{"paper_id":"2d7cd476-7900-466d-b24f-b027b808ccd0","body_text":"Barriers of Pediatric Vision Screening in Saudi Arabia: A National Cross-Sectional Study of PHC Healthcare Providers' Perspective | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers of Pediatric Vision Screening in Saudi Arabia: A National Cross-Sectional Study of PHC Healthcare Providers' Perspective Yousef A. Alotaibi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9077237/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Pediatric vision screening is an essential preventive service for early detection of amblyopia, refractive errors, strabismus, and other childhood visual disorders. Despite its importance, implementation in primary healthcare (PHC) settings remains inconsistent, particularly in settings where provider training, referral systems, and family awareness may be limited. ​ Objective: To assess perceived barriers to pediatric vision screening among PHC healthcare providers in Saudi Arabia and to examine how these barriers vary according to provider characteristics and self-reported screening practices. ​ Methods: A national cross-sectional study was conducted among 1,215 healthcare providers working in PHC centers across Saudi Arabia. Data were collected using a structured self-administered questionnaire covering demographic and professional characteristics, prior training in pediatric vision screening, self-reported screening frequency, and nine perceived barrier items rated on a 5-point Likert scale. Exploratory factor analysis was used to identify underlying barrier domains. Independent t-tests, one-way analysis of variance, multivariate linear regression, and binary logistic regression were performed to assess associations between provider characteristics, barrier scores, and screening frequency. ​ Results: Three barrier domains were identified: system-level barriers (28.5% of explained variance), provider-level barriers (24.2%), and family-level barriers (15.7%), accounting collectively for 68.4% of total variance. The highest-rated individual barrier was lack of specific training in pediatric vision assessment (mean 4.41 ± 0.78). Providers with prior training reported significantly lower barriers across all domains. In multivariate analysis, professional role and prior training were the strongest predictors of overall perceived barriers. In logistic regression, provider-level barriers were the strongest predictor of low screening frequency (OR 2.85, 95% CI 1.85-4.39), followed by system-level barriers (OR 1.65, 95% CI 1.11-2.45) and family-level barriers (OR 1.42, 95% CI 1.01-1.99). ​ Conclusion: Pediatric vision screening in Saudi PHC settings is hindered by interrelated provider-, system-, and family-level barriers. Targeted training, improved referral pathways, adequate equipment, and enhanced parental awareness may strengthen screening uptake and support earlier detection of childhood visual disorders. Pediatric vision screening Primary healthcare Barriers Healthcare providers Saudi Arabia Childhood eye disorders Vision screening practices Primary care Figures Figure 1 1. Introduction Visual disorders of childhood (eg, refractive errors, amblyopia, strabismus, and other preventable or treatable causes of visual impairment) are significant public health issues because undetected conditions can negatively impact visual development as well as school readiness, learning capabilities, and quality of life. Early recognition is particularly crucial in the preschool years: methods of intervention that are initiated promptly can enhance visual outcomes and lessen the burden of avoidable impairment later in life ( 1 , 3 , 4 ). This makes vision screening during early childhood a leading preventive service. According to the U.S. Preventive Services Task Force, at least one screening should be conducted in children ages 3 to 5 years to detect amblyopia or its risk factors. Other professional bodies, such as the American Association for Pediatric Ophthalmology and Strabismus, also provide age-based screening recommendations for early detection and referral. ( 1 – 2 ) Newer recommendations further emphasize the need for screening programs to incorporate robust follow-up mechanisms, ensuring that children with failed screens obtain full dilated eye examinations and appropriate treatments ( 4 ). These recommendations notwithstanding, the implementation of pediatric vision screening in actual primary care is still irregular. Evidence from primary care and community settings suggests that uptake of screening may be influenced by insufficient training, inadequate access to appropriate tools, poor referral pathways, time pressure during routine visits, and a lack of clarity over how the service will be organized ( 5 – 9 ). Similarly, barriers at the family and community levels, like inadequate knowledge among parents about screening tests, poor communication with health providers, and lack of appropriate follow-up after negative screening results, can further hinder the comparability of screening programmes ( 7 , 9 , 10 ). Pediatric eye health is a growing priority in Saudi Arabia, though available evidence indicates significant shortfalls in awareness, access, and service delivery. ( 5 , 6 , 11 ) In recent years, the importance of prioritizing pediatric eye health provision in Saudi Arabia has been emphasized alongside strengthening school and community regional initiatives, as well as addressing deficits in existing childhood eye health services. ( 5 , 6 ) Similarly, one review focusing on Saudi children suggested that lack of such screening pathways or their partial implementation could be one factor contributing to a delay in the detection of amblyopia and other eye disorders ( 6 , 12 ). As the first-step facilities providing preventive child health services, primary healthcare centers are ideally placed to provide pediatric vision screening. Successful implementation of any of these approaches in PHC is highly contingent on the preparedness of frontline providers, especially general practitioners, nurses, and allied staff, in addition to the organizational environment in which they operate. ( 3 , 8 , 9 ) Provider-perceived barriers are especially relevant in Saudi Arabia due to the potential impact of a national PHC-based approach on early detection through adequate training, equipment, and public awareness if referral systems were established ( 5 , 6 , 13 ). Despite prior studies focusing on childhood eye care needs, parental perspectives, and service gaps in Saudi Arabia, there is limited nationally-representative evidence investigating barriers to pediatric vision screening from the perspective of PHC providers themselves ( 6 , 7 , 11 , 12 ). Recognizing these hurdles is critical, as targeted efforts to bolster provider capacity and screening workflows will support timely access to equitable pediatric eye care ( 4 , 9 , 13 ). Thus, this study aimed to investigate the barriers primary healthcare providers (HCPs) in Saudi Arabia face in pediatric vision screening and how these barriers differ by provider characteristics and vision screening practices. 2. METHODOLOGY 2.1 Study setting and design The study was conducted among PHC providers in Saudi Arabia, where PHC settings are the first level of focal point for early identification and screening of pediatric vision problems. 2.2 Study population The target population included healthcare professionals involved in child health services or working in PHC settings where pediatric vision screening is expected. Based on the study's categories, the surveyed providers included general practitioners, nurses, optometrists/ophthalmologists, and health educators or other allied healthcare staff. Eligible participants were healthcare providers currently employed at PHC centers in Saudi Arabia who were willing to complete the study questionnaire. For the final analysis, we excluded those who were not practicing in PHC, did not complete the response, or refused to participate. A total of 1,215 health care providers were included in the study analysis. 2.3 Sampling and sample size They were recruited from all over Saudi Arabia to a national sample of primary health care providers that would broadly represent the provider characteristics and settings of practice. The final sample featured 1,215 participants. Data up to October 2023 were used to train the model. 2.4 Data collection A structured, self-administered questionnaire was used, designed to capture demographic and professional characteristics, prior training in pediatric vision screening, self-reported screening practices, and perceived barriers to screening. The questionnaire included items on gender, age group, professional role, educational level, years of experience, PHC center location, and previous formal training in pediatric vision screening. Perceived barriers were measured as nine items with a score from 1 to 5 in the range of a 5-point Likert scale (1 = not a barrier). Three conceptual domains covered: barriers to providers, systems, and patients/families. Provider-related barriers included a lack of training specifically related to pediatric vision assessment, low perceived efficacy in using the screening tool, and forgetting to cross-screen during busy clinics. System factors included a lack of clear referral pathways, limited time for work-ups in well-child visits, and a lack of screening tools and family and provider-related problems 2.5 Validity and construct assessment The barrier items were examined using an exploratory factor analysis (EFA) to evaluate the questionnaire's underlying construct structure. Kaiser-Meyer-Olkin was 0.89 and p < 0.01, indicating sufficient correlation between variables for factor analysis. It is significant if (p < 0.001), indicating the correlation matrix was suitable for factor extraction. The nine barrier items were explored using principal component analysis with Varimax rotation, which revealed a three-factor structure and accounted for 68.4% of the variance. The barriers were system-level (28.5%), provider-level (24.2%), and family-level (15.7%). System-level barriers included unclear referral pathways, insufficient visit time, and a lack of equipment. Provider-level barriers included a lack of training, low confidence in the use of tools, and forgetting to screen. Family-level barriers included guardians' lack of awareness, child noncompliance, and language issues. 2.6 Study variables The main outcome was the assessed burden of barriers to pediatric vision screening, characterized using individual barrier scores, an average domain-mean, and an overall mean barrier score. The second outcome was the reported frequency of pediatric vision screening, categorized as routine or low, for binary logistic regression. The independent variables included gender, age, professional role (doctor or nurse), years of experience, PHC location, and prior pediatrician screening training. 2.7 Data analysis Data were entered, cleaned, and analyzed using standard statistical procedures using STATA BE, version 19, 2025. Participant characteristics and questionnaire responses were summarized using descriptive statistics. Frequencies and percentages were used for categorical variables. Means and standard deviations were used for continuous variables. The mean scores for barrier domains were compared across provider characteristics using independent-samples t-tests and ANOVA. Professional role, prior training status, and PHC center location were among the key grouping variables examined in bivariate analysis. A p-value is considered statistically significant when less than 0.05. To identify independent predictors of overall perceived barriers, multivariate linear regression analysis was performed. The dependent variables was the composite overall mean barrier score. Independent variable: gender, age, professional role, number of years they had worked in PHC, and their previous training status. Regression coefficients, standardized beta values, 95% confidence intervals, and p-values were reported. To examine whether perceived barriers were associated with screening behavior, binary logistic regression analysis was conducted. The dependent variable was low screening frequency coded as 1 for providers who reported screening \"rarely\" or \"never\" and 0 for those who screened \"always\" or \"usually\"—primary barriers related to system-level, provider-level, and family-level predictors. The model controlled for professional role, experience, and previous exposure to pediatric vision screening. Associations were quantified with odds ratios, and 95% confidence intervals, and p-values. 