using AAC. Additionally, creating individualized educational plans in collaboration with allied healthcare professionals such as speech–language therapists (SLT), physiotherapists (PT), and occupational therapists (OT), as well as parents, within a transdisciplinary approach may assist teachers in providing the necessary support to the learners [14]. Collaboration within a transdisciplinary team may also promote feature matching of an AAC system with the learner’s specific capabilities and strengths that are contextually, culturally, and linguistically appropriate [15]. According to Terblanche et al. [11], using peer scaffolding may model and support the acquisition of a specific skill for the learner with diverse educational needs when using AAC. This demonstrates the importance of communication partner training to reduce the abandonment of an AAC system and improve acceptance of the AAC system by all the key actors [11].

The benefits and the importance of AAC in schools are also recognized by international policy, such as the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) [16], which emphasizes communication as a basic human right. Articles 8 and 9 of the UNCRPD advocate for freedom of speech and accessibility, while Article 20 stresses the importance of enabling learners with diverse educational needs, full access to information, and the freedom to express themselves [17]. Although these conventions emphasize the rights of persons with disabilities, a paucity of evidence exists on how persons access their rights. This is evident in school contexts where young children and adolescents with disabilities have difficulty communicating and experience challenges with the implementation of AAC in the classroom. This review was undertaken as part of the authors’ 30-year reflection on inclusive education in South Africa. The following research question was formulated: “What are the AAC strategies employed in African schools to facilitate participation for learners with diverse educational needs?” In this study, learners with diverse educational needs include learners who are candidates for AAC.

2. Materials and Methods

A qualitative literature review methodology was selected as it suited the purpose of this review [18]. Arksey and O’Malley’s framework was followed, including the following steps: (i) identifying the research question; (ii) identifying relevant studies; (iii) study selection; (iv) charting the data; and (v) collating, summarizing, and reporting the data [19]. This review aims to provide a broader, summarized view of the current evidence on AAC strategies employed in African schools. Reviews have been conducted on the use of AAC in low-to-middle-income countries [20,21] and inclusive education [22]; however, these reviews did not focus specifically on the African context.

2.1. Identifying Relevant Studies and Inclusion and Exclusion Criteria

Search Strategy

The Population Exposure and Outcome (PEO) approach [23] guided the research question and searches for this qualitative literature review. Descriptive information regarding the PEO approach and the inclusion and exclusion criteria can be obtained in

Table 1. Inclusion and exclusion criteria.

PEO Approach	Criteria	Rationale	Inclusion	Exclusion
Population (P)	School-aged learners (children from the age of five to the age of 17)	A child must be at least five years old or become six in June of the year they enter grade 1 [24].	Learners between the ages of 5 and 17 years.	Children younger than five years or older than 17 years were excluded from the review.
	Learners with diverse educational needs who are candidates for AAC	The World Health Organization (WHO) states that disability can be experienced in three dimensions: a person’s body structure and function, including anatomical and physiological impairments and mental functioning [25]. Anatomical and physiological impairments refer to a learner’s health condition [25].	Learners with diverse educational needs include learners with heterogeneous health conditions. The following are health conditions that contribute to communication difficulties for learners: Physical impairments: including cerebral palsy (CP), neuromuscular diseases, etc. Sensory impairments: Vision and hearing impairments, including sensory integration difficulties. Neurodiversity: autism spectrum disorder; Attention Deficit and Hyperactivity Disorder (ADHD); and intellectual, behavioural, and learning impairments (dyslexia).	Learners without disabilities were excluded.
	Mainstream schools or special schools	No schools are excluded, as learners with diverse educational needs are also situated in both mainstream and special schools.	Both public and private mainstream and special schools were included.	No schools were excluded.
Exposure (E)	Types of AAC strategies/systems used in the classroom	Both unaided and aided AAC support the social–academic inclusion of learners with diverse educational needs [20].	Unaided AAC includes eye movement, facial expressions, vocalizations, body movements, gestures, and signs. Aided AAC, consisting of strategies including non-speech-generated technology (e.g., picture boards, Pragmatic Organization Dynamic Display books, etc.), and speech-generating technology (e.g., Go Talk, phone, or iPad with software), will be included.	Studies that focused on oral communication or sign language only were excluded. This is because spoken and sign language are linguistic systems that can be utilized independently from AAC and are rule-based systems [6].
Outcome (O)	Success of the performance	Classroom instruction strategies: Teaching strategies used by communication partners in the classroom. Learning process: Activity or opportunity through which learners and teachers acquire new knowledge, skills, or attitudes. Participant proficiency: Capacity building in learners.	Studies were included if they focused on AAC strategies used in school-related activities and teacher reports on AAC strategies used in school-related activities.	Studies on symbol design, vocabulary selection for AAC systems, and teachers’ and professionals’ attitudes or perceptions of AAC were excluded.

.

2.2. Study Selection, Search Terms, and Database Searches

A cross-database search was conducted through various interfaces to identify relevant keywords from studies related to the topic [26]. Interfaces such as EBSCOhost were utilized, allowing access to databases including ERIC, Sabinet, ProQuest, Google Scholar, Academic Search Complete, Africawide, Education Source, and Teacher Reference Center. These databases were selected based on the recommendations from a librarian working at a South African university. Each database was searched using the identified keywords [26]. Iacono et al. [20] conducted a scoping review on the use of AAC in schools, focusing on international research. This study suggested the following search terms: ‘AAC’, ‘complex communication needs’, ‘intervention’, ‘disability’, ‘school children’, ‘school education’, and their variations (e.g., terms used for the target population included ‘Downsyndrome’, ‘intellectual disability’, ‘autism’, ‘autism spectrum’, ‘cerebral palsy’, and ‘severe motor impairment’), and those for AAC included specific forms, such as ‘communication boards’, ‘speech generating devices’, ‘signs’, and ‘graphic symbols’ [20]. Boolean operators and truncation were applied, and searches were conducted across all fields, including title, abstract, subject terms, and MeSH terms.

