WESTERN AND TRADITIONAL MEDICINE : CULTURAL BELIEFS AND PRACTICES OF SOUTH AFRICAN MUSLIMS WITH REGARD TO DOWN SYNDROME

The aim o f the study was to investigate the beliefs and practices o f caregivers and traditional healers within the South African Muslim community regarding Down syndrome. An exploratory-descriptive research design was utilized which incorporated individual interviews with 10 caregivers o f persons with Down syndrome as well as 10 traditional healers from the South African Muslim community. Common beliefs emanating from both groups relating to the cause o f Down syndrome included the notion that this condition was genetic in origin and that such children were perceived to be gifts from God. Others attributed Down syndrome to a punishment from God or the result o f curses from people. Treatment included the use o f inscriptions from the Quraan, water that had been prayed over and herbal medicines. Some caregivers seemed reluctant to approach western health care professionals due to negative past experiences. The main reasons fo r consulting traditional healers were cultural beliefs and pressure from fam ily members, their holistic approach and the personal nature o f their interventions. Collaboration between allopathic medicine and traditional healing was advocated by almost all o f the traditional healers. These findings underline the need fo r culturally sensitive rehabilitation practices in speech-language pathology and audiology; and collaboration between western health care practitioners and traditional healers.


INTRODUCTION
Differences in socio-cultural experiences, ethnic histories and family backgrounds are likely to influence people's worldviews regarding the aetiology o f illnesses and disorders, and the par ticular healing methods followed by individuals (Battle, 2002).In terms o f worldviews, there has been a tendency to distinguish between two main types o f health conventions, the so-called modem approach that is located within a western medical para digm and the traditional approach, which is based on indigenous belief systems (Hall, 1994).W estern biomedical or allopathic medicine,, is rooted in Anglo-Saxon and Judeo-Christian value bases (Tjale & de Villiers, 2004) and initially tended to view disease as a form o f biological malfunctioning, with ill health manifesting in chemical, anatomical or physiological changes (Ross & Deverell, 2004;Tjale &jde Villiers, 2004).Healing was perceived as the scientific process o f treating disease through appropriate medical, surgical j and chemical interventions (Chalmers, 1996).However, more recently, there have been at tempts by the W orld Health Organization (WHO, 2002) to inte grate the biomedical model with a social model to form a bi opsychosocial model which considers bodily functions and structures, activities performed by an individual, level o f partici pation in societal activities, and the influence o f personal, and environmental factors on functioning, disability and health.A major cause o f the pre-eminence o f W estern medical practice, specifically in South Africa, was its connection with the coloni alist and later apartheid regimes which stressed the superiority o f Western medical practice (Tjale & de Villiers, 2004:2).
University o f the W itwatersrand e-mail: rosse@ um thom bo.wits.ac.zaPrivate Bag 3 Tel.+27 11 717-4481 PO W its Fax.+27 11 717-4573 2050 Johannesburg .South Africa W ithin traditional medicine, the terms diseases, disorders, disabilities and ailments are often used interchangeably and are generally seen as arising from natural, social, spiritual or psycho logical disturbances that create disequilibrium expressed in the form o f physical or mental ill health.Traditional healing endeav ours to restore harmony and equilibrium through natural, spiritual and psychological healing while the concepts o f curing and heal ing are also often used interchangeably (Du Plessis, 2003).How ever, the problem involved in distinguishing between western biomedical and traditional healing systems is that in the process they tend to become polarized and the one system is often viewed as superior to the other.For example, the late Edward Said in his canonical text on Orientalism (1995) discussed the skewed view o f the Other, including the Islamic world, which was based on Western cultural hegemony.Despite the existence o f cultural hegemony, in many countries, people from all socio-economic and educational strata often utilize both biomedical approaches as well as traditional practices, creating a medical syncretism that integrates both models and has implications for treatment or man agement o f disorders and compliance with therapy (Muela, Rib era, Mushi & Tanner, 2002).
South African speech-language therapists and audiologists are expected to render culturally sensitive and appropriate ser vices to families from diverse cultural, linguistic, religious and ethnic groups.Hence, they need to be aware o f the beliefs and practices o f these different groups in relation to health, illness and disability, and ways o f restoring well-being.One community that forms an essential part o f the fabric o f South African society is the Muslim community.However, it is acknowledged that not all Muslims form part o f a homogeneous community; nor do they share the same cultural ideologies in relation to health and heal ing, illness and disability.
Down syndrome is a disabling condition that affects over two million people worldwide (The National Down Syndrome Society, 2004).In South Africa, many children with Down syn The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)drome are currently undiagnosed.Nevertheless, the condition would appear to be prevalent with a hospital /clinic diagnosis esti mated to occur in less than 20% o f cases (Christianson, 1995).However, despite the relatively high prevalence o f the condition, there would seem to be a paucity o f research focusing on the views o f members o f the South African M uslim community re garding the causes and management o f Down syndrome or the healers that are commonly consulted in this regard.
Speech-language therapists and audiologist have an impor tant role to play, not only with respect to the cognitive, speech, language and hearing sequelae o f Down syndrome, but in support ing people with Down syndrome and their families and caregiv ers, more specifically in multicultural settings.
Attitudes o f caregivers and healers often play a major role in deciding whether the child will go to school and be placed in a stimulating environment that promotes learning, -either a special school or inclusive educational setting -or remain at home.Man agement approaches are often influenced by cultural and religious beliefs and practices and also depend on socio-economic factors as well as access to facilities and resources, including members o f the multidisciplinary team.Although caregivers and parents form an integral component o f an effective intervention programme in a natural setting, formal and more structured therapy should not be overlooked (Bernstein & Tiegerman, 1999).Furthermore, therapy does not take place within a vacuum, but occurs within a social and cultural context.Culturally sensitive practice is likely to make clients feel more comfortable in therapy; can potentially increase client compliance; and increase the likelihood o f successful treat ment and interventions being achieved (Davis-McFarland, 2002).