3. RESULTS 3.1 Generaal characteristics: A total of 1,215 healthcare providers working in Primary Healthcare (PHC) centers across Saudi Arabia participated in the study (Table 1 ). The majority of participants were female (n = 802, 66.0%) and aged 30–39 years (n = 511, 42.1%). In terms of professional role, general practitioners constituted the largest group (n = 448, 36.9%), followed closely by nurses (n = 425, 35.0%). Most participants held a bachelor's degree (n = 704, 58.0%) and had more than 10 years of professional experience (n = 485, 39.9%). A significant proportion worked in urban centers (n = 851, 70.0%). Among those with prior training, only 279 (23.0%) had received formal pediatric vision screening training. Table 1 General Characteristics of Healthcare Providers (N = 1215) Characteristic Category Frequency (n) Percentage (%) Gender Male 413 34.0 Female 802 66.0 Age Group (years) 20–29 316 26.0 30–39 511 42.1 40–49 267 22.0 50 and above 121 10.0 Professional Role General Practitioner (GP) 448 36.9 Nurse 425 35.0 Optometrist / Ophthalmologist 97 8.0 Health Educator / Other 245 20.2 Educational Level Diploma 292 24.0 Bachelor's Degree 704 58.0 Postgraduate Degree (Master's/PhD) 219 18.0 Years of Experience Less than 5 years 351 28.9 5–10 years 379 31.2 More than 10 years 485 39.9 PHC Center Location Urban 851 70.0 Rural 364 30.0 Prior Training in Pediatric Vision Screening Yes 279 23.0 No 936 77.0 3.2 Barriers to Pediatric Vision Screening Participants rated the significance of various barriers on a 5-point Likert scale (1 = Not a barrier to 5 = Major barrier). The mean scores for each barrier item, grouped by domain, are presented in Table 2 . Among all items, \"Lack of specific training in pediatric vision assessment\" had the highest mean score (4.41 ± 0.78), indicating it was perceived as the most significant barrier. This was followed by \"Lack of clear referral pathways and protocols\" (4.28 ± 0.85) and \"Inadequate time during well-child visits\" (4.19 ± 0.91). Barriers related to parental cooperation, such as \"parental lack of awareness about the importance of vision screening\" (4.11 ± 0.88), were also highly rated. Table 2 Descriptive Analysis of Perceived Barriers to Pediatric Vision Screening Barrier Domain / Item Mean (SD) Provider-Related Barriers Lack of specific training in pediatric vision assessment 4.41 (0.78) Low confidence in using screening tools 4.02 (0.95) Forgetting to screen during busy clinics 3.85 (1.02) System-Related Barriers Lack of clear referral pathways and protocols 4.28 (0.85) Inadequate time during well-child visits 4.19 (0.91) Shortage of appropriate screening equipment 3.98 (1.10) Patient/Family-Related Barriers Parental lack of awareness about importance of screening 4.11 (0.88) Child's uncooperative behavior during screening 3.75 (1.05) Language barriers with parents 3.42 (1.15) *SD: Standard Deviation. Scale: 1 = Not a barrier, 5 = Major barrier.* 3.3 Factor Analysis of Barrier Items We used exploratory factor analysis (EFA) to go beyond mere descriptive accounts of the barrier items and better understand their deeper relationships (Table 3 ). Further statistical checks ratified that our data were ideally suited for this type of analysis, with a Kaiser-Meyer-Olkin measure of 0.89. The strongest predictor was System-Level Barriers, which accounted for the greatest proportion of variance (28.5%). Second, Provider-Level Barriers accounted for 24.2% of the variance. The third factor was labeled Family-Level Barriers, accounting for a still-substantial 15.7% of the variance. The framework laid out here is useful for designing focused interventions at a granular level. For example, addressing system-level barriers might require policy changes and resource allocation, while tackling provider-level barriers calls for enhanced training programs. This validated framework will guide subsequent analysis as we explore how these barrier domains differ across provider groups. Table 3 Factor Analysis of Perceived Barriers to Pediatric Vision Screening Barrier Item Factor 1: System-Level Barriers Factor 2: Provider-Level Barriers Factor 3: Family-Level Barriers Lack of clear referral pathways 0.82 0.21 0.15 Inadequate time during visits 0.79 0.28 0.10 Shortage of appropriate equipment 0.75 0.18 0.22 Lack of specific training 0.19 0.85 0.14 Low confidence in using tools 0.24 0.81 0.19 Forgetting to screen 0.31 0.68 0.25 Parental lack of awareness 0.18 0.20 0.83 Child's uncooperative behavior 0.12 0.25 0.77 Language barriers 0.29 0.11 0.70 Eigenvalue 3.82 2.51 1.93 Variance Explained (%) 28.5 24.2 15.7 Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. 3.4 Association Between Provider Characteristics and Perceived Barriers We compared the mean scores across the three barrier domains (System-Level, Provider-Level, and Family-Level) for different provider characteristics using independent t-tests and a one-way ANOVA. The results are summarized in Table 4 . Significant differences were observed across professional roles for all three barrier domains (p < 0.001). Providers who had received prior training in pediatric vision screening reported significantly lower barriers across all domains compared to those without training. The most pronounced difference was observed in the Provider-Level domain, where trained providers scored significantly lower (Mean = 3.65, SD = 0.81) than untrained providers (Mean = 4.21, SD = 0.68; t = -8.94, p < 0.001). Significant differences were also observed for System-Level (t = -2.11, p = 0.035) and Family-Level barriers (t = -2.01, p = 0.045). Practice between urban and rural areas across the three barrier domains was not significant (p > 0.05 for all). Table 4 Comparison of Mean Barrier Domain Scores by Provider Characteristics Characteristic Category System-Level Barriers Mean (SD) Provider-Level Barriers Mean (SD) Family-Level Barriers Mean (SD) Professional Role General Practitioner (GP) 4.18 (0.65) 4.15 (0.70) 3.89 (0.68) Nurse 4.25 (0.70) 4.22 (0.72) 3.95 (0.71) Optometrist/Ophthalmologist 3.45 (0.88) 3.38 (0.85) 3.41 (0.79) Health Educator/Other 3.98 (0.72) 3.91 (0.75) 3.75 (0.73) F-value (p-value) 25.41 (< 0.001) 28.15 (< 0.001) 12.87 (< 0.001) Prior Training Yes 4.01 (0.79) 3.65 (0.81) 3.71 (0.76) No 4.15 (0.72) 4.21 (0.68) 3.84 (0.72) t-value (p-value) *-2.11 (0.035)* *-8.94 (< 0.001)* *-2.01 (0.045)* PHC Location Urban 4.11 (0.74) 4.08 (0.75) 3.80 (0.73) Rural 4.14 (0.76) 4.11 (0.78) 3.83 (0.75) t-value (p-value) *-0.58 (0.562)* *-0.62 (0.536)* *-0.51 (0.610)* 3.5 Predictors of Overall Perceived Barriers: A multivariate regression was performed to test the independent predictors of the total score of perceived barriers. The complete results of this analysis are presented in Table 5 . Overall Model Fit The regression model was statistically significant (F(7, 1207) = 32.45, p < 0.001), indicating that the set of predictor variables, as a whole, reliably distinguished between providers with higher and lower perceived barrier scores. The model explained approximately 18.5% of the variance in overall barrier perceptions (Adjusted R² = 0.185). Professional Role as a Powerful Predictor The professional role was one of the strongest and most significant predictors. Being a GP was significantly associated with the total barrier score (unstandardised B = 0.62, standardized beta [β] = 0.45, p < 0.001, 95% CI: 0.47–0.77). The Protective Effect of Prior Training The most actionable finding relates to the role of prior training in pediatric vision screening. After controlling for professional role, experience, and all other variables, having received formal training emerged as a strong, negative predictor of overall barrier scores (Unstandardized B = -0.52, β = -0.38, p < 0.001, 95% CI: -0.63 to -0.41). The negative coefficient indicates that trained providers perceive significantly fewer barriers than their untrained counterparts. The standardized beta of -0.38 represents a moderate-to-large effect, comparable in magnitude (though opposite in direction) to the effect of being a GP or nurse—Table 4 . 3.6 Association Between Barrier Domains and Self-Reported Screening Practice A binary logistic regression analysis, adjusted for professional role, years of experience, and prior training, revealed that the predictor variables reliably distinguished between providers who screen routinely and those who do not (χ² = 98.45, p < 0.001), explaining approximately 24% of the variance in screening frequency (Table 6 ). Of the three barrier domains, provider-Level barriers was identified as a strong predictor of infrequent screening. For each one-unit increase in this domain, the odds of a provider being categorized as belonging to the \"Rarely/Never\" screening group were 2.85 times higher (p < 0.001), which signified low self-efficacy and training. This makes sense statistically, so each increase in the right direction provides greater odds that screening was not frequent (OR = 1.65, p = 0.012), which confirms structural challenges, such as lack of time or equipment, prevent even many motivated providers from obtaining screening for their patients. Imagine a dedicated GP who has received training and feels confident in her screening abilities. She wants to screen every child who comes through her door. However, if her clinic lacks the appropriate equipment, if her appointments are scheduled every ten minutes with no flexibility, and if she has no clear pathway for referring a child who fails the screening, her motivation will eventually hit a wall. The system itself becomes a barrier that no amount of individual confidence can overcome. Our data suggest that for every incremental increase in the severity of these system-level challenges, the likelihood of screening drops by 65%. Family-Level Barriers: The Interpersonal Dimension Family barriers were also significantly associated with lower screening frequency, although the effect size was more modest. The odds of being in the \"Rarely/Never\" screening group increased by 42% (OR = 1.42, 95% CI: 1.01 to 1.99, p = 0.041). Family barriers are identified as parents' unawareness of vision screening ( odds ratio of 1.42). Table 5 Multivariate Linear Regression Analysis for Predictors of Overall Perceived Barriers Variable Category Unstandardized B Standardized Beta (β) t p-value 95% CI for B (Constant) 3.25 28.10 < 0.001 (3.02, 3.48) Gender Male (Ref: Female) 0.04 0.02 0.71 0.478 (-0.07, 0.15) Age Group (Continuous, in years) 0.02 0.03 0.95 0.342 (-0.02, 0.06) Professional Role GP (Ref: Optometrist) 0.62 0.45 8.15 < 0.001 (0.47, 0.77) Nurse (Ref: Optometrist) 0.68 0.51 9.02 < 0.001 (0.53, 0.83) Health Educator (Ref: Optometrist) 0.31 0.19 3.55 < 0.001 (0.14, 0.48) Experience (Continuous, in years) -0.01 -0.02 -0.65 0.516 (-0.04, 0.02) Location Rural (Ref: Urban) 0.05 0.03 1.10 0.271 (-0.04, 0.14) Prior Training Yes (Ref: No) -0.52 -0.38 -8.91 < 0.001 (-0.63, -0.41) Dependent Variable: Overall Mean Barrier Score. CI: Confidence Interval. Ref: Reference Category. 3.6 Association Between Barrier Domains and Self-Reported Screening Practice: Binary Logistic Regression Analysis The logistic regression model was significant (χ²=98.45, p < 0.001), confirming that perceived barriers distinguish between routine and low-frequency screeners. Provider-Level barriers proved the strongest predictor: for every one-unit increase, providers were nearly three times more likely to rarely or never screen (OR = 2.85, p < 0.001). This captures the human reality that a provider who lacks confidence or training is far more likely to skip screening altogether. System-Level barriers also independently predicted low screening frequency (OR = 1.65, p = 0.012), meaning even motivated providers cannot overcome structural challenges like time constraints or equipment shortages. Family-Level barriers showed a modest but significant effect (OR = 1.42, p = 0.041). Together, these findings reveal that improving screening rates requires addressing not only provider confidence and competence, but also the systems they work within and the families they serve. Table 6 Binary Logistic Regression for Predictors of Low Screening Frequency (Rarely/Never Screen) Predictor Domain B S.E. Wald df p-value Odds Ratio (OR) 95% CI for OR System-Level Barriers Score 0.50 0.20 6.25 1 0.012 1.65 (1.11, 2.45) Provider-Level Barriers Score 1.05 0.22 22.77 1 < 0.001 2.85 (1.85, 4.39) Family-Level Barriers Score 0.35 0.17 4.18 1 0.041 1.42 (1.01, 1.99) Constant -4.12 0.58 50.45 1 < 0.001 0.02 *Dependent Variable: Screening Frequency (0 = Always/Usually, 1 = Rarely/Never). The model was adjusted for professional role, experience, and prior training.