Strategies to Improve Adherence to Eye Care Referrals for Children following Vision Screening: A Scoping Review

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Asare, Amy Amoah, Patrice M. Hicks, Allison M. Howard, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7436894/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Vision screening plays a critical role in identifying potential vision disorders; however, its effectiveness is compromised when follow-up with eye care professionals is not completed. Up to 60% of children with abnormal vision screenings do not attend recommended appointments with eye care providers. This study aims to identify and synthesize the strategies to improve adherence to eye care referrals following abnormal vision screening tests. Methods The Joanna Briggs Institute methodology was followed to conduct the scoping review. This review is part of a broader study exploring adherence to pediatric eye care referrals. A companion scoping review focusing on social risk factors of non-adherence has been submitted separately. Searches for relevant literature were performed across bibliographic databases and gray literature from their inception to July 2023, with an updated search in November 2024. The review protocol was registered with Open Science Framework. Four reviewers screened and extracted data from the included studies. Strategies were synthesized, and themes developed. Results Sixteen studies assessed strategies to overcome social risk factors. The most frequently reported strategy was enhanced direct communication such as phone calls and mailed notifications (n = 13), and logistical support, including transportation and pre-scheduled appointments (n = 9). Conclusion A variety of strategies have been implemented to improve adherence to pediatric eye care referrals, with communication and logistical support being the most common strategies used. Significant gaps, however, remain in evaluating the effectiveness of these strategies, especially in low-income countries. Vision Screening Referral and Consultation Eye Care Services Health Services Accessibility Health Literacy Health Behavior Health Services Needs and Demand Health Services Research Child Socioeconomic Factors Health Disparities Delivery of Health Care Access to Health Care Scoping Review Public Health Medically Underserved Area Vision health literacy Follow-up care Barriers to care Patient navigation School-based vision screening Health Knowledge Attitudes Practice Health Education Intervention Studies Community Health Services Preventive Health Services Figures Figure 1 Figure 2 Introduction To prevent long-term visual impairment, the early detection and treatment of vision disorders during childhood is essential.( 1 – 3 ) Vision screening enables the early identification of vision disorders through referrals to eye care professionals for a comprehensive eye examination.( 4 ) However, the effectiveness of vision screening programs is compromised when referrals to eye care professionals are not completed, preventing timely treatment for identified vision disorders. Vision screening is conducted in elementary schools, pediatric primary care, and/or other community-based settings in most countries.( 1 , 5 ) In spite of the widespread use and established benefits of vision screening and comprehensive eye examinations, ensuring follow-up eye care after abnormal screening results remains a significant challenge. Studies show that as many as 60% of children do not attend recommended appointments with eye care providers following abnormal vision screening tests.( 2 , 3 , 6 , 7 ) Lower adherence to eye care appointments disproportionally affects children from socially disadvantaged populations, including racial and ethnic minorities, underserved rural communities, people with low socioeconomic status, and sexual and gender minorities.( 4 , 8 – 11 ) Efforts to address low adherence to eye care appointments include developing evidence-based strategies and interventions. A previous study reviewed strategies to improve adherence to eye care professionals for adult populations.( 12 ) Strategies reported in the study included patient navigation and prescheduled appointments. It is however unknown if these strategies have been used in pediatric populations and their impact on referral adherence for children.( 12 ) These gaps highlight the need for a comprehensive synthesis of strategies for improving referral nonadherence in children. The objective of this study is to identify strategies from the existing literature to improve referral adherence for comprehensive eye exams by eye care professionals following abnormal vision screening tests for children. Methods Protocol and registration This scoping review followed the methodology outlined by the Joanna Briggs Institute (JBI) ( 6 ) for scoping reviews and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.