Culture and religion are inextricably intertwined within the South African M uslim belief system.A M uslim is one who sub mits to one God and is a follower o f the teachings o f Prophet M u hammad, who is regarded as the final messenger.W ithin Islam, illness, disease and disability are all seen to be A llah's (G od's) will, sent down by God.Adherents o f Islam are expected to act with compassion towards the poor, the sick and the disabled.Muslims also believe that the Prophet M uhammad was sent as a mercy to mankind, given the wisdom by Allah with regard to healing.This approach to healing is known as prophetic medicine (Tibb-an-Nabawi).It is not restricted to spiritual healing, but in stead balances the healing o f the soul and the physical being, so as to prepare man for the hereafter (Jauziyah, 1999).
The birth o f a child with a disability is not easily accepted without feeling sorrow and having negative emotions.W hat helps people to deal with these feelings is the worldview to which one subscribes.Caring for a child with a disability or disorder is seen as a form o f ibadah (worship).Another way o f approaching this experience is as a challenge or test from God. Devout Muslims believe that God does not give them a test without providing methods, which they can use to deal with this tragedy.Adherents to Islam are advised to share their tragedy with others, perform additional prayers, give extra charity and request others to pray for them (Sakr, 1996).Islam considers the world as a place in which difficulties and calamities are natural components.By knowing that difficulties are placed upon everybody and not just the individual, the feelings o f distress can be shared particularly with other family members (Bayanzandeth, Bolhari, Ghasemabadi & Ramasani, 1997).
In many eastern cultures, including the South African M us lim culture, families exist within extended family systems that form part o f collectivistic communities (Tomoeda & Bayles, 2002).A great deal o f respect, authority and decision-making is accorded to the elderly members, as they are perceived to have acquired great wisdom.The illness o f one individual is usually seen as a predicament affecting not only the nuclear family but also members o f the extended family, and one is expected to re spect the advice given by older family members.During such times, one is also expected to make use o f the agents that God has provided.This includes a responsibility to seek adequate medical (or other) advice.In this regard, western health care professionals and/or eastern traditional healers may be consulted (Bayanzadeth et al., 1997).
There are three main groups o f Muslim traditional healers: Firstly, there are Moulanas who are spiritual healers that occupy an essential and honoured position within the Muslim culture and are consulted by many South African Muslims for psychological, medical and social problems.They are defined as pious Islamic scholars who are well learned in all aspects o f the religion o f Is lam.Secondly, there are Hakeems, also known as Muslim physi cians, who are also consulted by the South African Muslim com munity.Their services include the providing o f ointments and mixtures, which are made from herbs that are known to have bene ficial healing properties and are designed to restore imbalances in the body humors i.e. blood, phlegm, bile and spleen.In addition, gift healers, who are blessed with supernatural powers, also assist the South African Muslim families with healing/treatment o f vari ous illnesses and disabilities (Desai, 1998).
Although accurate figures are not available regarding the number o f South African Muslims who consult with Muslim tradi tional healers, it is estimated that approximately 8 out o f 10 Black South Africans consult with various types o f traditional healers in conjunction with or in preference to western trained medical prac titioners (Keeton, 2004).The W orld Health Organisation (WHO) also recognizes traditional healing as an integral part o f the pri mary health care system in developing countries (W orld Health Organization, 1978:429).Consequently, several studies have fo cused on traditional healers' approaches to various disorders.For example, in terms o f African traditional healers, Du Plessis (2003) investigated their approaches to HIV/AIDS; de Andrade & Ross (2005) explored beliefs and practices in relation to hearing impair ment; while Platzky & Girson (1993) focused on stuttering.
According to Dagher & Ross (2004) beliefs regarding the causation o f birth anomalies are not always grounded in empirical science, but are often understood from a magico-religious or cul tural perspective (Tjale & de Villiers, 2004).For example, Badat (2003) interviewed a group o f Moulanas from the Gauteng Mus lim Community regarding their approaches to cleft lip and palate.A common belief was that cleft palate is God sent and should not be questioned.Participants in her study acknowledged the exis tence o f various superstitious beliefs and practices in the Muslim community.For instance, if a pregnant woman handled a sharp object during the time o f an eclipse, her baby was likely to be born with a birth anomaly.In Badat's (2003) study, emphasis was also placed on prayer and tarweez, which is an inscription from the Muslim Holy Scriptures written on a piece o f cloth and usually worn in the form o f an amulet.However, despite the relatively high prevalence o f Down syndrome worldwide, and the fact that many speech-language therapists and audiologists render services to these individuals and their families, few, if any studies have focussed on the approaches o f South African^Muslim traditional healers and caregivers in relation to this condition.For these rea sons the study aimed to investigate the beliefs and practices of caregivers and traditional healers within the South African Muslin1 community in Gauteng regarding Down syndrome.It was antifl' pated that this research would have important implications f°r Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)cross-cultural awareness and culturally sensitive rehabilitation practices for various disciplines functioning in multicultural set tings; improved referral systems and collaboration between west ern trained health care professionals and traditional healers; incor poration o f cultural issues surrounding health and illness into the training curricula o f health care professionals; and further re search.It was also felt that the study was both relevant and timely, given the recent promulgation by the South African government of the Traditional Health Practitioners Bill in 2004, which is de signed to incorporate traditional practitioners into the formal healthcare system and regulate their practice (Keeton, 2004).