* Exploratory factor analysis of the nine barrier items identified a clear three-factor structure, accounting for 68.4% of the total variance. Facilities-level barriers (44.7%) include a lack of clear referral pathways, insufficient visit time, and inadequate equipment. Provider-level barriers (24.2%) were a lack of specialized training, low confidence in screening tools, and forgetfulness to screen; 15.7% were family-level barriers (Fig. 1 ). 4. Discussion This national cross-sectional study provides important evidence on the barriers to pediatric vision screening among PHC healthcare providers in Saudi Arabia. The findings show that barriers to screening are multidimensional, clustering into provider-level, system-level, and family-level domains, with provider-related barriers emerging as both highly rated and the strongest predictor of low screening frequency. These findings are consistent with studies that childhood vision screening in primary care is often constrained by limited training and inadequate confidence ( 14 – 17 ). The lack of training in assessing vision in pediatric patients was the most common individual barrier, whereas prior training was associated with lower overall barriers. This aligns with recent evidence. A recent study in Saudi Arabia reported pediatricians may have reasonable baseline knowledge ( 18 ). A 19 PHC-based study from the Qassim region ( 19 ). There is a significant association between provider-level barriers and low screening frequency. This finding is allied with recent results ( 14 , 16 ). Practice implications of these results include the need to move from instruction in training programs toward the development of actual skills, validation, and competency ( 15 , 16 ). Systemic barriers contributed to a decrease in conductance frequency. These findings are strongly supported by recent evidence showing that screening programs are less effective when referral pathways are fragmented and when services lack mechanisms for timely referral completion and feedback. Updated recommendations for preschool vision screening emphasize that screening cannot improve outcomes unless systems are in place to ensure rescreening when needed, referral for confirmatory examination, and communication of results to relevant stakeholders. ( 15 ) Likewise, recent analyses of pediatric eye care delivery have highlighted that even when screening is performed, many children fail to receive follow-up care because of poor referral coordination, transportation barriers, cost, and limited access to eye care professionals. ( 16 , 17 ) The present findings also underscore the importance of family-level barriers. Parental lack of awareness, child uncooperative behavior, and language barriers were all relevant in the current study, and family-level barriers remained independently associated with reduced screening frequency after adjustment. This is consistent with evidence showing that screening effectiveness depends heavily on parental understanding of the purpose of screening and the need for follow-up when a child fails. Previous work has identified parental unawareness of failed screening as a major barrier to follow-up ophthalmic care. At the same time, recent research has similarly emphasized parental concerns, delays in seeking help, and the need for greater public awareness of children's eye health ( 17 , 20 ). These suggest family education strategies, culturally-sensitive communication, and accessible referral support. One of the more relevant contributions of this study is the noted variability across professional roles. PHC physicians and nurses must balance vision screening against many competing preventive and treatment priorities. Recent Saudi consensus work has emphasized the need to integrate optometrists more effectively into primary care and to expand workforce capacity for pediatric eye services, findings that directly support the current findings ( 21 ). These data therefore suggest that national strategies should be tailored to the professional realities of PHC teams, with targeted upskilling of general practitioners and nurses and stronger access to specialist support when needed. Another interesting finding was that although they had been previously associated with higher barrier scores, gender, age, years of experience, and urban/rural location were not significant predictors in a multivariable model for overall barrier scores. It appears that the obstacles to pediatric vision screening in Saudi Arabia are more related to structural readiness, training, and responsibilities than provider demographics. The limited urban-rural differences imply that the barriers highlighted in this work are purely systemic and at a national level rather than being driven by point-specific areas. This is backed by Saudi literature that illustrated the existence of key gaps in childhood eye care services available as well as regional discrepancies in the availability of such services despite their general acceptability, thereby calling for harmonized national-level planning instead of piecemeal local-based interventions ( 22 , 23 ). The three factors — provider, system, and family — supplementary interventions should bolster all three at once. The benefits of this comprehensive strategy lie at the core of the integrated, people-centered eye care model ( 24 ), emphasizing that effective screening depends on clinical expertise, organizational effectiveness, and family involvement. Limitations The study is a cross-sectional survey, limiting causal generalizability, but informative for future research focused on implementation. Conclusion This study highlights that pediatric vision screening in Saudi PHC settings is shaped by a combination of provider, system, and family factors, with provider-level barriers exerting the strongest influence on screening behavior. The findings suggest that the most effective response will be a comprehensive strategy that combines training, workflow redesign, equipment provision, referral strengthening, and family-centered communication. Such a strategy could improve the consistency of pediatric vision screening in PHC centers and support earlier identification and management of childhood visual disorders across Saudi Arabia. Declarations Ethics approval and consent to participate: Participation in this study was voluntary, and all healthcare providers completed the questionnaire after agreeing to participate. The institutional review board waived ethical approval for this study. The study was conducted in accordance with the Declaration of Helsinki. Consent for publication : Not applicable. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: No Funding declaration : Funded by the Deanship of Research and Graduate Studies at King Khalid University, KSA, for funding this work through the General Research Project under grant number (GRP/98/46) Authors’ contributions: This is a single author work, all the manuscript was done by the author himself. Acknowledgements: The author extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University, KSA, for funding this work through the General Research Project under grant number (GRP/98/46). 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Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. J Am Association Pediatr Ophthalmol Strabismus. 2013;17(4):385–90. Alghamdi MA, Almustanyir A, Alshuimi AA, Alrasheed SH, Alabdulkader B, Alanazi M, Altoaimi BH, Bin Dulaym M, Alsamnan LY, Alghamdi W. Prioritizing Pediatric Eye Care in Saudi Arabia: A National Delphi Consensus Study. InHealthcare 2025 Sep 29 (Vol. 13, No. 19, p. 2467). MDPI. Challa NK. Prevalence of amblyopia among the children of Saudi Arabia: A systematic review, 1990–2020. Afr Vis Eye Health. 2022;81(1):a752. https://doi.org/10.4102/aveh.v81i1.752​ . Lee L, Moo E, Angelopoulos T, Yashadhana A. Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings. PLoS ONE. 2023;18(1):e0278969. 10.1371/journal.pone.0278969 . PMID: 36656849; PMCID: PMC9851534. Killeen OJ, Saylor KM, Hogan C, Jacobson A, Collins M, Ehrlich JR. Barriers and facilitators of vision screening in the US pediatric primary care setting: a mixed methods systematic review protocol. JBI Evid Synth. 2023;21(5):985–992. 10.11124/JBIES-22-00026 . PMID: 36598114. Pang Y, Lyons SA, Nottingham Chaplin PK, Block SS, Fishman D, Ciner EB, Advisory Committee to the National Center for Children’s Vision and Eye Health at Prevent Blindness. Recommended practices for vision screening in pre-school-age children: A 2025 update. Optom Vis Sci. 2025;102(10):589–95. Epub ahead of print. PMID: 40892439; PMCID: PMC12520030. Ambrosino C, Dai X, Antonio Aguirre B, Collins ME. Pediatric and School-Age Vision Screening in the United States: Rationale, Components, and Future Directions. Child (Basel). 2023;10(3):490. 10.3390/children10030490 . PMID: 36980048; PMCID: PMC10047420. Su Z, Marvin EK, Wang BQ, van Zyl T, Elia MD, Garza EN, Salchow DJ, Forster SH. Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385 – 90. 10.1016/j.jaapos.2013.05.008 . PMID: 23993718. Alzuhairy S, Alsugair M, Alqubays M, Alzuhayri MA, Alsugair AM. Knowledge, Attitude, and Practice of Pediatricians for Eye Care of Children: A Personal Survey in Saudi Arabia. Cureus. 2024;16(9):e69630. 10.7759/cureus.69630 . PMID: 39429368; PMCID: PMC11487455. AlHarkan DH, AlRubaysh NS, Aldekhail MI, Alayidi SA, Alashgar MS, Almishali FF. Knowledge, Attitude, and Practice Regarding Vision and Eye Screening of Preschool Children Among Primary Health Center Staff in the Qassim Region, Saudi Arabia. Cureus. 2024;16(1):e52743. 10.7759/cureus.52743 . PMID: 38406065; PMCID: PMC10884783. Al Musalami SN, Al Qasim RJ, Alshuhayb BS, Al-Somali AI. Insights into parental perspectives: Children's eye care in Saudi Arabia. Heliyon. 2025;11(1). Alghamdi MA, Almustanyir A, Alshuimi AA, Alrasheed SH, Alabdulkader B, Alanazi M, Altoaimi BH, Bin Dulaym M, Alsamnan LY, Alghamdi W. Prioritizing Pediatric Eye Care in Saudi Arabia: A National Delphi Consensus Study. Healthc (Basel). 2025;13(19):2467. 10.3390/healthcare13192467 . PMID: 41095553; PMCID: PMC12523716. Aldhabaan W, Alkhammash ZM, Al Zomia AS, Alshahrani Y, Asiri R, Alqhtani MM, Alnahdi W, Alqahtani Y, Alqahtani S, Asiri A, Asiri B. Knowledge and practices of child eye healthcare among parents in Aseer Region, Saudi Arabia. Cureus. 2022;14(10):e30404. Al-Atawi S. Eye Health Awareness and School-Based Screening in Saudi Schools: A Systematic Literature Review. Clin Optom (Auckl). 2026;18:1–21. PMID: 41551543; PMCID: PMC12812045. Lee L, Moo E, Angelopoulos T, Yashadhana A. Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings. PLoS ONE. 2023;18(1):e0278969. 10.1371/journal.pone.0278969 . PMID: 36656849; PMCID: PMC9851534. Additional Declarations No competing interests reported. Supplementary Files Questionnaire.pdf floatimage1.png Grahic abstract Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 28 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers invited by journal 27 Apr, 2026 Editor assigned by journal 23 Apr, 2026 Editor invited by journal 02 Apr, 2026 Submission checks completed at journal 01 Apr, 2026 First submitted to journal 01 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9077237\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":634157060,\"identity\":\"7d24f9d1-8ba0-4e50-8176-0f3cbfee2fe4\",\"order_by\":0,\"name\":\"Yousef A. Alotaibi\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACgwPMDUBKIoGNvY0ZJMDYQFgLUM0BkBaeY0RqkWwAa2FIYJBII1ILP/vBxscfaizy+CSfJRvzMNjIbjjA/vADPi1sPInNBgeOSRSzSacdTuZhSDPecIDHWAKvFobENokDbBKJbdLpzYd5GA4nArUw4NfC/xCo5R9Qi+RxkJb/QC3sj3/g1QJULHGwDUSygRx2AKiFwQy/LRIPmw3O9gH9wpOWbDjHINl45mEeMwv8Dks++KDiW12efPsxY4k3FXayfcfbH9/ApwUNGAAxMwnqR8EoGAWjYBRgBwAMpkjdkezmBwAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"King Khalid University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Yousef\",\"middleName\":\"A.