( 7 ) This review is part of a broader study exploring adherence to pediatric eye care referrals. A companion scoping review focusing on social risk factors of non-adherence has been submitted separately, with adaptations to address a distinct research objective focused on intervention strategies. Searches were conducted across bibliographic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, and Web of Science) and gray literature were searched from their inception to July 2023, with an updated search performed in November 2024. The protocol for this review was registered with the Open Science Framework. As this study involved analysis of previously published sources with de-identified data and did not involve interaction with human participants, ethical approval and informed consent were not required and was exempt from the University of Utah Institutional Review Board. Search Strategy The review team met with a librarian (AMH) in June 2023 to develop a comprehensive search strategy for PubMed. The strategy was subsequently adapted for use across additional electronic databases. The initial literature search was conducted in July 2023 covering studies available from the inception of the respective databases up to July 2023. An updated search was conducted in early November 2024. The search aimed to identify relevant studies that examined social risk factors of and strategies to improve referral adherence following abnormal vision screenings in children. Search terms included keyword and controlled vocabulary, where applicable, and their synonyms for the following concepts: child, vision screening, referral adherence, and eye care professional . The complete search strategy used for PubMed can be found in Appendix I. Eligibility criteria Studies were selected based on specific characteristics including the type of target population, outcomes and study design. Screening for eligibility criteria was conducted in two phases: an initial review of the title/abstract followed by a full-text assessment, as detailed in Table 1 . Eligible studies included vision screening conducted in any setting, e.g., school, pediatric primary care, or another community-based setting. There were no limitations on date of publication or country of publication; however, studies not published in English were excluded (Table 1 ). Table 1 Inclusion and Exclusion Criteria Inclusion Exclusion Population • Parents or guardians of children requiring follow-up after vision screening • Children aged 3 to 18 years at the time of their vision screening test • Exclusion: Children 18 years Study Outcomes • Patient social risk factors of referral nonadherence to eye care professionals following abnormal vision screenings in children and strategies to address them • Strategies to improve referral nonadherence to eye care professionals following abnormal vision screenings in children and strategies to address them • None Type of study • Primary peer-reviewed studies, regardless of design • Commentaries, letters to the editor, editorials, and review papers Table 2 Sociodemographic Characteristics of Target Populations in Included Studies First author, Year Published Geographical Context WHO Income Level Target Population Screening setting Age range**, years Sex/gender distribution [Females/Girls n (%)] Race Ethnicity Chu et al., 2015 US, Santa Ana, California High Income Parents of at-risk students attending Title I schools* Title I school - NA NA NA Clarke et al., 2008 US, Southern California High Income Parents of preschool children in a large, urban public-school system Preschool 2 to 5 Parents: not specified Children: 292 (48.7%) NA Latino/Hispanic 516 (86%) Day et al., 2022 US, New York City High Income Parents of students attending public school School 3 to 18 Children: 129,035 (48.6%) Hispanic: 114, 696 (43.2%); Black: 62,603 (23.6%); Asian: 42,785 (16.1%); White: 42,141 (15.9%); Multiracial or Missing: 3,287 (1.2%) Hispanic:114,696 (43.2%) Non-Hispanic: 150,816 (56.8%) Diao et al., 2016 US, Philadelphia, Pennsylvania High Income At-risk/socioeconomically disadvantaged elementary students Elementary school*** - NA NA NA Dotan et al., 2015 US, Philadelphia, Pennsylvania High Income Parents of children with low SES Wills Eye Hospital 0 to18 Parents: not specified Children: 471 (51%) NA NA Hark et al., 2016 US, Philadelphia, Pennsylvania High Income Parents of children from underserved communities Elementary school 5 to 12 Children: 5,245 (49%) NA NA Kripke et al., 1970 US, Iowa High Income Parents of preschool children Field clinics 4 to 6 NA NA NA Latorre-Arteaga et al., 2016 Peru, Abancay, Apurimac region Upper Middle Income Preschool, primary, and secondary school children; teachers and directors Schools 3 to 17 NA NA NA Musch et al., 2020 USA, Wayne County, Michigan High Income Parents of children in grades 1 and 3 schools 5 to 10 78 (48.1%) NA NA Neville et al., 2015 USA, New Jersey High Income Parents of school-aged children in an urban middle school School (urban middle school) 11 to 14 47 (54.0%) African American 36(41.4%), Caucasian 23 (26.5%), Multiracial 3 (3.4%), Asian 3 (3.4%) Hispanic 22 (25.3%) Noma et al., 2012 Brazil, Guarulhos, Sao Paulo Upper Middle Public elementary school children in grade 1 to 4 Schools 7 to 10 5540 (50.70%) screened NA NA Rodriguez et al., 2018 USA, San Jose, California High Income School nurses and parents of minority public school children with low income Public schools 5 to 13 NA NA Latino/Hispanic students in demonstration schools 81.1%, and 70.2% in comparison schools Suchoff and Mozlin, 1991 USA, Bronx, New York High Income Parents of inner-city high school students (62% Hispanic, 27% Black) School 14 to 19 Not specified 47 (54.0%) NA NA Yawn