Aim
The aim o f the study was to investigate the beliefs and practices o f caregivers and traditional healers within the South African Muslim community regarding Down syndrome.

Objectives
Objectives with respect to the caregivers were: 1.
To obtain information regarding the time o f diagnosis, the person who conveyed the diagnosis, and participants' under standing o f the term Down syndrome; 2.
To probe personal and cultural beliefs regarding the aetiol ogy o f Down syndrome; 3.
To elicit views regarding the management o f Down syn drome with regard to the use o f traditional healing, medical approaches, speech-language therapy and audiology and other paramedical interventions; 4.
To ascertain whether caregivers had consulted with medical doctors, speech-language therapists and audiologists and other paramedical professionals; and to explore their experi ences with these western trained professionals.
Objectives with respect to the traditional healers were: 1.
To elicit from the traditional healers, personal and cultural beliefs about the aetiology o f Down syndrome; 2.
To examine the various methods used by the traditional heal ers to manage/treat Down syndrome; 3.
To probe attitudes o f traditional healers towards allopathic medical practitioners and collaboration with western medi cine; ; 4.
To explore the views o f traditional healers regarding the rea sons for being approached by caregivers in relation to Down syndrome.

Research design
An exploratory-descriptive research design, incorporating a two-group, parallel study was employed.The rationale for adopt ing an exploratory-descriptive design was that it allowed explora tion o f a relatively unchartered area, while providing the opportu nity for obtaining a rich and detailed description o f Muslim tradi tional healing in relation to Down syndrome (TerreBlanche & Durrheim, 1999).The two group, parallel study, enabled the re searchers to conduct individual interviews with a group o f care givers and a group o f traditional healers and thereafter to compare the findings and extract differences and similarities from the data.Due to time constraints, triangulation or the use o f multiple meth ods (Denzin & Lincoln, 1998) was not undertaken and other meth ods o f data collection were not selected.

Participants
A purposive, non-probability sample o f 10 caregivers of children with Down syndrome as well as 10 traditional healers was recruited from the Lenasia, Gauteng area.Within the purposive sampling paradigm, "snowball sampling" was employed.Prospec tive participants within the Muslim community were approached.They in turn were asked to obtain permission from other potential participants before giving their contact details to the researcher.Advertisements were also placed in the local community newspa per and on the Islamic radio station, inviting members o f the M us lim community to volunteer for participation in the study.How ever, it is acknowledged that using a volunteer sample may have introduced sources o f bias.

Participant Inclusion Criteria
The participants were required to be South African M us lims, as they were likely to have an understanding and knowledge o f the community's cultural beliefs that influence their decisions.Confirmation o f the diagnosis o f Down syndrome needed to have been made by a medical practitioner.The 10 caregivers needed to be direct and primary caregivers o f the child with Down syndrome and could be any member o f the affected individual's immediate family.
The traditional healers needed to be specifically trained or to have acquired some years' experience in traditional healing so that they would be able to comment on the type o f traditional heal ing approaches adopted in relation to Down syndrome.They also needed to have been consulted with respect to at least one person with Down syndrome.

Description o f Participants
The caregivers were all female and were all o f Indian ex traction.Eight o f the caregivers were mothers, one was a sister and one was a grandmother to the person with Down syndrome.The ages o f the caregivers ranged from 21 to 80 years.Five o f the indi viduals with Down syndrome were males and five were females and their ages ranged from one to 30 years.
The traditional healers comprised five Moulanas, two Hakeems, two spiritual healers and one herbalist.Nine o f the heal ers were male and one was female.In terms o f ethnic group, eight were Indian, one was Black and one was o f mixed descent.The period o f time spent practising traditional healing ranged from two to 22 years.

Research instrumentation
The study incorporated two semi-structured interview schedules presented in the form o f individual interviews.Copies o f the interview schedules for the caregivers and traditional healers are set out in Appendices A and B respectively.Several of the questions were adapted from studies by Bham & Ross (2005) and Badat (2003) and included both open and closed-ended items.Both schedules were divided into two sections, namely a section on biographical information and a section on information pertain ing to beliefs and practices in relation to Down syndrome.
Content validity o f the interview schedules appeared to be demonstrated as sufficient aspects covering the content o f the topic were investigated.In addition, a university researcher who was familiar with the area o f traditional healing scrutinized the inter view schedules.This person was o f the opinion that the schedules The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) had face validity as they appeared "on the face o f it" to measure what they purported to measure.

Pre-testing the interview schedule
After ethics clearance was obtained from the University Ethics Committee for Research on Human Participants, the inter view schedules were pre-tested on persons with similar characteris tics to the target group.These persons were excluded from partici pation in the final study.Due to difficulties experienced in recruit ing sufficient participants, pre-tests were conducted with only one Moulana and one caregiver.The pre-tests indicated that the inter view was fulfilling its purpose as the participants stated that they understood all the questions.Thus no amendments were made.

Data collection
Following the pre-test, the information sheets and consent forms were sent out to the prospective participants.The researcher contacted both caregivers and traditional healers by telephone and invited them to participate in the study.Individual appointments were made and thereafter, interviews were carried out with the traditional healers and caregivers.In order to comply with Muslim traditions, the researcher who conducted the interviews attired her self in the appropriate M uslim dress for a female, which is a cloak and a head scarf, and was accompanied by a male figure to all in terviews with persons o f the opposite sex.She also used the appro priate greetings on arrival and on terminating the interviews.

Interviews with caregivers and traditional healers:
All the interviews with the caregivers took place in the com fort o f the participants' homes and at times that were convenient for them.Most o f the interviews with the traditional healers were conducted in places where the traditional healers usually consulted with their patients.These areas were in the yards or gardens, close to the traditional healers' homes or in their offices.At the begin ning o f the interviews, participants were shown pictures o f children with Down syndrome so as to ensure correct recognition o f the syndrome.Although the original intention was to audiotape the interviews, participants tended to be suspicious o f and resistant to this procedure.Hand written field notes were therefore made o f all the responses provided by the participants.Data collection contin ued until 10 caregivers and 10 traditional healers had been inter viewed, because at this point data saturation appeared to have been achieved.According to Leininger (1994in Maxwell & Satake, 2006), saturation implies that the researcher has performed a "thick" description in an exhaustive effort to extract as much m eaning as possible from the data until no more can be said about the topic.

Data Analysis
The closed-ended items were analysed using descriptive statistics involving simple frequency counts, while semantic con tent analysis was applied to the open-ended questions in order to highligfit common themes expressed by participants.Content analysis is a research method for assembling and analysing the content o f a text (TerreBlanche & Durrheim, 1999).Morse (1994) has divided content analysis into two types, namely semantic con tent analysis (manifest) and inferred content analysis (latent), se mantic sontent analysis is used to convey what the participants have said, while Inferred Content Analysis infers or goes beyond what was said or written.Neuman (2003) emphasises the need to ensure the trustwor thiness or truth value and authenticity o f the qualitative framework (comparable to the positivist notions o f validity and reliability) by adopting the criteria developed by Guba & Lincoln (1989), namely credibility, transferability, dependability and confirmability.By using semantic rather than inferred content analysis, the researcher aimed to establish credibility (paralleling internal validity) o f the data as representing the "real world" as perceived by the partici pants.In terms o f transferability (which is comparable to the posi tivist construct o f external validity or generalizability), it was an ticipated that the information obtained from this study would be applicable to other therapy situations as well as to professionals who encounter clients from the Muslim community in South Af rica.In order to enhance dependability (the alternative to reliabil ity) o f data analysis, the same person conducted all the interviews and systematic steps adapted from TerreBlanche & Durrheim (1999) were followed.These steps included: firstly, familiarization and immersion, which involved putting into simpler terms by means o f reading through, making notes, drawing diagrams and brain storming to obtain a general idea o f the findings; secondly, inducing themes, which implied inferring general rules or classes from specific instances in a bottom up process; thirdly, coding, which encompassed the making o f different sections o f data as being instances o f or relevant to one or more o f the researcher's themes; fourthly, elaboration, which involved synthesising infor mation in a linear sequence; and fifthly, analysing data, interpre tation and inspection which included going back to all the above steps to make sense o f the data.In order to reduce researcher bias and establish confirmability (or objectivity) o f the data, correspon dence checking advocated by Pretorius & de la Rey (2004:31) was undertaken, whereby the primary researcher's categorization of themes was checked by her research supervisor for correspon dence.Once agreement had been reached regarding categorization o f themes, these were quantified.