\",\"lastName\":\"Alotaibi\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-09 22:53:27\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9077237/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9077237/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108630585,\"identity\":\"2793ef3f-7a52-49d3-aa94-1ba789a33170\",\"added_by\":\"auto\",\"created_at\":\"2026-05-06 16:38:06\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":452855,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003econceptual framework of barriers domains\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9077237/v1/37661f153ad72bace11cdf72.png\"},{\"id\":108805954,\"identity\":\"91d3c5c4-92ee-4fc8-8fd3-f9103f3fb0dd\",\"added_by\":\"auto\",\"created_at\":\"2026-05-08 15:27:17\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":865360,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9077237/v1/435bf3eb-e138-4330-819d-85c365009611.pdf\"},{\"id\":108630587,\"identity\":\"9be70fd5-5682-4d38-853b-4ab13b1f092b\",\"added_by\":\"auto\",\"created_at\":\"2026-05-06 16:38:06\",\"extension\":\"pdf\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":125784,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Questionnaire.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9077237/v1/f7d451e60fee63231b7702ad.pdf\"},{\"id\":108630586,\"identity\":\"9f17b183-808f-4ff1-9523-45e6e1ad24ac\",\"added_by\":\"auto\",\"created_at\":\"2026-05-06 16:38:06\",\"extension\":\"png\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":1163683,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eGrahic abstract\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9077237/v1/9fbe80725ca77473f362cc57.png\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Barriers of Pediatric Vision Screening in Saudi Arabia: A National Cross-Sectional Study of PHC Healthcare Providers' Perspective\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eVisual disorders of childhood (eg, refractive errors, amblyopia, strabismus, and other preventable or treatable causes of visual impairment) are significant public health issues because undetected conditions can negatively impact visual development as well as school readiness, learning capabilities, and quality of life. Early recognition is particularly crucial in the preschool years: methods of intervention that are initiated promptly can enhance visual outcomes and lessen the burden of avoidable impairment later in life (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThis makes vision screening during early childhood a leading preventive service. According to the U.S. Preventive Services Task Force, at least one screening should be conducted in children ages 3 to 5 years to detect amblyopia or its risk factors. Other professional bodies, such as the American Association for Pediatric Ophthalmology and Strabismus, also provide age-based screening recommendations for early detection and referral. (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) Newer recommendations further emphasize the need for screening programs to incorporate robust follow-up mechanisms, ensuring that children with failed screens obtain full dilated eye examinations and appropriate treatments (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThese recommendations notwithstanding, the implementation of pediatric vision screening in actual primary care is still irregular. Evidence from primary care and community settings suggests that uptake of screening may be influenced by insufficient training, inadequate access to appropriate tools, poor referral pathways, time pressure during routine visits, and a lack of clarity over how the service will be organized (\\u003cspan additionalcitationids=\\\"CR6 CR7 CR8\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Similarly, barriers at the family and community levels, like inadequate knowledge among parents about screening tests, poor communication with health providers, and lack of appropriate follow-up after negative screening results, can further hinder the comparability of screening programmes (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003ePediatric eye health is a growing priority in Saudi Arabia, though available evidence indicates significant shortfalls in awareness, access, and service delivery. (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e) In recent years, the importance of prioritizing pediatric eye health provision in Saudi Arabia has been emphasized alongside strengthening school and community regional initiatives, as well as addressing deficits in existing childhood eye health services. (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e) Similarly, one review focusing on Saudi children suggested that lack of such screening pathways or their partial implementation could be one factor contributing to a delay in the detection of amblyopia and other eye disorders (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eAs the first-step facilities providing preventive child health services, primary healthcare centers are ideally placed to provide pediatric vision screening. Successful implementation of any of these approaches in PHC is highly contingent on the preparedness of frontline providers, especially general practitioners, nurses, and allied staff, in addition to the organizational environment in which they operate. (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e) Provider-perceived barriers are especially relevant in Saudi Arabia due to the potential impact of a national PHC-based approach on early detection through adequate training, equipment, and public awareness if referral systems were established (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eDespite prior studies focusing on childhood eye care needs, parental perspectives, and service gaps in Saudi Arabia, there is limited nationally-representative evidence investigating barriers to pediatric vision screening from the perspective of PHC providers themselves (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Recognizing these hurdles is critical, as targeted efforts to bolster provider capacity and screening workflows will support timely access to equitable pediatric eye care (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Thus, this study aimed to investigate the barriers primary healthcare providers (HCPs) in Saudi Arabia face in pediatric vision screening and how these barriers differ by provider characteristics and vision screening practices.\\u003c/p\\u003e\"},{\"header\":\"2. METHODOLOGY\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.1 Study setting and design\\u003c/h2\\u003e \\u003cp\\u003eThe study was conducted among PHC providers in Saudi Arabia, where PHC settings are the first level of focal point for early identification and screening of pediatric vision problems.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.2 Study population\\u003c/h2\\u003e \\u003cp\\u003eThe target population included healthcare professionals involved in child health services or working in PHC settings where pediatric vision screening is expected. Based on the study's categories, the surveyed providers included general practitioners, nurses, optometrists/ophthalmologists, and health educators or other allied healthcare staff.\\u003c/p\\u003e \\u003cp\\u003eEligible participants were healthcare providers currently employed at PHC centers in Saudi Arabia who were willing to complete the study questionnaire. For the final analysis, we excluded those who were not practicing in PHC, did not complete the response, or refused to participate. A total of 1,215 health care providers were included in the study analysis.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.3 Sampling and sample size\\u003c/h2\\u003e \\u003cp\\u003eThey were recruited from all over Saudi Arabia to a national sample of primary health care providers that would broadly represent the provider characteristics and settings of practice. The final sample featured 1,215 participants. Data up to October 2023 were used to train the model.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.4 Data collection\\u003c/h2\\u003e \\u003cp\\u003eA structured, self-administered questionnaire was used, designed to capture demographic and professional characteristics, prior training in pediatric vision screening, self-reported screening practices, and perceived barriers to screening. The questionnaire included items on gender, age group, professional role, educational level, years of experience, PHC center location, and previous formal training in pediatric vision screening.\\u003c/p\\u003e \\u003cp\\u003ePerceived barriers were measured as nine items with a score from 1 to 5 in the range of a 5-point Likert scale (1\\u0026thinsp;=\\u0026thinsp;not a barrier). Three conceptual domains covered: barriers to providers, systems, and patients/families. Provider-related barriers included a lack of training specifically related to pediatric vision assessment, low perceived efficacy in using the screening tool, and forgetting to cross-screen during busy clinics. System factors included a lack of clear referral pathways, limited time for work-ups in well-child visits, and a lack of screening tools and family and provider-related problems\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.5 Validity and construct assessment\\u003c/h2\\u003e \\u003cp\\u003eThe barrier items were examined using an exploratory factor analysis (EFA) to evaluate the questionnaire's underlying construct structure. Kaiser-Meyer-Olkin was 0.89 and p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01, indicating sufficient correlation between variables for factor analysis. It is significant if (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), indicating the correlation matrix was suitable for factor extraction.\\u003c/p\\u003e \\u003cp\\u003eThe nine barrier items were explored using principal component analysis with Varimax rotation, which revealed a three-factor structure and accounted for 68.4% of the variance. The barriers were system-level (28.5%), provider-level (24.2%), and family-level (15.7%). System-level barriers included unclear referral pathways, insufficient visit time, and a lack of equipment. Provider-level barriers included a lack of training, low confidence in the use of tools, and forgetting to screen. Family-level barriers included guardians' lack of awareness, child noncompliance, and language issues.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.6 Study variables\\u003c/h2\\u003e \\u003cp\\u003eThe main outcome was the assessed burden of barriers to pediatric vision screening, characterized using individual barrier scores, an average domain-mean, and an overall mean barrier score. The second outcome was the reported frequency of pediatric vision screening, categorized as routine or low, for binary logistic regression. The independent variables included gender, age, professional role (doctor or nurse), years of experience, PHC location, and prior pediatrician screening training.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.7 Data analysis\\u003c/h2\\u003e \\u003cp\\u003eData were entered, cleaned, and analyzed using standard statistical procedures using STATA BE, version 19, 2025. Participant characteristics and questionnaire responses were summarized using descriptive statistics. Frequencies and percentages were used for categorical variables. Means and standard deviations were used for continuous variables.\\u003c/p\\u003e \\u003cp\\u003eThe mean scores for barrier domains were compared across provider characteristics using independent-samples t-tests and ANOVA. Professional role, prior training status, and PHC center location were among the key grouping variables examined in bivariate analysis. A p-value is considered statistically significant when less than 0.05.\\u003c/p\\u003e \\u003cp\\u003eTo identify independent predictors of overall perceived barriers, multivariate linear regression analysis was performed. The dependent variables was the composite overall mean barrier score. Independent variable: gender, age, professional role, number of years they had worked in PHC, and their previous training status. Regression coefficients, standardized beta values, 95% confidence intervals, and p-values were reported.\\u003c/p\\u003e \\u003cp\\u003eTo examine whether perceived barriers were associated with screening behavior, binary logistic regression analysis was conducted. The dependent variable was low screening frequency coded as 1 for providers who reported screening \\\"rarely\\\" or \\\"never\\\" and 0 for those who screened \\\"always\\\" or \\\"usually\\\"\\u0026mdash;primary barriers related to system-level, provider-level, and family-level predictors. The model controlled for professional role, experience, and previous exposure to pediatric vision screening. Associations were quantified with odds ratios, and 95% confidence intervals, and p-values.