The final component of the search involved screening reference lists of relevant studies and hand-searching paper-based journals [26]. The following inclusion criteria were applied:

• Studies on human participants and reviews.
• Material published between 1980 and July 2024, as the inception of the field of AAC was in 1980 [27].
• Qualitative, quantitative, and mixed-method research designs were included.
• Studies published in English.
• Peer-reviewed gray literature (published conference proceedings and reports were included, while book chapters, dissertations, websites, and newspapers were excluded due to the absence of peer review of unpublished literature for the qualitative literature review’s pre-determined inclusion criteria) [28].

A librarian assisted the first author in refining search terms, identifying studies, and eliminating duplicates. Initially, the searches yielded 123 studies, as shown in the PRISMA diagram in Figure 1 [29]. A total of 15 duplicates were identified and removed, leaving 108 studies. On the title level, 29 articles were excluded.

A total of 79 abstracts were uploaded to Rayyan, an online platform for collaborative systematic reviews [30]. Rayyan enhanced the objectivity of study selection and improved inter-rater agreement [30]. All the authors screened the abstracts, and a consensus of 51% was obtained [29]. Subsequently, an online meeting was scheduled to achieve a 100% interrater agreement. Abstracts were categorized into three groups: undecided, included, and excluded. Studies were excluded at the abstract level due to not having been conducted in Africa, not including AAC, and not being conducted in the school context, as depicted in Figure 1.

The same process was followed for full-text selection. The initial inter-rater agreement was 50%. Another online meeting was scheduled to discuss the disagreements until a 100% consensus was reached. Ultimately, 18 studies were selected for full-text inclusion based on the criteria in Table 1. The PRISMA diagram is shown in Figure 1 below.

2.3. Data Extraction and Analysis

Data extraction criteria included themes, demographics (author, date, aim, study design, and population), reported strategies, maintenance factors, and outcomes. Categories such as participants, language, context, communication partner, AAC strategy/system, classroom instruction strategies, learning process, and participant proficiency. The criteria were based on a scoping review of Iacono et al. [20]. Avidnote extracted the initial data for thematic analysis according to the themes identified. Avidnote is an AI-powered research tool that enhances researchers’ productivity [31]. Data were recorded on a data extraction form and transferred to an Excel spreadsheet. The first author analyzed and reviewed the data. The last author reviewed the themes and codes identified for accuracy, and online discussions were conducted to improve interrater agreement until 100% consensus was achieved.

Thematic analysis was used to analyze the data, allowing for the systematic and insightful identification and organization of data into themes to address the research aim [32]. The following six-step approach suggested by Braun and Clarke [32] was followed:

• The authors familiarized themselves with the data and focused on data reduction through triangulation.
• The authors hand-coded the data.
• Themes were determined through inductive coding (a bottom–up approach using data content to determine codes).
• The identified themes were reviewed.
• Themes were defined and named.
• The thematic analysis process concluded with the production of a report.

An example of the coding process included themes such as reported strategies and categories such as classroom instruction strategies and teaching Bliss symbols as a code. This process ensured that the data obtained and analyzed met the aims of the qualitative literature review.

3. Results

3.1. Summarizing and Reporting the Data

The results are depicted in

Table 2. Study characteristics.