Time o f diagnosis
Eight out o f the 10 caregivers stated that their children were diagnosed at birth.However, one participant stated thatithe first diagnosis was made during her pregnancy via an amniocentesis test.Another mother reported that her son was only diagnosed about six months after birth.|

Persons who made the diagnosis
The entire sample that was interviewed stated that their children were diagnosed with Down syndrome by either a gynae cologist or a paediatrician.

Understanding o f Down syndrome
Nine o f the participants appeared to be aware o f the main features and characteristics o f children with Down syndrome.Re sponses included: 'Genetic disability with one less chromosome, Mongolian; Low ears with weak muscle tone; Dry skin and prone to upper respiratory tract infections; Floppy child with stump fin gers and two segments on the baby finger; Two years slower than normal children.Some have a leaking heart and some are mentally retarded'.However, a mother o f a four-year-old child with Down Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)syndrome admitted that she did not understand the meaning o f the term Down syndrome.

Genetic counselling
Seven o f the 10 participants informed the researcher that they had not been for genetic counselling.One mother gave the following reason for refusing to go for genetic counselling: 'As a Muslim I had a child and was never going to abort, thus I fo u n d it meaningless.A fter my Down syndrome son I had two perfectly normal twins.' In contrast, one mother found that the genetic coun selling was useful."My fa th er fin a lly accepted my son, as my f a ther was very sensitive and defensive and said i f anyone saw my son they would laugh.'

Personal beliefs regarding the aetiology o f Down syndrome
It should be noted that the participants tended to regard terms such as "heal" and "cure" as synonyms, while concepts such as "illness, disorder, disease, ailment and condition" were used interchangeably.A common belief mentioned by five o f the participants was that all illnesses and birth conditions were due to G od's will.This belief was similar to findings by Bham & Ross (2005) that many o f the M uslim participants whom they interviewed felt that strokes were due to G od's will.
Two participants were convinced that the child was a gift from God and one must willingly accept it and not question, ' Why me G od?' One mother stated: 'This is a heaven special child and only fortunate people get these children.' A further two participants attributed the cause o f the condition to genetic factors and understood the scenario o f Trisomy chromosomes.Inter-marriage was also related to genetic factors, as one o f the participants felt that if marriages occurred between husbands and wives who were too closely related, the risk o f having a child with Down syndrome was high.One participant felt that the age o f the mother or father was one o f the causes of Down syndrome.This idea is supported in the research literature as the maternal age related risk for Down Syndrome is lower at age 20 (one in 1734 births), but higher at age 35 (one in 386 births) (Harperv 1998).,

Cultural beliefs regarding the aetiology o f D own syndrome
In addition to personal beliefs regarding the aetiology o f Down syndrome, caregivers were also asked if they were aware of the existence o f any cultural beliefs in their communities relating to this condition.Four o f the participants explained that according to their culture, having a child with a disability, such as Down syn drome, was regarded as a punishment from God. Punishment was directed to the mother, who was perceived to have committed wrong deeds in her past life.One caregiver emphasised that these were cultural beliefs, not Islamic beliefs.Furthermore, cultural beliefs assumed by the community were found to be closely linked to beliefs held by many o f the participants themselves.This find ing was consistent with the results obtained by Bham & Ross (2005).Several o f the M uslim caregivers and traditional healers whom they interviewed mentioned cultural beliefs regarding stroke being a form o f punishment.
Four o f the participants also suspected Jadu (evil curses) from family and friends.One participant added: 'These beliefs are myths which need to be eradicated fro m our thought patterns.In line with these findings, Dagher & Ross (2004) noted that the Afri can traditional healers in their study believed that cleft palate was caused by ancestors, spirits and witchcraft.In a similar vein, three participants mentioned that many people in their culture were un aware o f the cause o f Down syndrome.For example, one partici pant noted, 'These ignorant people often laugh at my son.'

Management o f Down syndrome
Six o f the caregivers reported that they had consulted tradi tional healers regarding the management o f their children with Down syndrome.Several o f the participants explained that many o f the elderly members o f their communities and families insisted on the use o f traditional healing.This finding was in line with the views expressed by those o f Tomoeda & Bayles (2002) who m ain tain that in collectivistic cultures such as those o f Indian Muslims in South Africa, members o f the family group tend to exert a direct influence on decisions about treatment options.
One caregiver noted that her son was constantly being ad mitted to hospital and that doctors had told her that he was not going to live long.She then approached a Moulana who gave her the tarweez and advised her to read a few verses from the Quraan in order to improve his condition.7 was happy with the results as my son's condition improved and he also stopped crying so much '.Another caregiver mentioned that she took her granddaughter to a Moulana.She reported that the Moulana had read from the Quraan for her granddaughter and thereafter her speech had become clearer.In this respect, it should be noted that traditional medicine has been shown to have several benefits, including reduced anxiety through a shared, unquestioned belief in the powers o f the healer (Hammond-Tooke, 1989).
One o f the participants explained that she did not approach traditional healers as she and her husband felt that one should ask God directly for help.She added that she and her husband read from the Quraan on a daily basis and they had seen tremendous improvement in their daughter's health.
Another participant shared a similar view and encouraged people to read the Quraan daily, as it contained shifa (cure) and a mercy for all mankind.One participant was convinced that her daughter was a gift from God and that she had to accept her the way she was.Another participant explained that her brother was physically disabled and this factor motivated her to take care o f G od's creatures herself and not seek cures for disabilities.
One participant informed the researcher that a Hakeem had provided him with a herbal ointment to strengthen his son's legs.