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"3. RESULTS\",\"content\":\"\\u003cp\\u003e3.1 Generaal characteristics: A total of 1,215 healthcare providers working in Primary Healthcare (PHC) centers across Saudi Arabia participated in the study (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The majority of participants were female (n\\u0026thinsp;=\\u0026thinsp;802, 66.0%) and aged 30\\u0026ndash;39 years (n\\u0026thinsp;=\\u0026thinsp;511, 42.1%). In terms of professional role, general practitioners constituted the largest group (n\\u0026thinsp;=\\u0026thinsp;448, 36.9%), followed closely by nurses (n\\u0026thinsp;=\\u0026thinsp;425, 35.0%). Most participants held a bachelor's degree (n\\u0026thinsp;=\\u0026thinsp;704, 58.0%) and had more than 10 years of professional experience (n\\u0026thinsp;=\\u0026thinsp;485, 39.9%). A significant proportion worked in urban centers (n\\u0026thinsp;=\\u0026thinsp;851, 70.0%). Among those with prior training, only 279 (23.0%) had received formal pediatric vision screening training.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eGeneral Characteristics of Healthcare Providers (N\\u0026thinsp;=\\u0026thinsp;1215)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFrequency (n)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePercentage (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eGender\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e413\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e34.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e802\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eAge Group (years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20\\u0026ndash;29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e316\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e26.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e30\\u0026ndash;39\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e511\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e42.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e40\\u0026ndash;49\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e267\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e50 and above\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e121\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e10.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eProfessional Role\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGeneral Practitioner (GP)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e448\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e36.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e425\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e35.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOptometrist / Ophthalmologist\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e97\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e8.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth Educator / Other\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e245\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e20.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eEducational Level\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiploma\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e292\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e24.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBachelor's Degree\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e704\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e58.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePostgraduate Degree (Master's/PhD)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e219\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e18.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eYears of Experience\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLess than 5 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e351\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e28.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u0026ndash;10 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e379\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e31.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMore than 10 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e485\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e39.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePHC Center Location\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUrban\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e851\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e70.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRural\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e364\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e30.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePrior Training in Pediatric Vision Screening\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e279\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e23.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e936\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e77.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.2 Barriers to Pediatric Vision Screening\\u003c/h2\\u003e \\u003cp\\u003eParticipants rated the significance of various barriers on a 5-point Likert scale (1\\u0026thinsp;=\\u0026thinsp;Not a barrier to 5\\u0026thinsp;=\\u0026thinsp;Major barrier). The mean scores for each barrier item, grouped by domain, are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. Among all items, \\\"Lack of specific training in pediatric vision assessment\\\" had the highest mean score (4.41\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.78), indicating it was perceived as the most significant barrier. This was followed by \\\"Lack of clear referral pathways and protocols\\\" (4.28\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.85) and \\\"Inadequate time during well-child visits\\\" (4.19\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.91). Barriers related to parental cooperation, such as \\\"parental lack of awareness about the importance of vision screening\\\" (4.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.88), were also highly rated.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDescriptive Analysis of Perceived Barriers to Pediatric Vision Screening\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBarrier Domain / Item\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMean (SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eProvider-Related Barriers\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLack of specific training in pediatric vision assessment\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.41 (0.78)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLow confidence in using screening tools\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.02 (0.95)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eForgetting to screen during busy clinics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.85 (1.02)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eSystem-Related Barriers\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLack of clear referral pathways and protocols\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.28 (0.85)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInadequate time during well-child visits\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.19 (0.91)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eShortage of appropriate screening equipment\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.98 (1.10)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003ePatient/Family-Related Barriers\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParental lack of awareness about importance of screening\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.11 (0.88)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChild's uncooperative behavior during screening\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.75 (1.05)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLanguage barriers with parents\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.42 (1.15)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"2\\\"\\u003e*SD: Standard Deviation. Scale: 1\\u0026thinsp;=\\u0026thinsp;Not a barrier, 5\\u0026thinsp;=\\u0026thinsp;Major barrier.*\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.3 Factor Analysis of Barrier Items\\u003c/h2\\u003e \\u003cp\\u003eWe used exploratory factor analysis (EFA) to go beyond mere descriptive accounts of the barrier items and better understand their deeper relationships (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Further statistical checks ratified that our data were ideally suited for this type of analysis, with a Kaiser-Meyer-Olkin measure of 0.89.\\u003c/p\\u003e \\u003cp\\u003eThe strongest predictor was System-Level Barriers, which accounted for the greatest proportion of variance (28.5%). Second, Provider-Level Barriers accounted for 24.2% of the variance. The third factor was labeled Family-Level Barriers, accounting for a still-substantial 15.7% of the variance. The framework laid out here is useful for designing focused interventions at a granular level. For example, addressing system-level barriers might require policy changes and resource allocation, while tackling provider-level barriers calls for enhanced training programs. This validated framework will guide subsequent analysis as we explore how these barrier domains differ across provider groups.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eFactor Analysis of Perceived Barriers to Pediatric Vision Screening\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBarrier Item\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFactor 1: System-Level Barriers\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFactor 2: Provider-Level Barriers\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFactor 3: Family-Level Barriers\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLack of clear referral pathways\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.82\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.21\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.15\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInadequate time during visits\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.79\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.28\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eShortage of appropriate equipment\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.75\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.22\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLack of specific training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.85\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.14\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLow confidence in using tools\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.24\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.81\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.19\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eForgetting to screen\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.31\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParental lack of awareness\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.83\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eChild's uncooperative behavior\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.77\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLanguage barriers\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.29\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.70\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEigenvalue\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.82\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2.51\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.93\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariance Explained (%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e28.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e24.