et al., 1996 USA, Rochester, Olmstead County, Minnesota High Income Parents of kindergarten children in public and private schools Public and private schools - NA 97% White NA Zeng et al., 2020 China, Yudu county, Jiangxi province Upper Middle Income - Parts of China have been categorized as High Income Parents of preschool children with abnormal screening results Preschool 4 to 7 535 girls (46.4%), 254 (42%) Control & 241 (50%) Intervention Group NA NA Zhang et al., 2021 China, Shaanxi and Gansu Provinces Upper Middle Income - Parts of China have been categorized as High Income Children in grade 4 to 6 living in poor, rural counties School 9 to 12 7,648 (48.5%) of children with visual impairment, 2718 (52.6%) of those complying with referral NA NA NOTES * Title I school = publicly funded school with a large portion of the surrounding attendance area are low-income families ** Refers to age range of children in the study sample ***Elementary school with more than 80% of students falling below the Federal Poverty Line (household income < $19,090 for family of three or < $23,050 for family of four) ABBREVIATIONS - US: United States of America; NA: Not Applicable – study did not provide Table 2: Identified Barriers and Interventions to Improve Referral Adherence to Eye Care Professionals First author, Year published Country and local context Participants Barriers to Referral Adherence Adherence (%) pre-strategy Interventions to Improve Referral Compliance Outcomes Adherence (%) post- strategy Chu et al., 2015 US, Santa Ana, California 1,306 screened, 382 (29%) with abnormal screenings 1) Unable to afford cost of care 2) Need to travel to an ECP NA 1) Provided on-site eye exams via grant provided by KVLF at no cost to families with free glasses 2) In the event that the consent form was not returned, school personnel attempted to call the student’s parent/guardian 52% (198/382) of parents consented to comprehensive eye exams NA Clarke et al., 2008 US, Southern California 592 screened, 42 (7%) with abnormal screenings, 29 (69.0%) answered follow-up calls NA NA 1) Provided brochures to families following abnormal vision screenings detailing recommendations and low-cost/no-cost vision care options and the school nurse’s phone number for assistance 2) School nurses conducted follow-up calls to check in and emphasize importance of follow up if patient had not followed up within 2-3 months after an abnormal vision screening result - 17% (5/29) plans to follow-up after receiving brochure - 83% (20/24) agreed to obtain a vision exam after follow-up calls - 76% (19/25) contacted to obtain results of follow-up exam. - 79% (15/19) with known follow up care - 17% (5/29) plans to follow-up after receiving brochure - 83% (20/24) agreed to obtain a vision exam after follow-up calls Day et al., 2022 US, New York City 84% (n=229,834) of Pre-K to 1 st grade students enrolled from 2018-19 were screened; Of the total number of students screened, 22.2% (n=42,859) of Pre-K to 1 st grade students had abnormal vision screenings, 69.1% (n=29,615) received follow-up efforts 1) Difficulties accessing eye exam services NA 1) SVP conducts follow-up calls immediately after screening, alerting parents to referral letters placed in the children’s backpack 2) Subsequent phone calls every two weeks to encourage and help parents find pediatric eye care. If family unreachable, letter mailed to parents Of the 22.2% (n=42,827) of screened students with abnormal vision screenings in 2018–19, 69.1% (n=29,598) received follow-up efforts, and 38.8% completed eye exams (n=16,617) NA Diao et al., 2016 US, Philadelphia, Pennsylvania 132 referred, 72% (95/132) students with consent to receive care by the WOW Mobile Eye Unit 1) Lack of transportation 53% WOW Mobile Eye Unit* 62% (CI: 54% to 70%) of patients (n= 82/132) were seen by the mobile unit. Historic rate of 53%. Statistically significant improvement in follow-up was noted (p = .036) 62% (n=82/132) Dotan et al., 2015 US, Philadelphia, Pennsylvania 924 children examined, 10% (n=96) needed follow-up care. 1) Lack of insurance or lack of awareness about how to use insurance/insurance benefits 2) Challenges with literacy 3) Inconvenience of follow-up 4) Lack of understanding about the benefits of early intervention 5) Family priorities 6) Concerns about costs 7) Transportation issues 8) Lack of effective communication methods 2% 1) Social worker was present during screening to ensure sufficient and accurate contact information was collected from parents (up to 5 telephone numbers were recorded for children needing follow-up) 2) Social worker helped arrange follow-up appointments, enrollment in insurance if needed, and vouchers for transportation to follow-up when needed 59% (n=57/96) received follow-up care 59% (n=57/96) Hark et al., 2016 US, Philadelphia, Pennsylvania 10,726 screened, 5% (n=509) referred because of suspected nonrefractive eye disease , 215 scheduled for follow-up appointment, 82% (n=177/215) did not have an eye care provider. NA NA 1) Social worker contacted parents and assisted with scheduling an appointment with pediatric ophthalmology at Wills Eye Hospital, which offered expedited appointments in reserved slots 2) Two movie tickets to incentivize parents to attend the follow-up appointment 3) Liaison with the school district