Demographics				Reported Strategies	Maintenance Factors	Outcomes
Reference and Country	Aim	Study Design	Population
Alant and Moolman [33] (South Africa)	To investigate the learning of Blissymbols by preschoolers with Down syndrome.	Quantitative small-group design	Participants: Preschoolers with Down syndrome (n = 4; 4.7–7 years old) Language: Afrikaans (n = 4) Context: Special schoolPreschool Communication partner: Teacher	AAC strategy/system Aided AAC: Aided language stimulation with Blissymbols Classroom instruction strategies: Teaching Blissymbols Modeling (point to the Bliss flashcard; identifying resemblance to a real object and acting out symbols with oral communication) New symbol introduced daily Review concepts Practice Cueing Positive feedback Learning process: Testing comprehension Theme-related activities Homework for parental reinforcement at home Participant proficiency: Picture–object matching Labeling symbols Identification of Bliss indicators (action, plural, and diminutives) Association (symbol with objects and pictures)	Timelapse between teaching and testing. Number of symbols taught. Subjects’ interest. Word class. The visual complexity of symbols.	Benefits from exposure to and learning of Blissymbols confirmed. Other issues identified to be considered: the number of symbols; word classes; familiarity with themes; and visual complexity of symbols. Complexity of symbol learning for children with disabilities confirmed.
Alant et al. [34] (South Africa)	To investigate whether the degree of translucency rated by children with autism spectrum disorder changed as a result of repeated exposures to Blissymbols.	Quantitative within-subject design	Participants: Learners with autism spectrum disorder (n = 22; 6–8 years old) Languages: Afrikaans (n = 10) English (n = 5) African languages (n = 7) Context: Special school Communication partner: Researcher (SLT); Teacher	AAC strategy/system: Aided AAC: Aided language stimulation with Blissymbols Unaided AAC: Pointing with the index finger Classroom instruction strategies: Teaching translucency of Blissymbols Modeling (identifies a circle, what it looks like, and shows a corresponding symbol) Cueing Review concepts Expectant delay Learning process: Testing comprehension Participant proficiency: Labeling of symbols Identification of symbols Translucency rating on a Likert scale	Peer influence. Contextual familiarity. Prior experiences with Bliss.	Average increase in translucency ratings from day one to day three. No specific symbol showed a significant change.
Bornman and Alant [35] (South Africa)	To establish the prevalence of non-speaking children enrolled in schools for children with severe mental disabilities in the greater Pretoria metropolitan substructure by compiling a profile regarding their functioning in different skill areas (cognitive, motor, sensory, communication, and social).	Quantitative survey	Participants: 412 children with a severe intellectual disability (n = 412; 3–12 years old) Language: Not specified Context: Special schools Communication partner: Teachers	AAC strategy/system: Aided AAC: Limited use of aided AAC (typing, writing, or communication boards) Unaided AAC: 20% used vocalizations 19% used facial expressions 18% had a functional yes/no response or head nodding 17% used touch and natural gestures to communicate Classroom instruction strategies: Not specified Learning process: Not specified Participant proficiency: Initiate interaction	Limited number of therapists. Low expectations from professionals. Lack of AAC knowledge.	Limited use of AAC by children with disabilities. 38% prevalence of non-speaking children. Heterogeneous abilities. High need for service delivery.
Dada et al. [36] (South Africa)	To explore the niche concept and its application in explaining the variation between individuals in activity-based interventions.	Quantitative, single-subject, multiple-probe design with four participants	Participants: Children with cerebral palsy (n = 3) and Down syndrome (n = 1); between 8.1 and 12.1 years old. Language: Not specified Context: Special school Communication partner: Researcher	AAC strategy/system: Aided AAC: Aided language stimulation with PCS on a communication board. Classroom instruction strategies: Teaching with PCS Modeling (pointing to PCS and oral communication) Learning process: Not specified Participant proficiency: Identification of symbols Labeling symbols	Student characteristics	All participants acquired the target receptive vocabulary items. There was variability in the rate of acquisition and the specific items acquired. The participants’ performance improved even after the implementation of activities had ceased.
Dada et al. [37] (South Africa)	(a) To examine the frequency with which the PCS were selected as target symbols and non-target PCS. (b) To explore the factors that might contribute to errors. (c) To determine the correlation between the participants’ scores on English vocabulary measures and their accuracy in selecting target PCS.	Quantitative non-experimental descriptive design	Participants: Children with a mild intellectual disability (n = 30; 12–15 years old) Language: isiZulu (n = 22) Sepedi (n = 3) Setswana (n = 3) Sesotho (n = 1) isiXhosa (n = 1) Context: Special school Communication partner: Researcher (SLT)	AAC strategy/system: Aided AAC: Aided language stimulation with PCS Unaided AAC: Pointing with index finger Classroom instruction strategies: Teaching the use of measuring instruments and PCS stimuli Modeling (pointing to PCS and oral communication) Cueing Positive feedback Learning process: Testing comprehension Participant proficiency: Identification of symbols	Familiarity with context and vocabulary	Participants selected PCS symbols correctly.
Geiger [38] (Botswana)	To describe the first cycle of an ongoing, long-term action research study, which focuses on valuable resources within several southern African cultures in order to foster inclusive environments where children with little or no functional speech can participate communicatively.	Quantitative case study	Participants: Child with CP (n = 1; seven years) Language: Setswana Context: Residential rehabilitation center that provides classroom instruction programs Communication partner: Teacher Researcher (SLT) Grandmother	AAC strategy/system: Aided AAC: Aided language stimulation with a communication board and various symbol representations Unaided AAC: Pointing with eyes or hands Vocalizations Classroom instruction strategies: Teaching concepts and object functions Modeling (pointing to toy objects, photographs, and realistic drawings and using natural gestures and oral communication) Practice Learning process: Use of the AAC system and recall activities Participant proficiency: Indicate basic needs Initiate interactions Recall events Picture–object matching Labeling symbols	Lack of generalization of AAC to other contexts. Caregiver involvement. Consideration of context or communication environment. Literacy level of caregiver. Exposure to concepts. Learnability of symbols.	The cultural elements that were identified as valuable starting points here can be built upon in intervention contexts where therapeutic and professional resources are limited. Increased communication participation by creating communication opportunities.
Heslop and Mophosho [39] (South Africa)	To expand our understanding of the communication strategies used by teachers of pre-schoolers with autism spectrum disorder in Johannesburg, South Africa.	Qualitative descriptive interviews	Participants: Teachers (n = 5) Languages: Not specified Context: Special schoolPreschool Communication partner Children with autism spectrum disorder between the ages of 3–5.11 years	AAC strategy/system: Aided AAC: Aided language stimulation with PECS and Makaton Classroom instruction strategies: Teaching concepts Modeling (PECS and Makaton with oral communication) Practice Learning process: Music to engage learners Participant proficiency: Identification of symbols Labeling symbols	Teachers’ perception that communication difficulties hinder interactions. Teachers adapting to the diverse needs of children.	Positive teacher perceptions enhance communication.
Johnson et al. [40] (South Africa)	To identify how professionals identify pain in children with cerebral palsy and how these children communicate their pain.	Qualitative descriptive focus groups	Participants: Teachers (n = 38) Languages: Not specified Context: Special school Communication partner: Children with CP	AAC strategy/system: Aided AAC: Aided language stimulation with PCS symbols on a communication board, drawings, speech-generating device, and computer. Unaided AAC: Use of non-verbal messages such as facial expressions and vocalizations. Classroom instruction strategies: Teaching stimuli Modeling (Faces pain scale, communication board, drawings, and oral communication) Asking questions (e.g., How do you feel? Do you have pain? Is it here?) Learning process: Testing comprehension Participant proficiency: Identification of symbols Labeling symbols	Under-utilization of AAC due to skills and attitudes of staff. Professional interpretation of pain behavior may be inaccurate as they require a verbal response.	Limited understanding of pain. Inadequate vocabulary.
Laher and Dada [41] (South Africa)	To determine and compare the acquisition of receptive vocabulary items during implementation of aided language stimulation with dosages of 40% and 70%, respectively.	Quantitative adapted alternating treatment design	Participants: Children with a severe intellectual disability (n = 6; 8–13 years) Languages: Not specified Context: Special school Communication partner: Researcher (SLT)	AAC strategy/system: Aided AAC: Aided language stimulation with PCS symbols on a communication board Classroom instruction strategies: Teaching the use of PCS Modeling (the use of PCS by pointing and oral communication) Cueing (facilitator communication board) Learning process: Testing comprehension Participant proficiency: Identification of symbols Labeling symbols	Dosage of input. Frequency of interaction.	Receptive language acquisition was noted at 40% and 70%. Maintenance of vocabulary following withdrawal.