"Soon after treatment my son started walking. H e also provided my son with a syrup fo r his constipation and this too was useful and I have lots o f fa ith in this Hakeem
Another participant re ported that he approached a Hakeem, not to cure his son o f Down syndrome but merely to get her remedy for his heart condition.She provided a diet to follow which included goat's milk and some herbal powders.The father noted that his son lost weight and he then discontinued the diet and was not satisfied with the healer's management.Another participant explained that her Hakeem had provided her with a herbal mixture in a liquid, but her son, who was very small at time, did not drink it.Thus she was not sure if it would have been effective.

Approaching M edical Doctors]
Six o f the caregivers stated that they had approached medi cal doctors.These participants were convinced that the doctoi The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) could assist them with this medical condition.One o f participants explained that the doctor she approached was very encouraging and provided her with advice and management strategies.Another participant reported that her doctor introduced her to other moth ers/caregivers of children with Down syndrome, which helped her deal with her feelings towards her child and contributed to more effective care and management o f the condition.
Four parents stated that they had independently searched the internet and read books to assist them in the management o f their children.They found the doctors to be unhelpful in terms o f giving advice, and lacking in counselling skills regarding dealing with parents' feelings.Another mother informed the researcher that her doctor had told her that her baby was going to be deaf.However, she explained that she and her husband used to read from the Quraan and that her daughter hears perfectly well.Conse quently, she no longer takes the doctors' theories or their progno ses in respect o f her child seriously, but perseveres with faith.

Approaching Param edical Professionals
O f all the participants who were interviewed, nine stated that they had approached speech-language therapists to assist in the remediation process o f their children with Down syndrome.Among the nine children who did attend therapy, seven were cur rently attending, either privately or at schools.All nine caregivers stated that they had experienced success in therapy.However, one mother explained that she terminated therapy as she felt that her son had reached a plateau at the age o f 12 years.Examples o f use ful aspects of therapy included buying toys that depicted every day routines in order to facilitate basic identification; encouraging the child to vocalize and to expand his or her sentences; avoiding baby talk; and using gestures to complement verbal input.The impression gained was that caregivers had insight into the speechlanguage therapy services provided for their children and had im plemented the advice o f speech-language therapists.The one par ticipant who did not approach a speech-language therapist noted that her daughter started talking spontaneously and she therefore did not find the need for speech-language therapy intervention.None o f the participants mentioned using audiological services.
Five of the caregivers reported that they had consulted with other paramedical professionals including physiotherapists, occu pational therapists, paediatricians, cardiologists and counsellors.Those that had approached these paramedical professionals re ported being satisfied with their services.However, two o f the caregivers mentioned that they did not find the need to seek pro fessional help as their children were developing adequately.Care givers articulated the viewpoint that they felt more secure and re laxed about going to professionals who understood their culture and their use o f alternate remedies.

PART TWO: Results from the interviews with the traditional healers
Ten traditional healers were interviewed, all o f who reported that they had treated children with Down syndrome.

Beliefs regarding the cause of Dons syndrome
Participants' views were elicited on the causes o f the Down syndrome as it was felt that the cause would reflect societal beliefs about the condition.Five o f the participants were o f the opinion that the aetiology o f Down syndrome could be attributed to ge netic factors.One o f the participants added that when family members inter-marry this behaviour also causes the child to be bom with some kind o f anomaly.
Five o f the participants attributed Down syndrome to God's will.They noted that babies that are bom with such a disorder are all in G od's (Allah's) hands and we should avoid questioning God.Furthermore, such an experience was considered a 'test' for the parents.''Keep in m ind that sickness is given to the patient as a trial fo r the patient him self or herself and fo r their f a m i l y This finding was consistent with the Islamic belief that the reward in the life to come is based on how one reacts to a 'test,' namely how one treats a disabled child (Sakr, 1996).One participant also men tioned in passing that abortion, amniocentesis and sterilization were contrary to the teachings o f Islam.
A further theme that emanated from the responses o f four of the participants related to cultural beliefs in curses, also known as Jadu, and evil eyes or evil spirits (Jinn) from other people.Hall (1994) suggests that some people are believed to have native pow ers, which they utilize together with medicines or charms to inflict hurt on others.Campbell (1998) maintains that supernatural and magico-religious belief systems distinctive to each culture, are often alien to and not easily understood by allopathic practitioners.
Two out o f the 10 participants attributed the condition to an imbalance between hot and cold in the body, which caused the child to be bom with Down syndrome.This imbalance was re ferred to by the Hakeems as a disequilibrium in the body's hu moral system.It was believed that this imbalance could have oc curred during the mother's pregnancy.They believed that the prac tice o f looking at the symptoms in isolation, provided only short term relief, rather than long term healing.They thus advocated a multi-dimensional approach, which took into account an under standing o f patients themselves, their life contexts and life styles, and finally the ways in which their spirit-mind-body interacted with each other in an attempt to achieve balance and healing, thereby attempting to establish homeostasis o f the spirit-mindbody.In this way one could heal the whole patient and not just alleviate the symptoms.This type o f approach appeared to be de rived from Unani Tibb or Tibb, which is a holistic healing system based on the philosophies of Hippocrates, the father o f western medicine (Sykiotis, Kalliolias & Papavassiliou, 2006), and the well known Islamic scholar, philosopher and physician Ibn Sina.Tibb is a type o f natural medicine which takes into account the individ u al's body, mind and soul.Tibb was practised about 150 years ago and is the foundation on which modem medicine is based.Unani Tibb is recognized in South Africa, largely due to it.being cost effective and providing an effective understanding o f the aetiology o f illness.The principles o f Tibb are in accordance with the Quraan and the teachings o f the Prophet Muhammed (Sina, 2004).
It was clear that the traditional healers who were inter viewed were concerned with the reasons why a particular disease has occurred and that the search for causality was perceived to be one o f their greatest assets.In contrast with the finding that the traditional healers who were interviewed, were concerned with the reasons why a particular disorder had occurred, Green (1988) sug gests that western medical practitioners tend to show more concern with control as opposed to considering the root o f the problem.The importance o f holistic healing highlighted by the two Hakeems, is also shared by many Black South African traditional healers, who believe that if the mind is healed the body takes care o f itself (Dagher & Ross, 2004).This assumpti6n contrasts with that o f western medicine, which contends that if the body is healed the mind takes care of itself (Hall, 1994).
One of the Hakeems noted that he usually asked him self the following questions derived from Selzer ( 2004) during his consul tations, namely: '1) What does a symptom mean? 2) How should it Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 55, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)be listened to? 3) What does this p a tie n t's symptom mean in this particular patient as opposed to another patient?4) What does this symptom tell us about the totality o f this patient fro m the sym ptom 's picture? 5) How can I as a practitioner, be o f the greatest help to this person in his wholeness, and assist his soulmind body complex to achieve its healing?' (Selzer, 2004:10).
One o f the participants stated that the ruh (soul) asks God to be bom in that state, i.e. with Down syndrome.He added that God provides healers and parents with the knowledge to cope with a child with Down syndrome.He further noted that God pun-! ishes the parents by giving them a child with Down syndrome, so that the parents can become more conscious o f God and become more loving.
A female spiritual healer attributed the aetiology o f Down syndrome to a virus, and believed that something had gone wrong in the mother's womb.She explained that it was a natural devel opment and that there was a negative influence, which disturbed the development o f the foetus.