conducted up to 3 phone call reminders to parents who did not return completed consent forms within 4 weeks Referral adherence was 72% (n=127/177) 72% (n=127/177) Kripke et al., 1970 US, Iowa 1233 screened (585 in 1967, 648 in 1968) 92 referred (49 in 1967, 43 in 1968) NA 22.4% (n=11/49) 1) Parents and physicians encouraged to arrange full eye examinations for student with abnormal vision screening tests 2) Shortened time between abnormal vision screening and sending report letters to parents 3) Forms requesting replies were enclosed with report letters to parents 63% (n=27/43) of children referred in 1968 completed an eye examination vs 22.4% (n=11) in 1967 62.8% (n=27/43) Latorre-Arteaga et al., 2016 Peru, Abancay, Apurimac region 1,522 screened, 259 (17%) referred NA 66% (n=45/68) 1) Develop health education materials for families 2) Provide logistic support (i.e., transportation) 3) Provide outreach clinic in remote locations, free eye exams, and financial subsidies for patients who could not afford the cost of glasses, medical treatment or transport to the eye hospital 237 received an eye exam representing a 39% increase in attendance rate at eye clinic [from 66% (45/68) to 92% (237/259)] 92% (n=237/259) Musch et al., 2020 USA, Wayne County, Michigan 162 with abnormal screening tests NA 48% (n=39/82) 1) Coordinator contacted parents within 3 weeks of mailing the initial letter to check if the follow-up examination has been scheduled or was completed 2) Coordinator provided reminders and a list of ECPs in the area willing to examine the child, including designation of those who accept Medicaid as well as those who would see the child at no cost 3) If no completed ECP form was received within 6 weeks of abnormal screening, coordinator made a second phone call to ensure follow-up care is being pursued 65% (52/80) children had a documented ECP exam within 16 weeks in the enhanced group vs 47.6% (39/82) in the standard group (p=0.025) 65% (n=52/80) Neville et al., 2015 USA, New Jersey 341 screened, 87 abnormal screens 1) Didn't receive or lost referral letter 2) Financial concerns 3) Lack of insurance 4) Language barriers 5) Lack of time/busy/procrastination 5) Do not believe vision screening results 6) Inattention to school documentation 17% (n=17/100) Within 2 weeks of mailing an informative letter, school nurses conducted follow-up telephone calls 84% (71/85) either returned referrals documenting follow-up from an exam or made an appointment with the enhanced protocol vs 20% (20/100) in the standard protocol 54% returned eye specialist report or has appointment (n=47/87) Noma et al., 2012 Brazil, Guarulhos, Sao Paulo 51,509 screened, 14,651 referred, 5,968 invited for second round of ophthalmology eye exams 1) Financial constraints 2) Weather changes 3) Child or family member sick 4) Logistical challenges, including transportation challenges, scheduling challenges with school, finding someone to stay with younger children, challenges with work schedules, and absent caregiver 5) Lack of confidence in program 6) Parents do not believe screening results 7) Lack of awareness 8) Fear 9) Caregiver forgetfulness 59% (n=8,683/14,651) A second round of ophthalmology eye exams for children with abnormal vision screening test who missed a first round. 37% (2,228/5,968) attended second round of ophthalmology eye exams [compared to 59% (8,683/14,651) at first round]. Second round resulted in coverage increment of 15% (59 to 75%) 75% (n=10,911/14,651) Rodriguez et al., 2018 USA, San Jose, California 6,067 screened in demonstration schools, 7,014 students screened in comparison schools between 2007 and 2012 NA 67% Full-time school nurses at demonstration schools made additional efforts to contact parents (3 times on average) to adhere to referrals to eye care professionals for eye exams, compared to part-time nurses at comparison schools Follow-up rates in demonstration schools ranged between 96% (2011-12) and 98% (2010-11) vs 69% in the pre-intervention year (2007-2008). Follow-up rates were between 41% and 67% in comparison schools 96% Suchoff and Mozlin, 1991 USA, Bronx, New York 37 identified in screening as priority cases (hyperopia, myopia or astigmatism ≥ 2D) NA NA 1) Hired paraprofessional called parents of priority students on phone 2) If parents could not be reached, a family worker visited the home in the evening 3) Appointments were made for parents to speak to the optometrist at school to emphasize the importance of addressing their child's visual problems 50% (7/14) attended the scheduled appointment with an optometrist 50% (n=7/14) Yawn et al., 1996 USA, Rochester, Olmstead County, Minnesota 2,887 screened, 820 with an abnormal vision screening test NA NA 1) Multiple referral cards sent home and parents asked to sign referral cards to acknowledge receipt 2) Public health nurses made telephone calls and home visits to families not returning the cards to ensure that each card was received 80% (657/820) had records of optometric or ophthalmologic evaluation after referral. Another 11% (91/820) were wearing lenses for the first time on a subsequent school vision screening. 