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eExtraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.4 Association Between Provider Characteristics and Perceived Barriers\\u003c/h2\\u003e \\u003cp\\u003eWe compared the mean scores across the three barrier domains (System-Level, Provider-Level, and Family-Level) for different provider characteristics using independent t-tests and a one-way ANOVA. The results are summarized in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e. Significant differences were observed across professional roles for all three barrier domains (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Providers who had received prior training in pediatric vision screening reported significantly lower barriers across all domains compared to those without training. The most pronounced difference was observed in the Provider-Level domain, where trained providers scored significantly lower (Mean\\u0026thinsp;=\\u0026thinsp;3.65, SD\\u0026thinsp;=\\u0026thinsp;0.81) than untrained providers (Mean\\u0026thinsp;=\\u0026thinsp;4.21, SD\\u0026thinsp;=\\u0026thinsp;0.68; t = -8.94, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Significant differences were also observed for System-Level (t = -2.11, p\\u0026thinsp;=\\u0026thinsp;0.035) and Family-Level barriers (t = -2.01, p\\u0026thinsp;=\\u0026thinsp;0.045). Practice between urban and rural areas across the three barrier domains was not significant (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05 for all).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eComparison of Mean Barrier Domain Scores by Provider Characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCharacteristic\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSystem-Level Barriers Mean (SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eProvider-Level Barriers Mean (SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eFamily-Level Barriers Mean (SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003eProfessional Role\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGeneral Practitioner (GP)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.18 (0.65)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.15 (0.70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.89 (0.68)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.25 (0.70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.22 (0.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.95 (0.71)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOptometrist/Ophthalmologist\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.45 (0.88)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3.38 (0.85)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.41 (0.79)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth Educator/Other\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.98 (0.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3.91 (0.75)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.75 (0.73)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eF-value (p-value)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003e25.41 (\\u0026lt;\\u0026thinsp;0.001)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003e28.15 (\\u0026lt;\\u0026thinsp;0.001)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003e12.87 (\\u0026lt;\\u0026thinsp;0.001)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003ePrior Training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.01 (0.79)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3.65 (0.81)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.71 (0.76)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.15 (0.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.21 (0.68)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.84 (0.72)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003et-value (p-value)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e*-2.11 (0.035)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e*-8.94 (\\u0026lt;\\u0026thinsp;0.001)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e*-2.01 (0.045)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003ePHC Location\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUrban\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.11 (0.74)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.08 (0.75)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.80 (0.73)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRural\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.14 (0.76)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.11 (0.78)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.83 (0.75)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003et-value (p-value)\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e*-0.58 (0.562)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e*-0.62 (0.536)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e*-0.51 (0.610)*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.5 Predictors of Overall Perceived Barriers:\\u003c/h2\\u003e \\u003cp\\u003eA multivariate regression was performed to test the independent predictors of the total score of perceived barriers. The complete results of this analysis are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eOverall Model Fit\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe regression model was statistically significant (F(7, 1207)\\u0026thinsp;=\\u0026thinsp;32.45, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), indicating that the set of predictor variables, as a whole, reliably distinguished between providers with higher and lower perceived barrier scores. The model explained approximately 18.5% of the variance in overall barrier perceptions (Adjusted R\\u0026sup2; = 0.185).\\u003c/p\\u003e \\u003cp\\u003eProfessional Role as a Powerful Predictor\\u003c/p\\u003e \\u003cp\\u003eThe professional role was one of the strongest and most significant predictors. Being a GP was significantly associated with the total barrier score (unstandardised B\\u0026thinsp;=\\u0026thinsp;0.62, standardized beta [β]\\u0026thinsp;=\\u0026thinsp;0.45, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001, 95% CI: 0.47\\u0026ndash;0.77).\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eThe Protective Effect of Prior Training\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe most actionable finding relates to the role of prior training in pediatric vision screening. After controlling for professional role, experience, and all other variables, having received formal training emerged as a strong, negative predictor of overall barrier scores (Unstandardized B = -0.52, β = -0.38, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001, 95% CI: -0.63 to -0.41). The negative coefficient indicates that trained providers perceive significantly fewer barriers than their untrained counterparts. The standardized beta of -0.38 represents a moderate-to-large effect, comparable in magnitude (though opposite in direction) to the effect of being a GP or nurse\\u0026mdash;Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.6 Association Between Barrier Domains and Self-Reported Screening Practice\\u003c/h2\\u003e \\u003cp\\u003eA binary logistic regression analysis, adjusted for professional role, years of experience, and prior training, revealed that the predictor variables reliably distinguished between providers who screen routinely and those who do not (χ\\u0026sup2; = 98.45, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), explaining approximately 24% of the variance in screening frequency (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab6\\\" class=\\\"InternalRef\\\"\\u003e6\\u003c/span\\u003e). Of the three barrier domains, provider-Level barriers was identified as a strong predictor of infrequent screening. For each one-unit increase in this domain, the odds of a provider being categorized as belonging to the \\\"Rarely/Never\\\" screening group were 2.85 times higher (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), which signified low self-efficacy and training. This makes sense statistically, so each increase in the right direction provides greater odds that screening was not frequent (OR\\u0026thinsp;=\\u0026thinsp;1.65, p\\u0026thinsp;=\\u0026thinsp;0.012), which confirms structural challenges, such as lack of time or equipment, prevent even many motivated providers from obtaining screening for their patients.\\u003c/p\\u003e \\u003cp\\u003eImagine a dedicated GP who has received training and feels confident in her screening abilities. She wants to screen every child who comes through her door. However, if her clinic lacks the appropriate equipment, if her appointments are scheduled every ten minutes with no flexibility, and if she has no clear pathway for referring a child who fails the screening, her motivation will eventually hit a wall. The system itself becomes a barrier that no amount of individual confidence can overcome. Our data suggest that for every incremental increase in the severity of these system-level challenges, the likelihood of screening drops by 65%.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eFamily-Level Barriers: The Interpersonal Dimension\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eFamily barriers were also significantly associated with lower screening frequency, although the effect size was more modest. The odds of being in the \\\"Rarely/Never\\\" screening group increased by 42% (OR\\u0026thinsp;=\\u0026thinsp;1.42, 95% CI: 1.01 to 1.99, p\\u0026thinsp;=\\u0026thinsp;0.041).\\u003c/p\\u003e \\u003cp\\u003eFamily barriers are identified as parents' unawareness of vision screening ( odds ratio of 1.42).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eMultivariate Linear Regression Analysis for Predictors of Overall Perceived Barriers\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eUnstandardized B\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eStandardized Beta (β)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003et\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e95% CI for B\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e(Constant)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e28.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(3.02, 3.48)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGender\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMale (Ref: Female)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.04\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.71\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.478\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(-0.07, 0.15)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge Group\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(Continuous, in years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.95\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.342\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(-0.02, 0.06)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eProfessional Role\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGP (Ref: Optometrist)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.62\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e8.15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(0.47, 0.77)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNurse (Ref: Optometrist)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.68\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.51\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e9.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(0.53, 0.83)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealth Educator (Ref: Optometrist)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.31\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3.55\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(0.14, 0.48)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eExperience\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(Continuous, in years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.01\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-0.65\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.516\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(-0.04, 0.02)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLocation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRural (Ref: Urban)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.05\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.271\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(-0.04, 0.14)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrior Training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eYes (Ref: No)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.52\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-0.38\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-8.91\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e(-0.63, -0.41)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eDependent Variable: Overall Mean Barrier Score. CI: Confidence Interval. Ref: Reference Category.