Lilienfield and Alant [42] (South Africa)	To determine the effect of a peer-training program on the interaction patterns of an adolescent who used AAC.	Quantitative descriptive single-case study; observational data collection via video; and pre- and post-intervention measures	Participant: A child with CP (n = 1; 15 years and 2 months) Languages: Not specified Context: Special school Communication partner: Peers	AAC strategy/system: Aided AAC: Use of a DeltaTalkerTM speech-generating device Use of a head pointer to access the device Unaided AAC: Use of body movement Classroom instruction strategies: Peer engagement and scaffolding Learning process: Not specified Participant proficiency: Peer interaction	Peer relationships. Natural communication opportunities. Contextual factors.	Increase in frequency and extent of interactions. Increased use of natural speech as the primary mode of communication. Increased use of body movements as the primary mode of communication. Increased understanding in communication partners. Increased selfconcept. Increased sociometric status.
McDowell and Bornman [43] (South Africa)	To determine the perceptions of special education teachers in South Africa regarding using KWS.	Quantitative descriptive paper-based survey	Participants: Teachers (n = 101) Language: Not specified Context: Special schools Communication partner: Children with CCN	AAC strategy/system: Aided AAC: Aided language stimulation with pictures Unaided AAC: Aided language stimulation with keyword signs Classroom instruction strategies: Teaching the use of symbols Modeling (keyword sign, pointing to pictures, and oral communication Cueing Positive feedback Individualized teaching Learning process: Theme-related activities Structured classroom activities Testing comprehension Participant proficiency: Identification of symbols Labeling symbols	Classroom setting. Teacher’s knowledge and skills. Untrained staff. Learner-related considerations. Inadequate support from school curriculum to incorporate keyword signing. Limited resources.	Positive attitude towards the use of keyword signing. Understanding the benefits of keyword signing. Use of keyword signing in the classroom and on the playground.
Naudé et al. [44] (South Africa)	To describe the effect of an augmented-input intervention in facilitating change, combine, and compare subtraction word problems in children with intellectual disabilities.	Quantitative multiple baseline experimental design across behaviors	Participants: Children with an intellectual disability (n = 7; 8–12.11 years) Languages: English Context: Special school Communication partner: Researchers (SLT and audiologist)	AAC strategy/system: Aided AAC: Aided language stimulation with PCS on a communication board Classroom instruction strategies: Teaching the use of symbols to support comprehension of word problems Modeling (pointing to symbols, counters, and oral communication) Cueing (probe answer sheet) Learning process: Theme-related activities Testing comprehension Participant proficiency: Identification of symbols Labeling symbols	Participants’ initial skills, language comprehension, graphical symbol recognition, chronological age, and the use of concrete apparatus.	This study suggests that augmented-input intervention may provide language support for subtraction word problem-solving for some children with a mild intellectual disability.
Tönsing and Dada [5] (South Africa)	To understand the barriers and facilitators in supporting students using aided AAC for expression, this study aimed to assess the provision and implementation of communication boards in classrooms in special schools across six districts in a metropolitan area in South Africa, and to explore teachers’ perceptions of factors influencing AAC implementation.	Concurrent mixed methods	Participants: Teachers (n = 27) Languages: Not specified Context: Special schools (preschool and foundation phase (grade 1–3)) Communication partner: Children with CCN	AAC strategy/system: Aided AAC: Aided language stimulation with PCS on a communication board and speech-generating devices Classroom instruction strategies: Teaching the use of PCS Modeling (pointing to PCS and oral communication) Learning process: Not specified Participant proficiency: Increased use of the AAC system	Teacher-related factors. Size of the class. Diverse student needs in the classroom. Aided AAC. Other team members. Student characteristics.	Limited provision and implementation of aided AAC. Challenges in implementation due to lack of time. Limited peer understanding of aided AAC.Lack of parental involvement.
Tönsing et al. [45] (South Africa)	To determine if an intervention strategy targeting two-symbol combinations, which uses a hierarchy of prompts during shared story reading, can facilitate the production of both target and non-target graphic symbol combinations in response to picture stimuli (not used in the story) by children with limited speech.	Quantitative single-subject multiple-probe design across three types of semantic relations	Participants: Children with CCN (n = 4; 6.5–10.8 years) Languages: English Context: Special school Communication partner: Researcher (SLT)	AAC strategy/system: Aided AAC: Aided language stimulation with PCS on a communication board Classroom instruction strategies: Teaching the use of symbols Modeling (pointing to PCS and oral communication) Cueing Positive feedback Learning process: Storybook reading Participant proficiency: Identification of symbols Labeling symbols	Student characteristics	Mixed results—two participants showed improvement in combining symbols, while two participants showed less consistent evidence of learning.
Travis and Geiger [46] (South Africa)	To determine the effect of PECS on the frequency of requesting and commenting behavior and length of verbal utterances in two children with autism spectrum disorder.	Mixed research design: quantitative (single-subject multiple-baseline design) and qualitative components	Participants: Children with autism spectrum disorder (n = 2; 9.6–9.10) Language: English Context: Special school Communication partners: Teachers and class assistants	AAC strategy/system: Aided AAC: Aided language stimulation with PECS Classroom instruction strategies: Teaching the use of PECS Modeling (use of PECS and oral communication) Learning process: Not specified Participant proficiency: Identification of symbols Increased use of the AAC system (request and comment)	Change of educators, parent involvement, and environment.	Increased intentional communicative acts; a significant increase in requesting; and mixed results for commenting and length of utterances.
Uys and Harty [47] (South Africa)	To increase teachers’ knowledge and skill regarding the use of aided language stimulation in inclusive classrooms.	Quantitative two-phase training program including pre-test and post-test designs	Participants: Teachers (n = 78); 2 SLTs (n = 2) Language: Afrikaans English Setswana Context: Mainstream school and preschool (inclusive classroom) Communication partner: Children with CCN and typical learners	AAC strategy/system: Aided AAC: Aided language stimulation with PCS symbols on a communication board Classroom instruction strategies: Teaching the use of PCS Modeling (use of PCS and oral communication) Cueing (facilitator board and scripts for activities) Self-reflection Learning process: Not specified Participant proficiency: Increased knowledge of aided language stimulation	Feedback from researchers and self-reflection sessions.	Significant performance improvement in classroom management strategies, the use of aided language stimulation, and interaction facilitation.
Van der Bijl et al. [48] (South Africa)	To compare two strategies of sight word instruction in children with moderate to severe mental disability.	Quantitative pre-test–post-test comparison group design with a withdrawal period	Participants: Children with intellectual disability (n = 33) Languages: Afrikaans Context: Special school Communication partner: Teacher	AAC strategy/system: Aided AAC: Aided language stimulation Classroom instruction strategies: Teaching sight words by using traditional orthography, modified orthography and modified orthography with an association with traditional orthography Cueing (flashcards with words) Learning process: Sight word reading Participant proficiency: Sight word recall	Influence of the association between modified and traditional orthography on learning retention.	Both the MO/TO and TO groups showed a potential for word identification, with MO/TO being the most effective; no significant differences were noted on a 5% level.
Van Niekerk and Tönsing [49] (South Africa)	To provide a broad perspective on factors that facilitate communication and participation in preliterate children using electronic AAC systems accessed through eye gaze.	Qualitative case study	Participants: Children with CP (n = 2; 7 and 9 years) Language: Afrikaans English Context: Special school Communication partners: Parents and teachers	AAC strategy/system: Aided AAC: Aided language stimulation with a speech-generating device using eye gaze to access the device and the Grid 2 software Classroom instruction strategies: Teaching the use of PCS and speech-generating device Individualized teaching Learning process: Structured classroom activities Participant proficiency: Increased use of the AAC system	Lack of support from wider ecological systems, limited access to resources and professionals, and a lack of collaboration between service providers.	Limited functional use of eye-gaze technology for communication tasks; challenges with device implementation.