91% (n=748/820) Zeng et al., 2020 China, Yudu county, Jiangxi province 9,936 screened (5,053 in intervention and 4,883, in control), 1,114 with abnormal screening results (513 intervention and 601 control) 1) Lack of awareness about eye disease 2) Longer travel time to the hospital and lack of access 37% (n=225/601) 1) Pre-arranged appointments at local hospital for follow-up care were made 2) Parents were reassured that doctors at the referral center had received professional training Intervention children had significantly higher compliance than controls (60% [308/513] vs.37% [n=225/601], P<0.001) 60% (n=308/513) Zhang et al., 2021 China, Shaanxi and Gansu Provinces 15,763 screened, 5,361 had visual impairment, 5,163 were referred NA 18% (n=962/5,361) 1) Community-based vision center that provides free eye exams and free spectacles following abnormal vision screening 2) Follow-up phone calls to schools and families to encourage parents to bring their children for vision care services Visitation rate for referred students was 43% (2,237/5,163) 43% (n=2,237/5,163) ABBREVIATIONS ECP = eye care professional WOW = Wills on Wheels, a mobile unit that provides free ophthalmology care at school to low income children with an abnormal vision screenings following optometric exams through Eagles Eye Mobile KVLF = Kids Vision for Life Foundation SVP = School Vision Program US: United States of America; NA: Not Applicable – study did not provide Information sources Searches were conducted across multiple electronic databases, including PubMed (NLM), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Scopus (Elsevier), and Web of Science (Clarivate). Sources of grey literature were OAIster, NIH RePORTER, Trials Register of Promoting Health Interventions (TRoPHI), National Center for Children's Vision and Eye Health website, American Association for Pediatric Ophthalmology and Strabismus website, Conference Proceedings Citation Index, and Cochrane CENTRAL Register of Controlled Trials. Additionally, a review of citations in included studies and relevant reviews was performed. Evidence selection Search results were initially collected in EndNote for deduplication and then uploaded into the Rayyan-Intelligent Systematic Review program (Rayyan Systems Inc., Cambridge, MA) to review retrieved articles. The article selection process followed a two-step approach: a review of titles and abstracts, followed by a review of full-text articles. Eligibility was assessed according to the criteria described earlier. All reviewers (AOA, PMH, AA, and AR) were involved in a pilot test on a random 10% of full-text articles retrieved from the initial search to ensure inter-rater reliability (IRR). The reviewer team screened the articles using the initial eligibility criteria outlined in our protocol and made minor changes to the inclusion criteria, such as the addition of studies involving caregivers of children, and clarity on the type of vision screening programs. Screening began once at least 75% agreement had occurred between all four reviewers on the pilot test. Each study was independently assessed at both stages by two reviewers at each level (title, abstract, and full-article review). Discrepancies were resolved through discussion or by a third reviewer (AOA or PMH). Study selection and data collection process Data from studies that were included in the review were extracted using a pilot-tested form. Key variables collected included author, year of publication, geographical context (i.e., city/state, country), World Health Organization income level, target population, screening setting, age range, and sex/gender, race, and ethnicity distributions (Appendix II) Synthesis of findings Data extracted from full-text studies selected for inclusion were synthesized following a three-stage process: inductive coding, theme generation, and theme mapping. Inductive coding was conducted using descriptive coding labels created inductively by one reviewer (AA) to allow patterns and preliminary subthemes related to social risk factors and strategies to emerge from existing published knowledge. The codes were reviewed and confirmed by a second reviewer (AOA) to ensure accuracy. Theme generation involved the identification, analysis, and interpretation of patterns within the data set (‘thematic synthesis’). Coded data was organized in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) by one reviewer (AA) into thematic groups, which were subsequently reviewed by another reviewer (AOA) to confirm consistency. The approach of theme generation facilitated the synthesis of findings to extend beyond the original studies, offering analytic insights. During the generation of themes, the reviewers consistently considered the study’s overarching research question and objectives. Results The initial search identified 5,538 studies through databases and grey literature, with 26 additional records identified through citation searching. After 2,308 duplicates were excluded, 3,230 studies were screened at the level of the abstract and title. An additional 2,893 citations were removed in the title and abstract screening as not relevant. During the full-text screening stage, 337 articles were required for retrieval, of which 11 were not available for retrieval. Of the 326 full-text articles assessed for eligibility, 31 studies met the inclusion criteria and were included in the review. Citations of included studies were searched to identify any additional studies, and two were