Information regarding management of Dons syndrome
Three Moulanas indicated that they would provide the pa tient with a tarweez (an inscription o f verses from the Quraan on a | piece o f paper).A tarweez is usually worn around the neck or | attached to the child's clothing.The tarweez serves to provide the child with protection against any evil and eradicates any evil pro-! jected onto the child.One o f the moulanas noted, 'For every ill ness there is a cure, and Muslims are encouraged to believe in the unseen'.This participant also encouraged people to approach I medical professionals for treatment as God has made them avail able in order to help people.Another participant noted that he had used tarweez to help stabilize the child, and the child then started "thinking and talking", i One Moulana mentioned that he gave his patients oils, which were either part o f a mixture or on their own to be applied to the body and head.In addition, he provided them with five | different types o f seeds.He encouraged them to drink almond milk, which he first prayed over.The Moulana also mentioned the i use o f holy water (water that he prayed over), which he provided to most o f his patients.Another method that he used was to advise his patients to put salt on their bodies at night, as it 'cools the body and makes life easy'.

j
The same M oulana mentioned the use o f honey in combi-; nation with hot water.He emphasised that honey was a cure for many illnesses as stated by the prophet Muhammed.

j
The Hakeems reported that they would examine the patient 1 and establish which humour was [blocked or not functioning opti mally.Treatment included changing a certain aspect of the tem-1 perament o f one o f the four humours by providing herbal medica tion.This herbal medication often consisted o f an infusion o f powders that assisted in balancing the humours, attempting to harness the body's energy to treat itself.
One o f the Hakeems noted that when the illness was evi dent from birth as in children with Down syndrome, eradicating or achieving homeostasis o f spirit-mind-body was impossible.In stead they assisted these children by providing medication in the form o f herbs that minimized the degree o f the problem.He ex plained that he had once provided a child with Down syndrome with a herbal balm to aid his joint/walking pains as the leg was i very cold.Another point that he mentioned was that children with I Down syndrome often straggled to talk as 'the tongue was drier and colder than it should b e He therefore provided medication to increase the moisture and heat |On the tongue and this process helped to increase blood flow to the tongue.He believed that this action made the tongue more mobile, thereby promoting speech production.In addition, he stressed the fact that treatment was 'holistically based taking into account the m other's pregnancy, the child, the effect o f the condition and his environm ent'.
Herbal treatment was identified by two o f the participants.A herbalist noted that he provided a child, with Down syndrome who had a severe hearing problem, with a herb mixture in the form o f porridge, which the child had to eat every morning.He also provided him with a mixture, which he had to take in the morning and at night.The herbalist stated that this child used to be hospitalised every month, but after his treatment, doctors were amazed at his improved health.His main medicines were made from plants, herbs and powder o f seeds and roots, juices, leaves and minerals.On probing the specific herbs that the healer pre scribed for children with Down syndrome, he replied that it was his secret.Hammond-Tooke (1989) suggests that many herbalists possess knowledge o f natural substances, which have an authentic remedial effect but are not always willing to share this knowledge out o f fear that this knowledge will be appropriated by otherswhich highlights the need to protect the intellectual property rights o f traditional healers.
One participant emphasised the fact that no matter what approach to management or treatment a person pursued, success and recovery were all in G od's hands.Two o f the participants believed that spiritual healing was a necessary procedure that had to be implemented as part o f the treatment o f Down syndrome.Firstly, permission is sought from God to work on the child.Thereafter they scan the body from the spiritual realm and then intervene via touch therapy.
Many traditional healers believed that the cause o f Down syndrome was due to evil spirits that had possessed the mother and the child.The spiritual healing is a process that helps to dispel the evil spirits and cleanse the patient.Another spiritual healer mentioned that she would meet both the mother and child and then clear the mother o f evil spirits that she had been carrying during pregnancy.She noted that her treatment, which included a combination o f touch therapy, reiki, automatic writing and mas sage, helped to remove any negativity within the child or mother and assisted with various difficulties.
One participant noted that counselling o f the parents forms an integral part o f his treatment.He demonstrated to the parents how to approach their child with love, and comforted them by assisting them to deal with their spiritual needs.