CP—cerebral palsy; CCN—complex communication needs; PCS—Picture Communication Symbols; PECS—Picture Exchange Communication System; SLT—speech–language therapist; OT—occupational therapist; PT—physiotherapist trustworthiness.

and include a discussion on the following themes that were identified during data analysis.

3.1.1. Demographics

Most of the research was conducted in South Africa (n = 17), with only one study conducted in Botswana [38]. The most frequently used research design was quantitative (n = 14), with only two qualitative approaches. Additionally, two studies used a mixed-methods approach. The different research designs were used to meet short-term rather than long-term goals in all studies. The contexts in which the studies were conducted included mostly special schools (South Africa) (n = 16), a community rehabilitation center providing an educational instruction program (Botswana), and an inclusive classroom at a mainstream school (South Africa). The languages of participants within this study were mostly not specified (n = 8), but those specified included English (n = 5), Afrikaans (n = 4), and African languages (n = 7). Of the African languages, one study was not specified, and others included participants speaking Setswana (n = 2), IsiZulu (n = 1), Sepedi (n = 1), Sesotho (n = 1), and IsiXhosa (n = 1). A total of 528 study participants (learners with diverse educational needs) were included, with ages ranging from three to 15 years. The participant population was heterogeneous, consisting of learners with intellectual disability (n = 488), autism spectrum disorder (n = 24), CP (n = 7), Down syndrome (n = 5), and CCN (n = 4). The communication partners mentioned in individual studies included researchers, specifically SLTs (n = 7) and a dual-qualified SLT and audiologist (n = 1), teachers (n = 7), parents (n = 1), and a grandmother (n = 1). The study participants also included a total of 171 teacher participants. Studies mentioned that the teacher population had communication partners such as learners with autism spectrum disorder (n = 1), CP (n = 1), and CCN (n = 1), which were not included in the learner population mentioned above.