subsequently included, making a total of 33 included studies. Overall, 16 studies assessed strategies to improve rates of referral adherence (Fig. 1 ). Seventeen studies assessed social risk factors following an abnormal vision screening test and have been reported in a separate manuscript. Of the included studies that assessed strategies to overcome referral nonadherence, 14 (88%) studies targeted vision screening programs conducted in schools ( 15 – 28 ), and two (13%) studies targeted programs in health care settings. ( 29 , 30 ) Vision screening programs in two studies (13%) targeted preschool-aged children (2 to 5 years) [16]; four studies (25%) targeted school-aged children (6 to 19 years) [22, 23, 25, 26]; and nine studies (56%) targeted both preschool- and school-aged children (2 to 19 years).( 15 , 17 , 20 , 21 , 24 , 27 , 28 , 30 , 31 ). Race was reported in three (19%) studies, ( 22 , 26 , 30 ) and ethnicity was reported in four (25%) studies.( 16 , 17 , 22 , 24 ) Nine studies targeted underserved or socially disadvantaged populations.( 15 , 16 , 18 , 22 , 24 , 25 , 28 , 29 , 31 ) Study designs varied with 10 included studies being intervention (63%) ( 15 , 16 , 18 , 20 – 22 , 24 , 25 , 30 , 31 ) compared to three descriptive (19%) ( 17 , 23 , 28 ) designs to assess strategies to improve referral adherence. Retrospective design was used in two (13%) studies ( 32 , 33 ), and one (6%) study implemented a cluster-randomized controlled trial. ( 27 ) In total, 12 studies (75%) were conducted in high income countries [United States (US) ( 15 – 18 , 21 , 22 , 24 – 26 , 29 – 31 )], and four (25%) studies were conducted in an upper middle-income country [(Peru, ( 20 ) Brazil, ( 23 ) China ( 27 , 28 )]. The most frequently reported strategy for improving referral adherence was enhanced direct communication reported in 13 studies (81%) (Fig. 2 ).( 16 , 17 , 21 – 31 ). This was followed by logistical support ( 15 , 17 , 18 , 20 , 24 , 27 – 29 , 31 ) in nine (56%) studies and financial support ( 15 , 16 , 18 , 20 , 21 , 28 , 31 , 33 ) in eight studies (50%). The least reported strategy was related to information and resources ( 16 , 20 , 21 , 25 , 27 ) in five studies (31%). Direct Communication Enhanced direct communication was implemented in vision screening programs reported by 13 studies (81%), ( 16 , 17 , 21 – 31 ) that were conducted in upper-middle [Brazil, ( 23 ) China ( 27 , 28 )] and high-income countries [United States (US), ( 16 , 17 , 21 , 22 , 24 , 25 , 30 – 33 )]. Particularly, organizers of vision screening programs in nine studies reported the placement of phone calls to caregivers to notify them of referrals after a vision screening test and encourage adherence. Another popular strategy reported in five studies was helping caregivers to schedule referral appointments (e.g., answering caregivers’ questions about covering the cost of the follow-up appointment, type of eye care provider to see, and where to find these providers), and coordinating these appointments. In some cases, pre-arranged appointments with eye care professionals were provided. (Table 3 ) Table 3 Synthesis of Strategies to Improve Adherence to Eye Care Referrals for Children following Abnormal Vision Screening Tests Intervention Theme Interventions Identified Studies Adopting This Intervention Communication Phone calls to notify and encourage follow-up eye exams* ( 14 ), ( 15 ), ( 21 ), ( 22 ), ( 24 ), ( 25 ), ( 26 ), ( 28 ), ( 29 ) Parent resources to assist follow-up (list of pediatric eye care providers, their health insurance, and other low-cost/no-cost vision care options) * ( 14 ), ( 21 ) Assistance with scheduling and coordinating follow-up appointments including pre-arranged appointments* ( 15 ), ( 18 ), ( 24 ), ( 30 ), ( 27 ) Multiple contact numbers collected at screening for follow-up ( 30 ) Detailed informative letter for parents by mail ( 22 ) Caregiver- optometrist interaction at school* ( 25 ) Referral letters encourage parents and family physicians to arrange exams and forms for eye care professional requesting replies* ( 19 ) Home visits to inform parents about abnormal test, if the parent is not available by phone ( 25 ) Information and Resources Caregiver resources to assist follow-up (list of pediatric eye care providers, their health insurance, and other low-cost/no-cost vision care options) * ( 14 ), ( 21 ) Appointments scheduled for caregivers to meet optometrists at school* ( 25 ) Developed health education materials for families ( 20 ) Caregiver reassurance of the provider training ( 27 ) Financial Support Free comprehensive eye exams and prescription glasses within proximity of vision screening location* ( 13 ), ( 28 ), ( 16 ) Caregiver resources to assist follow-up (health insurance accepted, and other low-cost/no-cost vision care options) * ( 14 ), ( 21 ) Social workers assist with enrollment in relevant health insurance ( 30 ), ( 20 ) Transportation support – vouchers * ( 30 ), ( 20 ) Free movie tickets to incentivize follow-up eye exams ( 18 ) Financial subsidies for glasses and treatment ( 20 ) Logistical Support Free comprehensive eye exams and prescription glasses within proximity of vision screening location* ( 13 ), ( 16 ), ( 28 ), ( 20 ) Assistance with scheduling and coordinating follow-up appointments including pre-arranged