Money and Awareness, Not Distance, Keep Kids From Follow-Up Eye Care After Failed Vision Screenings

When a child fails a routine vision screening at school or the pediatrician’s office, the next step should be simple: a referral to an eye care professional for a comprehensive examination. In practice, that step is anything but simple. According to a scoping review published in BMC Pediatrics, up to 60 percent of children with abnormal vision screening results never attend the recommended follow-up appointment with an eye care professional. That staggering figure means a large share of children whose potential vision problems are detected early nevertheless slip through the cracks, undiagnosed and untreated, at precisely the stage of life when interventions for conditions such as amblyopia are most effective.

The review, led by Amy Amoah of the University of South Florida Morsani College of Medicine together with colleagues at the University of Utah, the University of Michigan, Creighton University and other institutions, set out to answer a deceptively straightforward question: which social risk factors are associated with a family’s failure to follow through on pediatric eye care referrals after an abnormal screening? The answer, distilled from seventeen studies, points not primarily to geography or clinic opening hours but to two intertwined forces: limited affordability and low awareness of why the referral matters. Both factors were cited in fourteen of the seventeen included studies, making them by far the most frequently reported barriers in the literature.

Methodologically, the team followed the Joanna Briggs Institute methodology for scoping reviews, a structured approach designed to map the breadth of existing evidence on a topic rather than to statistically pool effect sizes. The researchers searched bibliographic databases and grey literature from their inception through July 2023, with an updated search in November 2024. Grey literature, which includes reports, theses and other material outside conventional journal publication, is particularly valuable in health services research because much of what is known about why patients fail to attend appointments lives in program evaluations and policy documents rather than randomized trials. Four reviewers independently screened and extracted data, and the review protocol was registered with the Open Science Framework, a step that increases transparency and reduces the risk of selective reporting.

The analytical framework the authors applied is equally notable. They synthesized the identified social risk factors through a three-stage process consisting of inductive coding, theme generation, and theme mapping onto the Penchansky and Thomas model of access, as extended by Saurman. The classic Penchansky and Thomas framework, first articulated in the early 1980s, decomposes access to care into five dimensions: availability, accessibility, accommodation, affordability and acceptability. Saurman’s later extension added a sixth dimension, awareness, capturing whether patients even know the service exists or understand its purpose. Notably, the review found that none of the seventeen included studies had themselves used a conceptual framework to organize their data, a striking gap that the authors argue has fragmented the literature and made it harder to compare findings across settings.

Mapping the reported barriers onto this six-dimensional model produces a clear hierarchy of problems. Affordability, the financial burden of examinations, glasses, treatments and associated costs such as transportation and lost wages, emerged as the dominant obstacle, appearing in fourteen studies. Awareness, the dimension describing whether caregivers recognize the significance of an abnormal screening result and understand the need for a comprehensive examination, matched it at fourteen studies. Acceptability and accommodation, which capture cultural fit and the convenience of scheduling and service organization, appeared at intermediate frequencies. At the bottom of the list was accessibility, the physical geography of getting to a provider, cited in only five studies. That finding challenges a common intuition: the problem is not primarily that eye doctors are too far away, but that care is too expensive and too poorly understood to be pursued.

The clinical stakes of these missed referrals are considerable. Pediatric vision disorders, including refractive error, strabismus and amblyopia, are most treatable during early childhood, when the visual system retains neuroplasticity. A failed screening is a warning signal; a comprehensive examination is what converts that signal into a diagnosis and, ultimately, into treatment such as corrective lenses, patching therapy or surgical intervention. When more than half of flagged children never receive that examination, screening programs lose much of their public health value. The pipeline breaks not at detection but at confirmation, and the children who fall out are disproportionately those whose families face financial strain or who have not been helped to understand why the follow-up matters.

The review also exposes a profound geographic imbalance in the evidence base itself. Most of the included studies targeted populations in high-income countries, leaving a critical data void in low- and middle-income countries, where the burden of uncorrected vision impairment among children is often greatest and where affordability constraints may be even more severe. Without studies from these settings, policymakers and health systems lack the evidence needed to design context-appropriate interventions. The authors frame this gap as one of the review’s central conclusions: the field knows a good deal about why families in wealthy countries miss referrals and almost nothing rigorous about the barriers in the parts of the world where vision loss is most likely to go unaddressed.

By anchoring their synthesis in a validated conceptual model, the authors argue they have created an evidence-based foundation for policy reforms and targeted interventions. The framework mapping suggests that interventions aimed at cost reduction, such as insurance coverage expansion, subsidies for examinations and eyeglasses, or no-cost follow-up programs, and those aimed at education, such as clearer communication of screening results, culturally tailored outreach and reminders that explain the consequences of untreated vision problems, should target the two dimensions with the strongest evidence behind them. It also implies that simply building more clinics or expanding geographic coverage, while valuable, would address the least frequently reported barrier and may not move the needle on adherence by itself.

The timing of this work is significant in the United States context, where the Affordable Care Act expanded insurance coverage for pediatric vision benefits, yet adherence gaps persist. Coverage on paper does not automatically translate into completed referrals, because awareness of benefits, understanding of screening results, and the practical friction of navigating appointments all operate independently of formal eligibility. This disconnect helps explain why affordability remains the most cited barrier even in health systems where some form of coverage exists: deductibles, copayments, the cost of glasses not fully covered by plans, and the income lost when a parent takes time off work all compound into a financial burden that falls hardest on families least equipped to absorb it.

The scoping review is part of a broader research program on adherence to pediatric eye care referrals, and the authors note that a companion review examining strategies to improve adherence is under separate review. Together, the two projects aim to close the loop between identifying barriers and testing solutions. For now, the message of the current review is unambiguous: the weakest link in pediatric vision care is not the screening itself but the social and economic terrain families must cross afterward. Ensuring that a child who fails a vision screening actually reaches an eye care professional requires treating affordability and awareness as first-order clinical problems, not as background noise. Until health systems do so, a majority of children flagged by screening will continue to walk away from the care that could protect their sight for a lifetime.

Subject of Research: Social risk factors associated with non-adherence to pediatric eye care referrals after abnormal vision screening findings

Article Title: Social risk factors associated with non-adherence to pediatric eye care referrals after abnormal vision screening findings: a scoping review

Article References: Social risk factors associated with non-adherence to pediatric eye care referrals after abnormal vision screening findings: a scoping review. (n.d.). https://doi.org/10.1186/s12887-026-07810-6

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07810-6

Keywords: vision screening, pediatric eye care, referral non-adherence, social determinants of health, affordability, health awareness, access to care, scoping review, amblyopia, Penchansky and Thomas model, health services research, low- and middle-income countries