Views o f traditional healers regarding the reasons for being approached by caregivers o f children with Down syndrome
The issue o f culture and pressure from family members was strongly emphasized by eight participants.One healer noted that the elderly members o f the Muslim community tend to feel that alternative methods o f healing should be attempted.He ex plained that many o f these elderly people have a strong belief that some ailments are caused by unseen forces.They also believe that religion holds a cure for many ailments, and can improve the well being o f the child.Another participant shared a similar view and stated that 'many people have faith in what their grandparents believed as they grew up strong and healthy'.This theme was articulated by four o f the healers.
One o f the participants remarked, ' We work with uncondi tional love.Many o f our people maintain that modern doctors are generally in a hurry and they do not give enough time, care and The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)attention, in contrast to traditional healers'.Several of the tradi tional healers emphasized the importance of establishing a rela tionship of trust and unconditional positive regard with people who consulted them.This approach is similar to that advocated by m any western counselling professionals (e.g.Manning, 2001).The argument put forward was that western doctors derived most o f their answers from the patient, whereas traditional healers con firmed what their patients conveyed to them.A M oulana empha sised the fact that he took the time to converse with children with Down syndrome as many might be mentally handicapped.7 greet them and hear their stories and I see a little world open, beauty and not ju s t a child with Down syndrome.I make the child comfortable and make the child develop a liking towards me and build up his confidence'.Another participant explained that he sat with these children, was sensitive to their needs and paid par ticular attention to the way in which he addressed them.
This theme of a holistic approach was encapsulated in the responses of four participants.One of the Hakeems noted that caregivers tended to approach him more often than medical pro fessionals as he provided a holistic approach to assessment and treatment.A spiritual healer attributed the popularity of her treat ment to her approach being a combination of physical and spiri tual dimensions.This preference for a holistic approach to treat ment was consistent with results documented by Bham & Ross (2005) and Badat (2003).
Previous successful results with other patients was a com mon theme mentioned by three participants.Thus these patients usually recommended other persons to their traditional healers.One of the spiritual healers mentioned that she was well known within her community and if the illness or condition recurs she goes back to the birth of the child to discover the original cause.'Moreover, ju st like people have fa ith in certain doctors, they believe our hands are good at healing.M any people perceive my approach at a lower level and one that is more affordable.There has been a revolution in that many people approach traditional healers'.The herbalist stated: 'Herbalists can help cure things, such as bone fractures and we can also help control illnesses such as diabetes.Therefore we are successful like the doctors in treating people.Likewise, we are able to control and manage conditions such as Down syndrom e'.
Three participants emphasized that when all else fails within the world of modem medicine, people tend go back to their roots in order to find a cure.This finding is similar to the assertion by Campbell (1998) that traditional healers are usually well respected, accepted and trusted by their communities be cause they are culturally and religiously congruent with their own beliefs and practices.
One traditional healer expressed the view: 'They come for security; dependent on you for a cure .. .They usually come and see us to alleviate them from guilt.They want some kind of rein forcement that it is not their fault'.Finally, one participant stated: 'They think they've been cursed'.

The traditional healers' attitudes towards allopathic medical practitioners and collaboration with western medicine
Nine out o f the 10 traditional healers who were inter viewed reported that at some point they had advised the parents of children with Down syndrome to approach a medical doctor.One of the participants expressed the view that he would like to work with doctors and therefore advised parents to approach Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 medical practitioners.A spiritual healer reported that she had re ceived a prophecy to work with doctors.Another participant ar ticulated the opinion that if his treatment was unsuccessful he then referred to doctors.In line with these findings, it has been noted that some traditional healers take a keen interest in primary health care training provided by modern formal medicine (van Wyk, van Oudtshoom & Gericke, 2003) Furthermore, a Moulana admitted that Jadu was not always the cause of the child's condition and in these cases he would re fer to medical professionals for help.Another Moulana mentioned that he regularly sat with doctors and consulted with them.Most of the participants referred patients to doctors as they felt that some children needed surgery, particularly those with heart prob lems.
In contrast, one of the Hakeems stated that he did not refer to medical doctors as most of the patients that came to him had often given up hope and lost faith in medical doctors as they had not experienced success with allopathic medicine.
Five of the participants had referred their patients to speech-language and hearing therapists.One participant reported that he had not referred to a speech-language therapist, because whenever a child had presented with a speech or language prob lem, his treatment had proved successful 'and with time the child started to talk in long sentences, understand better and his think ing power increased'.
Nine of the participants reported that they did not consult with other medical or paramedical professions.The time factor was noted to be one of the reasons for not consulting with other western trained professionals.The herbalist stated that he did not approach other professionals, as he preferred to control the child's condition with the use of herbs.
The entire group of traditional healers who were inter viewed supported collaboration with health care professionals and expressed a keen interest in learning about modem medicine and the roles of the various team members involved in the rehabilita tion of the child with Down syndrome.They also felt that there was a need for the modem world to be acquainted with traditional healing and that western professionals should respect this form of healing.For example, a spiritual healer stated that she would do her work and they (medical doctors) would do theirs and the com bined effect was likely to produce optimal results for the patient.One participant stressed the fact that Islam proclaims that we should go out and find a cure, because he believed that for every disease there was a cure, thus alternative methods should be en couraged, including medical doctors' approaches to healing.A Moulana supported collaboration with western medical profes sionals as he felt that a disorder can be both spiritual and medical in aetiology and hence both realms can potentially help in differ ent ways.One Hakeem conveyed the view that his work included providing a balance with the humours, to minimize harm emanat ing from them and that other professionals were needed to aid the child with Down syndrome in other avenues.For example, he stated 'The speech-therapist will assist the child in her expertise o f language and speech'.In fact, two of the participants men tioned that at the time of the study they were collaborating with western practitioners especially when surgery was required or when their medicine was not healing their patients.
However, one Moulana, although in favour of collabora tive treatments, was somewhat dubious about the feasibility of collaboration as western medicine often failed to appreciate the connection between the body and the soul.He also e x p r e s s e d deep concern regarding the negative views that he p e r c e i v e d m any medical doctors to hold in relation to traditional healers a n d the services they offer.
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)

Summary o f main findings
In summary, common beliefs that emanated from both the caregivers and the traditional healers with reference to the cause of Down syndrome, included the notion that this condition was genetic in origin and that such children were perceived to be a gift from God.Other frequent responses attributed Down syndrome to a punishment from God and also a result of Jadu (curses from people).Common treatment/management approaches mentioned by both the caregivers and the traditional healers included the use of tarweez and water that had been prayed over which was pro vided by M oulanas and spiritual healers, and herbal medicines prescribed by Hakeems.Both groups emphasized the need to treat children with Down syndrome with patience and unconditional positive regard, and to focus on their strengths.Some caregivers seemed reluctant to approach medical doctors relative to tradi tional healers and this reluctance was attributed to their negative past experiences with medical practitioners.Furthermore, nine of the caregivers had approached speech-language and hearing thera pists compared to five of the traditional healers.Both groups re ported making limited use of other paramedical professionals.The main reasons given for consulting traditional healers were cultural beliefs and pressure from family members, their holistic view of management, and the personal nature of their approaches.Col laboration between modem medicine and traditional healing was advocated by almost all of the traditional healers.
However, these findings need to be critically evaluated.A critique of the study revealed several limitations.