appointments* ( 15 ), ( 18 ), ( 24 ), ( 30 ), ( 27 ) Transportation support – vouchers * ( 30 ), ( 20 ) Reserved slots to expedite referral appointments ( 10 ) * Stars represent interventions that were represented in more than one theme. Information and Resources Five studies (31%) conducted in high [US ( 16 , 21 , 25 )], and upper-middle income [Peru,( 20 ) China ( 27 )] countries reported the provision of additional information and resources to motivate caregivers to adhere to referrals, and simplify the process of referral adherence. The resources and information included lists of pediatric eye care professionals, the insurance the provider accepted, and contact information to facilitate appointment scheduling. ( 16 , 21 ) Suchoff et al. created opportunities for optometrists to meet one-on-one with caregivers of children identified with severe vision impairment to amplify the importance of adhering to the referral. ( 25 ) A vision screening program in China offered comprehensive eye examinations for referred children, delivered by local nurses, ocular technicians, and ophthalmologists. These providers were trained by specialists from the Zhongshan Ophthalmic Center, a renowned eye clinic affiliated with Sun Yat-sen University. To promote caregiver adherence to referrals, program organizers emphasized the training received by these providers from Zhongshan experts, who would also be present at the referral clinic to oversee the management of any diagnosed eye conditions.( 27 ) (Table 3 ) Financial Support Vision screening programs reported in eight studies (50%) provided financial support ( 15 , 16 , 18 , 20 , 21 , 28 , 31 , 33 ) to improve adherence to referral eye exams. The vision screening programs were conducted in high-income (US) ( 15 , 16 , 18 , 21 , 31 , 33 ) and upper-middle-income [China, ( 27 ) Peru ( 20 )] countries. To overcome the financial constraints related to referral eye exams for families, the most popular strategy of financial support was free comprehensive eye exams in the same location or within proximity to the vision screening. ( 15 , 18 , 28 ) A study conducted in rural Peru trained teachers to perform basic vision screening of students. ( 20 ) Children with abnormal vision screening tests were examined onsite by an optometrist at school. Adherence rates were not reported, but a high follow-up rate with onsite eye exams was implied. ( 20 ) Other strategies to provide financial support include the use of social workers to assist families in enrolling in affordable health insurance programs, ( 20 , 33 ) vouchers for transportation to referral appointments, ( 20 , 33 ) and financial subsidies for glasses and treatment of eye disorders. ( 20 ) A novel approach by Hark et al. was to provide two free movie tickets to caregivers who adhered to referral appointments with eye care professionals for their children. ( 31 ) (Table 3 ) Logistical Support Logistical support was used to improve adherence in nine studies (56%) from upper-middle [China, ( 27 , 28 ) Peru ( 20 )] and high-income countries [US, ( 15 , 17 , 18 , 24 , 31 , 33 )]. The most frequently used method was assistance with scheduling and coordinating referral eye appointments to include providing pre-arranged appointments with eye care professionals. ( 17 , 24 , 27 , 31 , 33 ) Also mentioned in five studies was the provision of comprehensive eye exams on the same site as (or within close proximity to) the vision screening to encourage adherence to referral eye appointments. ( 17 , 24 , 27 , 31 , 33 ) In addition to this, support for transportation (vouchers and covering cost of transportation), ( 20 , 33 ) and reserved slots at eye clinics to expedite referral appointments had been strategies employed in prior studies. ( 31 ) Rates of Referral Adherence In total, 10 studies (63%) reported rates of adherence pre- and post-strategy intervention, ( 18 , 20 – 24 , 27 , 28 , 30 , 33 ) while four studies reported rates of adherence post-intervention only. ( 16 , 25 , 26 , 31 ) The highest rates of adherence were 96% (an increase from 67% pre-intervention) in the US-based study by Rodriguez et al., followed by 92% (an increase from 82% pre-intervention) in the Peru-based study by Latorre-Arteaga et al, and 91% in the study by Yawn et al. ( 26 ) The lowest rate of adherence of 43% in a study by Zhang et al. conducted in China. ( 28 ) Rodriguez et al. and Latorre-Arteaga et al. used multiple strategies to improve rates of referral adherence. Specifically, Rodriguez et al. used direct communication (i.e., phone calls to notify and encourage adherence to follow-up appointments) and logistical support (i.e., assistance with scheduling and coordinating follow-up appointments) strategies. ( 24 ) Latorre-Arteaga used information and resources (i.e., written health education materials for caregivers), and financial/logistical support (i.e., social workers’ assistance with enrolling in health insurance, transport vouchers, and subsidies for treatment and glasses). ( 20 ) Yawn et al., on the other hand, used one communication strategy, i.e. phone calls to notify and encourage adherence to follow-up appointments. ( 26 ) In the screening program conducted in China reported by Zhang et al., the lowest rate of referral adherence (43%) was reported despite the use of multiple strategies to