Primary caregivers’ perspectives on referral compliance following school eye health screening in Eastern Nepal: a qualitative study of behavioral and health system barriers

Uncorrected refractive error (URE) is a major cause of visual impairment among school-aged children worldwide and represents an important public health concern. School-based vision screening programs aim to facilitate early detection and treatment; however, the effectiveness of these programs depends on caregiver compliance with referral recommendations. This study explored the perspectives of primary caregivers of school-aged children on referral compliance and non-compliance following school eye health screening in Eastern Nepal. A qualitative descriptive study was conducted in 2023 among 17 primary caregivers of children referred from school-based vision screening programs in Sunsari District and Biratnagar Metropolitan City, Nepal. Purposive sampling was used to recruit both referral-compliant and non-compliant caregivers. Seventeen semi-structured face-to-face interviews were conducted in Nepali. Interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed using inductive thematic analysis. Five key thematic domains were identified: (1) caregiver awareness of referral, (2) perceived motivators for referral compliance, (3) perceived barriers to referral compliance, (4) caregiver views on child eye health and treatment, and (5) Caregiver experiences and perceptions of eye-care services. Referral information was commonly described as being communicated indirectly through children, which sometimes limited caregiver understanding of the urgency of follow-up care. Among caregivers of non-compliant children, low perceived severity of visual problems, normalization of mild or asymptomatic symptoms, misconceptions regarding hereditary eye conditions, and logistical challenges such as travel distance and time constraints were described as barriers to follow-up. In contrast, recognition of children’s visual difficulties, concerns about academic performance, and perceived benefits of treatment motivated referral compliance. Structural barriers within the health system, including long waiting times and concerns about provider communication, also influenced care-seeking decisions. Referral compliance following school vision screening is influenced by an interplay of behavioral, informational, and health system factors. Strengthening direct communication between schools and caregivers, improving caregiver health literacy regarding childhood eye conditions, and addressing structural barriers within eye care services may enhance referral compliance. Integrating these strategies into school health programs may improve the effectiveness of vision screening initiatives and contribute to the prevention of avoidable childhood visual impairment in low-resource settings.