Limitations
Firstly, theorists such as Bhopal (1997) have questioned whether research in ethnicity and health is racist, unsound, or im portant science.It is the contention of the present writers that such research can potentially enhance awareness of the beliefs and practices"of different groups in relation to traditional healing.Sec ondly, as the researcher who conducted the interviews was from the same religion and part of the same South African community as many of the participants, they took for granted the fact that she was acquainted with their cultural beliefs and practices, and con sequently failed to elaborate and provide explanations for many o f their answers.Thirdly, as some cultural beliefs were seen to be sacred or even offensive to caregivers or the children concerned, participants were initially reluctant to admit having such beliefs for example, Jadu and the evil eye, and instead seemed to famish socially desirable responses.Only once the researcher was able to establish rapport with the participants, were some of them able to admit that they subscribed to such beliefs.A third limitation re lated to the fact that participants were unwilling to allow the re searcher to tape-record the interviews.She was therefore com pelled to make hand written notes, which occasionally tended to detract from the flow of the interviews.Fourthly, little informa tion was given regarding the type of herbs used for treatment.Pre sumably, the traditional healers felt that the researcher might ex pose their secrets to pharmacists and other persons who might ap propriate their knowledge.The fifth limitation was related to the failure to use triangulation, which would have added rigor, breadth, and depth to the investigation (Denzin & Lincoln, 1998).
Triangulation refers to the process of "enhancing the value of a theory by using multiple methods and perspectives to investigate the truth" (Maxwell & Satake, 2006:7).A further limitation re lates to the lack of generalizability of the data.However, a counter argument is that the issue of generalizability is irrelevant to re search of this nature as the purpose of the study was not to obtain generalizable findings but rather to elicit a rich and thick descrip tion of the phenomenon under investigation.

Recommendations
Despite these limitations inherent in the research design and methodology, important recommendations can be made in respect of culturally sensitive rehabilitation practices in speechlanguage pathology and audiology; collaboration between western health care practitioners and traditional healers; theory and future research.

Culturally sensitive rehabilitation practices in speech-language pathology and audiology
Although the findings cannot be generalized to the entire South African Muslim community, they suggest that some m em bers of this community tend to place a great deal of emphasis on cultural and religious beliefs.It is therefore recommended that speech-language therapists and audiologists need to adopt cultur ally sensitive practices when managing children with Down syn drome from this community as cultural beliefs may influence how people perceive affected individuals and how they are treated or managed.For example, the Muslim belief that disability is from God, may impact on the management process and needs to be taken into consideration when undertaking diagnostic evaluations and planning therapy interventions with this client population.In addition, information on treatment recommended by traditional healers is useful to western health care professionals, as they need to be aware of other forms of treatment that parents may be utiliz ing as these interventions might be useful or harmful when used in combination with modem medical treatment methods.Further more, the finding, regarding the influence of elderly and extended family members, has implications for both counselling and ther apy in terms of the guilt which may be felt if certain remedies are not implemented or traditional healers are not consulted.Such findings also underscore the importance of involving the extended family in therapy and adopting family-focused interventions.

Collaboration between western health care practitioners and traditional healers
The fact that almost all of the traditional healers who were interviewed supported collaboration with health care professionals and expressed a keen interest in learning about modem medicine, highlights the need for collaboration between the these two sys tems of medicine.However, the finding that very few of the tradi tional healers made referrals to paramedical professionals was possibly related to the fact that the participants were not knowl edgeable about the services provided by these practitioners.There would thus appear to be a need for these paramedical profession als to create public awareness of their services and the roles they can potentially play with respect to children with Down syn drome.
Moreover, approximately 80% of South Africans make use of traditional healers and an estimated 250 000 and 300 000 tradi tional healers are currently practising in South Africa.This wide spread use of traditional medicine has to do with issues of afforda bility, cultural acceptability and accessibility (Du Plessis, 2003).It The South African Journal o f Communication Disorders, Vol. 53, 2006 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) is therefore recommended that western health care practitioners be educated regarding the roles o f traditional healers and the medi cines they use, so that there can be greater collaboration and mu tual respect.The South African health ministry is currently looking for ways to incorporate informal medicine into the formal health sector, and the recent promulgation o f the Traditional Health Prac titioners Bill ( 2004) is designed to facilitate this process.

Theory and Future Research
This exploratory-descriptive study represents an effort, in some small measure, to enhance theoretical understanding o f the South African M uslim community's multifaceted approach to health, illness and disability.However, while respecting these cul tural beliefs and practices, one cannot endorse their effectiveness without further evidence-based research.Moreover, in view o f the fact that the small sample size and the use o f snowball sampling precluded generalization o f results to the broader population of caregivers and traditional healers, it is recommended that this re search be replicated on a larger, more representative sample.Given the point raised by one o f the traditional healers regarding the ap parent contradiction o f such practices as abortion, sterilization and amniocentesis, with the teachings o f Islam, future researchers need to explore the views o f traditional versus western health care pro fessionals regarding the ethics o f traditional healing and western health care in relation to these practices.Finally, it would seem to be an opportune time to begin the process o f monitoring the imple mentation o f the new Traditional Health Practitioners Bill in South Africa and assessing its effectiveness in promoting collaboration between western medicine and traditional healing over the next few years.
In conclusion, the findings that several participants attrib uted Down syndrome to genetic factors as well as G od's will, and many o f the traditional healers had referred patients to western professionals, suggests a degree o f medical syncretism whereby "biomedical knowledge transmitted in health messages coexists, interacts and merges with local pre-existing ideas and lo gics" (Muela et al., 2002:403).Moreover, the fact that Muslim humoral medicine is partly rooted in the writings o f Hippocrates, the father o f western medicine (Sykiotis et al., 2006), coupled with the finding that m any o f the caregivers in the present study utilized both eastern and western medicine, and all the traditional healers who were interviewed were in favour o f collaboration, suggests that these two systems do not necessarily represent incommensur able paradigms but can potentially fulfil complementary functions.Hence, both approaches need to be taken into consideration by speech-language therapists and audiologists seeking to render cul turally sensitive services to clients from the South African Muslim