3.1.2. Reported Strategies

AAC Strategy or System

The AAC strategies category is defined as techniques used to teach AAC system use. Aided language stimulation (n = 16) was the most frequently used AAC strategy. This strategy combines oral communication with modeling the AAC system to teach an individual to use the system functionally. AAC systems refer to unaided and aided AAC systems. Unaided systems convey messages using natural nonverbal communication such as eye movement, facial expressions, vocalizations, gestures, signs, and body movements [6]. The unaided systems mentioned consisted of vocalizations (n = 3), facial expressions (n = 2), head nodding (n = 1), gestures (n = 1), signs (keywords) (n = 1), body movement (n = 1), and touch (n = 1).

Aided AAC involves external communication supports, including non-speech-generating technology (i.e., real or miniature objects, photographs, graphic symbols, and communication boards) and speech-generating technology [5,7]. Non-speech-generating technology was used most often, specifically communication boards (n = 9), typing (n = 1), and writing (n = 1). Speech-generating technology was used less frequently, with only three studies mentioning speech-generating devices. The symbol sets or systems (symbols used to represent meaning) included PCS (Picture Communication Symbols) (n = 8), PECS (Picture Exchange Communication Symbols) (n = 2), Blissymbols (n = 2), and Makaton (n = 1). The level of symbol representation included colored line drawings (n = 11), real objects (n = 2), text (n = 2), and pictures (not specified, n = 1). Access for the AAC system included direct access via pointing with an index finger (n = 2), eye (n = 2), and hand pointing (n = 1) and using adapted access, including a head pointer (n = 1).

Classroom Instruction Strategies

Classroom instruction strategies were a theme defined as strategies communication partners use to teach AAC in the classroom. These strategies included a variety of codes, specifically teaching stimuli, modeling, new symbols introduced daily, review of symbols, cueing, positive feedback, expectant delay, practice, asking questions, peer engagement and scaffolding, individualized teaching, self-reflection, and not specified. Of these codes, teaching stimuli (n = 16), modeling (n = 13), cueing (n = 9), positive feedback (n = 4), and practice (n = 3) were used the most. Communication partners prepared children for testing procedures and how to use specific AAC systems (aided and unaided) through modeling by pointing to the specific symbol or gesture/sign and combining this with oral communication. Visual cues such as flash cards and positive feedback were used to prompt responses from participants. The teaching strategies used the least included individualized teaching (n = 2), review of symbols (n = 2), expectant delay (n = 1), asking questions (n = 1), self-reflection (n = 1), peer engagement and scaffolding (n = 1), and not specified (n = 1).

Learning Process

The learning process refers to an activity or opportunity through which learners and teachers acquire new knowledge, skills, or attitudes. This theme included codes such as testing comprehension, theme-related activities, structured classroom activities, homework, indicating needs, initiating interaction, recalling events, music and songs, storybook reading, and sight word reading. Most of the studies did not specify the learning strategy (n = 6) or referred to testing comprehension (n = 6) as the learning strategy. Testing comprehension included assessing teachers’ and learners’ understanding of symbols and the testing procedures, such as translucency ratings. Additional learning processes mentioned referred to using theme-related activities (n = 3) or structured classroom activities (n = 2), such as teaching word-solving problems. The learning process mentioned least included providing homework (n = 1), storybook reading (n = 1), sight–word reading (n = 1), and music (n = 1).

Participant Proficiency

Participant proficiency is defined as the capacity building of teachers and learners. This category included codes for teachers such as increased knowledge on AAC, increased use of the AAC system, identification of symbols, and labeling of symbols. The most frequently occurring codes for teachers were the identification of symbols (n = 3) and the labeling of symbols (n = 3). Codes related to learners included increased use of the AAC system, indicating needs, initiating interaction, and recalling events, peer interaction, picture–object matching, associations, translucency ratings, sight word recall, word problem solving, labeling of symbols, and identification of symbols. Of these codes, identification of symbols (n = 8), labeling of symbols (n = 6), increased use of the AAC system (to request or comment) (n = 2), initiating interaction (n = 2), and picture–object matching (n = 2) occurred the most. The codes that occurred the least included sight word recall (n = 1), recalling events (n = 1), peer interaction (n = 1), translucency rating of symbols (n = 1), and associations between a symbol/picture and object (n = 1).

3.1.3. Maintenance of AAC Use and Outcomes

The most frequently mentioned factors affecting the maintenance of AAC use were learner characteristics (n = 3), contextual familiarity (n = 2), and peer influence (n = 2). Table 2 outlines several outcomes and recommendations. The most frequent outcomes include increased understanding of communication partners (n = 5), improved performance in symbol selection (n = 4), and variability in the rate of acquisition (n = 3). The most common recommendations are further research needed (n = 7), increased training for professionals (n = 5), and development of AAC services (n = 4).