\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.6 Association Between Barrier Domains and Self-Reported Screening Practice: Binary Logistic Regression Analysis\\u003c/h2\\u003e \\u003cp\\u003eThe logistic regression model was significant (χ\\u0026sup2;=98.45, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), confirming that perceived barriers distinguish between routine and low-frequency screeners. Provider-Level barriers proved the strongest predictor: for every one-unit increase, providers were nearly three times more likely to rarely or never screen (OR\\u0026thinsp;=\\u0026thinsp;2.85, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). This captures the human reality that a provider who lacks confidence or training is far more likely to skip screening altogether. System-Level barriers also independently predicted low screening frequency (OR\\u0026thinsp;=\\u0026thinsp;1.65, p\\u0026thinsp;=\\u0026thinsp;0.012), meaning even motivated providers cannot overcome structural challenges like time constraints or equipment shortages. Family-Level barriers showed a modest but significant effect (OR\\u0026thinsp;=\\u0026thinsp;1.42, p\\u0026thinsp;=\\u0026thinsp;0.041). Together, these findings reveal that improving screening rates requires addressing not only provider confidence and competence, but also the systems they work within and the families they serve.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab6\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 6\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eBinary Logistic Regression for Predictors of Low Screening Frequency (Rarely/Never Screen)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"8\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePredictor Domain\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eB\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eS.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eWald\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003edf\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003ep-value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eOdds Ratio (OR)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e95% CI for OR\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSystem-Level Barriers Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.50\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6.25\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.012\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.65\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e(1.11, 2.45)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProvider-Level Barriers Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.05\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.22\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e22.77\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e2.85\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e(1.85, 4.39)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFamily-Level Barriers Score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.35\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4.18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.041\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e1.42\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e(1.01, 1.99)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eConstant\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-4.12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.58\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e50.45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"8\\\"\\u003e*Dependent Variable: Screening Frequency (0\\u0026thinsp;=\\u0026thinsp;Always/Usually, 1\\u0026thinsp;=\\u0026thinsp;Rarely/Never). The model was adjusted for professional role, experience, and prior training.*\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eExploratory factor analysis of the nine barrier items identified a clear three-factor structure, accounting for 68.4% of the total variance. Facilities-level barriers (44.7%) include a lack of clear referral pathways, insufficient visit time, and inadequate equipment. Provider-level barriers (24.2%) were a lack of specialized training, low confidence in screening tools, and forgetfulness to screen; 15.7% were family-level barriers (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThis national cross-sectional study provides important evidence on the barriers to pediatric vision screening among PHC healthcare providers in Saudi Arabia. The findings show that barriers to screening are multidimensional, clustering into provider-level, system-level, and family-level domains, with provider-related barriers emerging as both highly rated and the strongest predictor of low screening frequency. These findings are consistent with studies that childhood vision screening in primary care is often constrained by limited training and inadequate confidence (\\u003cspan additionalcitationids=\\\"CR15 CR16\\\" citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe lack of training in assessing vision in pediatric patients was the most common individual barrier, whereas prior training was associated with lower overall barriers. This aligns with recent evidence. A recent study in Saudi Arabia reported pediatricians may have reasonable baseline knowledge (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). A 19 PHC-based study from the Qassim region (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThere is a significant association between provider-level barriers and low screening frequency. This finding is allied with recent results (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). Practice implications of these results include the need to move from instruction in training programs toward the development of actual skills, validation, and competency (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eSystemic barriers contributed to a decrease in conductance frequency. These findings are strongly supported by recent evidence showing that screening programs are less effective when referral pathways are fragmented and when services lack mechanisms for timely referral completion and feedback. Updated recommendations for preschool vision screening emphasize that screening cannot improve outcomes unless systems are in place to ensure rescreening when needed, referral for confirmatory examination, and communication of results to relevant stakeholders. (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) Likewise, recent analyses of pediatric eye care delivery have highlighted that even when screening is performed, many children fail to receive follow-up care because of poor referral coordination, transportation barriers, cost, and limited access to eye care professionals. (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe present findings also underscore the importance of family-level barriers. Parental lack of awareness, child uncooperative behavior, and language barriers were all relevant in the current study, and family-level barriers remained independently associated with reduced screening frequency after adjustment. This is consistent with evidence showing that screening effectiveness depends heavily on parental understanding of the purpose of screening and the need for follow-up when a child fails. Previous work has identified parental unawareness of failed screening as a major barrier to follow-up ophthalmic care. At the same time, recent research has similarly emphasized parental concerns, delays in seeking help, and the need for greater public awareness of children's eye health (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). These suggest family education strategies, culturally-sensitive communication, and accessible referral support. One of the more relevant contributions of this study is the noted variability across professional roles. PHC physicians and nurses must balance vision screening against many competing preventive and treatment priorities. Recent Saudi consensus work has emphasized the need to integrate optometrists more effectively into primary care and to expand workforce capacity for pediatric eye services, findings that directly support the current findings (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThese data therefore suggest that national strategies should be tailored to the professional realities of PHC teams, with targeted upskilling of general practitioners and nurses and stronger access to specialist support when needed.\\u003c/p\\u003e \\u003cp\\u003eAnother interesting finding was that although they had been previously associated with higher barrier scores, gender, age, years of experience, and urban/rural location were not significant predictors in a multivariable model for overall barrier scores. It appears that the obstacles to pediatric vision screening in Saudi Arabia are more related to structural readiness, training, and responsibilities than provider demographics. The limited urban-rural differences imply that the barriers highlighted in this work are purely systemic and at a national level rather than being driven by point-specific areas. This is backed by Saudi literature that illustrated the existence of key gaps in childhood eye care services available as well as regional discrepancies in the availability of such services despite their general acceptability, thereby calling for harmonized national-level planning instead of piecemeal local-based interventions (\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe three factors \\u0026mdash; provider, system, and family \\u0026mdash; supplementary interventions should bolster all three at once. The benefits of this comprehensive strategy lie at the core of the integrated, people-centered eye care model (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e), emphasizing that effective screening depends on clinical expertise, organizational effectiveness, and family involvement.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eLimitations\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe study is a cross-sectional survey, limiting causal generalizability, but informative for future research focused on implementation.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study highlights that pediatric vision screening in Saudi PHC settings is shaped by a combination of provider, system, and family factors, with provider-level barriers exerting the strongest influence on screening behavior. The findings suggest that the most effective response will be a comprehensive strategy that combines training, workflow redesign, equipment provision, referral strengthening, and family-centered communication. Such a strategy could improve the consistency of pediatric vision screening in PHC centers and support earlier identification and management of childhood visual disorders across Saudi Arabia.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u0026nbsp;\\u003c/strong\\u003eParticipation in this study was voluntary, and all healthcare providers completed the questionnaire after agreeing to participate. The institutional review board waived ethical approval for this study. The study was conducted in accordance with the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e: Not applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials:\\u0026nbsp;\\u003c/strong\\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests:\\u0026nbsp;\\u003c/strong\\u003eNo\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding declaration\\u003c/strong\\u003e: Funded by the Deanship of Research and Graduate Studies at King Khalid University, KSA, for funding this work through the General Research Project under grant number (GRP/98/46)\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions:\\u003c/strong\\u003e This is a single author work, all the manuscript was done by the author himself.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u003c/strong\\u003e The author extend their appreciation to the Deanship of Research and Graduate Studies at King Khalid University, KSA, for funding this work through the General Research Project under grant number (GRP/98/46).\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eFuseya K, Matsumoto T, Matsumura S, Kawakami M, Chiba E, Tomita M, Kunugi Y, Hori Y, Fukushima Y. Esotropia Missed During Pre-health Checkup Screening With the Spot Vision Screener: A Case Series. Cureus. 