3.2. Trustworthiness

In the context of a qualitative literature review, the four aspects of trustworthiness—credibility, transferability, dependability, and confirmability—are crucial for ensuring the reliability and validity of the findings [50]. Credibility refers to the confidence in the truth of the data and its interpretation, which can be achieved through techniques such as triangulation, member checking, and prolonged engagement with the data. For this specific study, all the authors engaged in the title/abstract and full-text selection of manuscripts, which improved the credibility through interrater agreement. Transferability involves the extent to which the findings can be applied to other contexts, which is facilitated by providing rich, detailed descriptions of the study settings and participants. Dependability focuses on the consistency and repeatability of the research process, often ensured through an audit trail and detailed documentation of the methodology. This ensured that the authors’ methodology was transparent and included the relevant aspects when reporting the qualitative literature review. Finally, confirmability pertains to the objectivity and neutrality of the findings, which can be supported by maintaining a reflexive journal and using external audits to minimize researcher bias. In this study, all the authors were involved in the data selection, data assessment, and data extraction process, which added to the objectivity of the findings portrayed. Together, these aspects help to establish the trustworthiness of a qualitative literature review, making its conclusions more robust and credible.

4. Discussion

This review aimed to identify the AAC strategies employed to facilitate the participation of learners with diverse educational needs in African schools. This section includes a discussion on demographics, reported strategies, maintenance factors, and outcomes. Categories such as language, communication partner, AAC strategy/system, classroom instruction strategies, learning process, and participant proficiency were used.

4.1. Demographics

All the studies in this review used different research designs to target short-term aims rather than long-term aims. Additionally, the included studies may lean toward fragmentation, as almost all studies were conducted in South Africa with limited mention of other African countries except Botswana. Instead, longer-term objectives should include follow-up training and promote collaborative research between countries on the African continent for increased sustainability of AAC strategies in African schools [51]. From the included studies, emphasis was placed on the multilingual population who use AAC within the school context. This emphasizes the need for AAC service provision to accommodate the linguistic and cultural diversity of the population.

From the review, it was evident that SLTs were the most common communication partners of the learner participant group. As AAC and communication are part of the scope of practice of SLTs, a great emphasis should be placed on collaborative efforts to support both teachers and learners with diverse educational needs within the school context.

Teachers were often communication partners of learners with diverse needs, but also participants in the studies. Given the central role of teachers as communication partners, training should focus on the effective use of communication partner strategies [52]. Additionally, teachers should participate in creating linguistically and culturally suitable AAC activities for their specific context. This involvement will empower and support them in maintaining AAC practices for learners with diverse educational needs [53].

However, the current review indicated that speech–language therapists appear to be working in a “disciplinary silo” [54] when undertaking research and (short-term) training in schools, which constitutes a barrier to multidisciplinary education for sustainability. Based on this, teachers and therapists should work together to transform inclusion through AAC [55]. Such “interprofessional practice” [56] should be guided by the principles of equitable partnerships [22]. This finding is supported by the scoping review by Flores et al. [51], which highlighted that teamwork is a key area for continuous professional development to ensure that all team members have the needed knowledge and skills to function effectively within the team.

To facilitate equitable partnerships, a co-design process could be followed to determine the stakeholders’ (teachers’) training needs [57]. Following a co-design process through active collaboration among teacher stakeholders, solutions can be developed for a predetermined problem [58]—in this case, the implementation of AAC in the classroom.

4.2. Reported Strategies

4.2.1. AAC Strategy or System

AAC systems refer to unaided and aided AAC systems. Apart from the unaided AAC systems that were mentioned in the review, aided systems, communication boards, were used the most. Non-speech-generating technology (often self-made and low-cost) was used more often than speech-generating technology (i.e., a computer with the Grid software) [8]. Communication boards are non-speech-generating technologies used in studies to communicate with learners with diverse educational needs. Muttiah et al. [21] emphasized that non-speech-generating technology is often used in low- and middle-income countries due to cost-effectiveness, accessibility, and linguistic and cultural inclusiveness.

AAC strategies mostly used in the included studies were unaided communication, such as verbal expressions, facial expressions, and natural gestures. However, limited information was shared on whether teachers acknowledged the learners’ unaided communication (i.e., gestures, vocalizations, and eye gazes) as communication attempts. Since AAC aims to help support individuals’ communication needs [59], merely introducing AAC systems and symbols to learners will not improve communication per se. Communication partners (i.e., teachers, therapists, parents, and peers) should collaborate to enhance the individual’s communication and adopt a person-centered approach [59]. It is proposed that teachers and other key actors (i.e., therapists and teaching assistants) should receive continuous professional development programs in AAC to improve their AAC skills, knowledge, and self-efficacy [51]. The participation of peers in using AAC systems can increase learners’ motivation and involvement and, in so doing, facilitate the maintenance of AAC strategies [42].

As mentioned earlier, aided language stimulation was used most frequently to support learners’ understanding and use of AAC symbols. The use of aided language stimulation was one of the four instructional strategies identified that meet the criteria for provisional consideration as effective in supporting graphic symbol learning and/or aided language acquisition [60]. Teachers and SLPs face numerous considerations when supporting AAC use for learners with CCN in the classroom [61]. They may be uncertain about where to start when designing classroom support and activities for learners with CCN, since this process is not intuitive, and teachers need suitable training and resources to support learners with CCN sufficiently [61].