2026;18(3).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChu R, Huang K, Barnhardt C, Chen A. The effect of an on-site vision examination on adherence to vision screening recommendations. J School Nurs. 2015;31(2):84\\u0026ndash;90.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKemper AR, Fan T, Grossman DC et al. Childhood eye examination in primary care. Am Fam Physician. 2023;108(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePang Y, Lyons SA, Nottingham Chaplin PK, Block SS, Fishman D, Ciner EB, Advisory Committee to the National Center for Children\\u0026rsquo;s Vision and Eye Health at Prevent Blindness. Recommended practices for vision screening in pre-school-age children: A 2025 update. Optom Vis Sci. 2025;102(10):589\\u0026ndash;95. Epub ahead of print. PMID: 40892439; PMCID: PMC12520030.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl-Atawi S. Eye Health Awareness and School-Based Screening in Saudi Schools: A Systematic Literature Review. Clin Optom (Auckl). 2026;18:1\\u0026ndash;21. PMID: 41551543; PMCID: PMC12812045.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoafa MA, Alrasheed SH. Status of childhood eye care services in the Kingdom of Saudi Arabia: eye care professionals\\u0026rsquo; perspectives. Open Ophthalmol J. 2022;16(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl Musalami SN, Al Qasim RJ, Alshuhayb BS, Al-Somali AI. Insights into parental perspectives: Children's eye care in Saudi Arabia. Heliyon. 2025;11(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmbrosino CM, Killeen OJ, Collins ME. Pediatric Eye Care in Federally Qualified Health Centers. InJAMA Health Forum 2025 Apr 4 (Vol. 6, No. 4, pp. e250414\\u0026ndash;250414). American Medical Association.​.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRahmat BS, Md-Muziman-Syah MM, Nor NM, Sanmugam T. Barriers and limitations of conventional oculovisual screening methods in children: a systematic review perspective. BMC Ophthalmol. 2026;26(1):64. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1186/s12886-025-04592-w\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/s12886-025-04592-w\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 41555267; PMCID: PMC12874825.​.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSu Z, Marvin EK, Wang BQ, Van Zyl T, Elia MD, Garza EN, Salchow DJ, Forster SH. Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. 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Afr Vis Eye Health. 2022;81(1):a752. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.4102/aveh.v81i1.752​\\u003c/span\\u003e\\u003cspan address=\\\"10.4102/aveh.v81i1.752​\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee L, Moo E, Angelopoulos T, Yashadhana A. Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings. PLoS ONE. 2023;18(1):e0278969. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1371/journal.pone.0278969\\u003c/span\\u003e\\u003cspan address=\\\"10.1371/journal.pone.0278969\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 36656849; PMCID: PMC9851534.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKilleen OJ, Saylor KM, Hogan C, Jacobson A, Collins M, Ehrlich JR. Barriers and facilitators of vision screening in the US pediatric primary care setting: a mixed methods systematic review protocol. JBI Evid Synth. 2023;21(5):985\\u0026ndash;992. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.11124/JBIES-22-00026\\u003c/span\\u003e\\u003cspan address=\\\"10.11124/JBIES-22-00026\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 36598114.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePang Y, Lyons SA, Nottingham Chaplin PK, Block SS, Fishman D, Ciner EB, Advisory Committee to the National Center for Children\\u0026rsquo;s Vision and Eye Health at Prevent Blindness. Recommended practices for vision screening in pre-school-age children: A 2025 update. Optom Vis Sci. 2025;102(10):589\\u0026ndash;95. Epub ahead of print. PMID: 40892439; PMCID: PMC12520030.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmbrosino C, Dai X, Antonio Aguirre B, Collins ME. Pediatric and School-Age Vision Screening in the United States: Rationale, Components, and Future Directions. Child (Basel). 2023;10(3):490. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3390/children10030490\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/children10030490\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 36980048; PMCID: PMC10047420.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSu Z, Marvin EK, Wang BQ, van Zyl T, Elia MD, Garza EN, Salchow DJ, Forster SH. Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385\\u0026thinsp;\\u0026ndash;\\u0026thinsp;90. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.jaapos.2013.05.008\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jaapos.2013.05.008\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 23993718.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlzuhairy S, Alsugair M, Alqubays M, Alzuhayri MA, Alsugair AM. Knowledge, Attitude, and Practice of Pediatricians for Eye Care of Children: A Personal Survey in Saudi Arabia. Cureus. 2024;16(9):e69630. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.7759/cureus.69630\\u003c/span\\u003e\\u003cspan address=\\\"10.7759/cureus.69630\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 39429368; PMCID: PMC11487455.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlHarkan DH, AlRubaysh NS, Aldekhail MI, Alayidi SA, Alashgar MS, Almishali FF. Knowledge, Attitude, and Practice Regarding Vision and Eye Screening of Preschool Children Among Primary Health Center Staff in the Qassim Region, Saudi Arabia. Cureus. 2024;16(1):e52743. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.7759/cureus.52743\\u003c/span\\u003e\\u003cspan address=\\\"10.7759/cureus.52743\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 38406065; PMCID: PMC10884783.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl Musalami SN, Al Qasim RJ, Alshuhayb BS, Al-Somali AI. Insights into parental perspectives: Children's eye care in Saudi Arabia. Heliyon. 2025;11(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlghamdi MA, Almustanyir A, Alshuimi AA, Alrasheed SH, Alabdulkader B, Alanazi M, Altoaimi BH, Bin Dulaym M, Alsamnan LY, Alghamdi W. Prioritizing Pediatric Eye Care in Saudi Arabia: A National Delphi Consensus Study. Healthc (Basel). 2025;13(19):2467. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3390/healthcare13192467\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/healthcare13192467\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 41095553; PMCID: PMC12523716.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAldhabaan W, Alkhammash ZM, Al Zomia AS, Alshahrani Y, Asiri R, Alqhtani MM, Alnahdi W, Alqahtani Y, Alqahtani S, Asiri A, Asiri B. Knowledge and practices of child eye healthcare among parents in Aseer Region, Saudi Arabia. Cureus. 2022;14(10):e30404.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl-Atawi S. Eye Health Awareness and School-Based Screening in Saudi Schools: A Systematic Literature Review. Clin Optom (Auckl). 2026;18:1\\u0026ndash;21. PMID: 41551543; PMCID: PMC12812045.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee L, Moo E, Angelopoulos T, Yashadhana A. Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings. PLoS ONE. 2023;18(1):e0278969. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1371/journal.pone.0278969\\u003c/span\\u003e\\u003cspan address=\\\"10.1371/journal.pone.0278969\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. PMID: 36656849; PMCID: PMC9851534.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-primary-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"famp\",\"sideBox\":\"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://author-welcome.nature.com/12875\",\"title\":\"BMC Primary Care\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pediatric vision screening, Primary healthcare, Barriers, Healthcare providers, Saudi Arabia, Childhood eye disorders, Vision screening practices, Primary care\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9077237/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9077237/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003ePediatric vision screening is an essential preventive service for early detection of amblyopia, refractive errors, strabismus, and other childhood visual disorders. Despite its importance, implementation in primary healthcare (PHC) settings remains inconsistent, particularly in settings where provider training, referral systems, and family awareness may be limited.\\u003c/p\\u003e\\n\\u003cp\\u003e​\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e To assess perceived barriers to pediatric vision screening among PHC healthcare providers in Saudi Arabia and to examine how these barriers vary according to provider characteristics and self-reported screening practices.\\u003c/p\\u003e\\n\\u003cp\\u003e​\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e A national cross-sectional study was conducted among 1,215 healthcare providers working in PHC centers across Saudi Arabia. Data were collected using a structured self-administered questionnaire covering demographic and professional characteristics, prior training in pediatric vision screening, self-reported screening frequency, and nine perceived barrier items rated on a 5-point Likert scale. Exploratory factor analysis was used to identify underlying barrier domains. Independent t-tests, one-way analysis of variance, multivariate linear regression, and binary logistic regression were performed to assess associations between provider characteristics, barrier scores, and screening frequency.\\u003c/p\\u003e\\n\\u003cp\\u003e​\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Three barrier domains were identified: system-level barriers (28.5% of explained variance), provider-level barriers (24.2%), and family-level barriers (15.7%), accounting collectively for 68.4% of total variance. The highest-rated individual barrier was lack of specific training in pediatric vision assessment (mean 4.41 ± 0.78). Providers with prior training reported significantly lower barriers across all domains. In multivariate analysis, professional role and prior training were the strongest predictors of overall perceived barriers. In logistic regression, provider-level barriers were the strongest predictor of low screening frequency (OR 2.85, 95% CI 1.85-4.39), followed by system-level barriers (OR 1.65, 95% CI 1.11-2.45) and family-level barriers (OR 1.42, 95% CI 1.01-1.99).\\u003c/p\\u003e\\n\\u003cp\\u003e​\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e Pediatric vision screening in Saudi PHC settings is hindered by interrelated provider-, system-, and family-level barriers. Targeted training, improved referral pathways, adequate equipment, and enhanced parental awareness may strengthen screening uptake and support earlier detection of childhood visual disorders.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Barriers of Pediatric Vision Screening in Saudi Arabia: A National Cross-Sectional Study of PHC Healthcare Providers' Perspective\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-06 16:37:58\",\"doi\":\"10.21203/rs.3.rs-9077237/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-28T08:37:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"170018929869243051534714951230795296896\",\"date\":\"2026-04-27T10:19:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-27T09:46:11+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-23T08:44:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-04-02T09:50:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-02T00:15:21+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Primary Care\",\"date\":\"2026-04-02T00:11:03+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-primary-care\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"famp\",\"sideBox\":\"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://author-welcome.nature.com/12875\",\"title\":\"BMC Primary Care\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"ee56988e-f1b6-4cc9-97f9-0a4c552bb022\",\"owner\":[],\"postedDate\":\"May 6th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-06T16:37:58+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-06 16:37:58\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9077237\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9077237\",\"identity\":\"rs-9077237\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}