4.2.2. Classroom Instruction Strategies

The instructional strategies utilized in AAC interventions can significantly impact the effectiveness of AAC implementation in classrooms. Teaching stimuli were the most evident classroom instruction strategy, with modeling, cueing, positive feedback, and practice also being used. Given the resource demands of AAC interventions, the instructional strategies employed must be both effective and efficient [60]. The review demonstrates that AAC strategies, such as aided language stimulation, testing the learner’s language abilities, and verbal reinforcement, are generally utilized to support comprehension for learners with diverse educational needs. Implementing AAC modeling in the classroom across various contexts should offer various opportunities to demonstrate a range of communicative functions [61]. In the African context, where multilingualism and diverse cultural practices are prevalent, it is fundamental to explore how receptive AAC strategies can be modified to suit local linguistic and cultural contexts [36,38]. The Education White Paper 6: Building an Inclusive Education and Training System [62] and the Policy for Screening, Identification, Assessment, and Support [63] guide the educational provision of learners with disabilities in South Africa. However, Tönsing and Soto [64] state that despite both policies recognizing that the language of teaching and learning could pose a barrier if it differs from the learners’ home language, no recommendations are provided for addressing this barrier. Reliance on positive feedback may be ineffective for learners who speak languages different from the language of teaching and learning in the school. As such, strategies such as aided language stimulation could be considered to improve learners’ understanding. Moreover, this insinuates a need for more research into culturally and linguistically responsive AAC strategies that consider the local communication practices of African learners. In many African countries, teachers often use code-switching in the classroom [65]. Code-switching is a strategy that even a teacher with a strong command of English (if it is the language of instruction) might use when they notice their students do not understand [66].

4.2.3. Learning Process

This review highlighted adult-led interactions where learners’ knowledge of AAC symbols was tested. Most studies reported testing of comprehension, theme-related activities, and structured classroom activities in which AAC was used with limited interactions, where the learners initiated the communication. The actual implementation of AAC for communication in African schools is thus questioned. Reference 6 places an emphasis on the participation of learners with diverse educational needs and learner-led interactions. Future research should therefore focus on creating more opportunities for learner-led interaction, as this will accommodate their needs, motivation to participate in communication, and linguistic diversity.

4.2.4. Participant Proficiency

Within the studies included in the review, both teachers and learners became more proficient in using AAC systems. Beukelman and Light [6] indicate that creating opportunities for both learners and teachers during functional everyday activities increases the relevance of AAC systems as well as improves the motivation for teachers and learners when successful use of AAC is established.

4.3. Maintenance and Outcomes

Factors influencing the sustainability of AAC in schools include learner characteristics (i.e., linguistic skills), contextual familiarity (cultural considerations), and peer influence. Cultural and linguistic differences influence the use of symbols that align with a learner’s cultural understanding of emotions or objects and can enhance their ability to maintain AAC use [38]. Nevertheless, the lack of culturally appropriate AAC systems in Africa hampers learners’ ability to generalize AAC use beyond the classroom.

The barriers to AAC maintenance in schools identified in this review include limited access to AAC technology, a shortage of trained professionals, inadequate curriculum support, and socio-economic factors. In rural and under-resourced schools, the lack of digital infrastructure exacerbates these challenges, making it difficult to introduce speech-generating technology or provide continuous support to teachers and caregivers. The limited training and awareness of AAC among teachers in African schools appeared as a major barrier to the successful implementation of AAC strategies [39]. Teachers’ perceptions and knowledge influenced the choice and efficiency of AAC strategies. As such, the importance of ongoing professional development is underlined by Flores and Dada [51].

In a school setting, teachers are the key actors who engage the most with learners. As expected, 39% of the reviewed studies (n = 7) focused on teachers as key communication partners in schools. Unfortunately, there has been a minimal uptake of AAC strategies as recommended in the published studies. As such, AAC professionals should consider how to broaden teachers’ capacity to apply AAC strategies in their classrooms through community engagement programs, teaching and learning of undergraduate and postgraduate teaching students, and research activities.

5. Limitations

This study has several limitations that should be acknowledged. Firstly, the diversity of settings and participant groups across the 18 selected studies introduces variability that may affect the generalizability of the findings. Most of the participants were children with intellectual disabilities (n = 488), which may limit the applicability of the results to other disability groups. Additionally, the age range of participants (3–15 years) is broad, potentially obscuring age-specific effects. The reliance on quantitative research designs (n = 10) with limited qualitative insights may restrict the depth of understanding regarding the participants’ experiences. The varied methodologies and activities employed across studies also pose challenges in synthesizing the results. Finally, the maintenance of AAC use was influenced by factors such as learner characteristics and contextual familiarity, which were not uniformly measured across studies, potentially impacting the consistency of the findings.

6. Conclusions

This study highlights the diverse settings and participants involved in AAC research, emphasizing the importance of a collaborative approach among communication partners to support learners with diverse educational needs. The findings underscore the effectiveness of various AAC strategies in enhancing communication skills. However, this study also reveals significant variability in the outcomes, influenced by factors such as learner characteristics and contextual familiarity. The need for further research, increased professional training, and the development of AAC services is evident to address the multifaceted needs of learners and ensure the sustainability of AAC use. These insights contribute to a deeper understanding of AAC implementation in African schools and its impact on communication development in learners with diverse educational needs.