improve referral adherence, specifically, financial/logistical support (i.e., free comprehensive eye exams and prescription glasses within proximity of vision screening) and communication strategies (i.e., phone calls to notify and encourage follow-up eye exams). The highest increase in the rates of adherence to referrals post-intervention was 57% reported in the study by Dotan et al., ( 33 ) followed by a 40% increase in adherence in the study by Kripke et al., ( 30 ) and a 37% increase in the study by Neville et al. ( 22 ) The vision screening programs described in these studies employed different strategies to improve rates of referral non-adherence. ( 22 , 30 , 33 ) For instance, in the study by Dotan et al., they used communication, financial, and logistical support strategies, specifically, social workers, transportation vouchers, and the collection of multiple contact numbers for the caregivers of children who were referred. ( 33 ) In the study by Kripke et al., they used a single communication strategy, specifically, sending letters to parents and family physicians to inform them of the referral and need for a comprehensive eye exam. ( 30 ) The program in the study by Neville et al. also used two communication strategies; specifically, follow-up phone calls to caregivers and a detailed informative letter (separate from the standard referral notification). ( 22 ) Discussion This scoping review synthesized published evidence on strategies designed to increase adherence to pediatric eye care referrals following abnormal vision screening results. Across the 16 included studies, ( 13 – 28 ) direct communication with caregivers emerged as the most frequently implemented approach to improve referral adherence, ( 14 , 15 , 18 , 19 , 21 , 22 , 24 – 30 ) often combined with logistical or financial supports to address common barriers. Gaps in the Literature None of the included studies reported strategies to improve referral adherence in lower-middle and low-income countries. This lack of studies highlights a significant gap in our understanding of the availability and types of strategies in settings where resources may be limited despite the high burden of vision impairment. ( 31 ) The limited research in eye care topics in lower-middle and low-income countries. ( 32 – 34 ) may reflect the overall lower investment in global health research. ( 35 – 37 ) Free Comprehensive Eye Exams Free comprehensive eye exams were frequently offered as a means of financial and logistical support to improve referral adherence. However, the impact of free comprehensive eye exams on referral adherence was mixed. In the study by Chu et al., which provided on-site free comprehensive eye exams in low-income schools by an optometrist, only 52% of children returned consent forms, and adherence rates were reported as similar to traditional referrals. ( 13 ) The Wills on Wheels Mobile Eye Unit provided follow-up eye exams by pediatric ophthalmologists at school for children referred by an optometrist with positive feedback from school nurses. ( 16 ) The presence of the mobile eye unit led to a statistically significant improvement in follow-up rate from a historical rate of 53% to an improved rate of 62%. However, in rural China, vision centers established to offer free eye exams and a pair of glasses for children while increasing access to comprehensive eye exams, resulted in only 43% of referred students visiting vision centers.( 16 ) Impact of Strategies on Referral Adherence Strategies implemented had varying impact on adherence to referrals for children with the rates of adherence ranging from 43–96%. The highest increase in adherence pre and post implementation of a new strategy was 57%. The rate of adherence did not appear to be additive based on the number of strategies employed. That is, employing more than one strategy did not translate to higher rates of adherence. While communication strategies were the most frequently used, it remains unclear whether it had greater impact on rates of adherence compared to other strategies. Improvements in the rates of adherence may depend on the target population and confounding factors such as race and ethnicity, geography, and socioeconomic status. Causal inferences of the effect of strategies on adherence to referrals cannot be drawn using scoping review methodology. To draw inferences and therefore assess the effectiveness of strategies on referral adherence, alternative methodologies such as systematic reviews, meta-analyses or randomized controlled trials are needed. Comparisons to Prior Studies Our companion study indicated that the most common social risk factor for referral nonadherence is a lack of affordability and awareness. Therefore, the results of this current study reflect that of the prior, given that communication, financial, and logistical support were the most frequently reported strategies. The study results also closely reflect that of Zeng et al. who reported health interventions to increase follow-up rates for ophthalmology eye exams following vision screening in the community. ( 12 ) The study population in the study by Zeng et al. was adult patients with diabetic retinopathy, glaucoma, refractive error, or cataract, and the most frequently reported interventions were free or subsidized follow-up eye exams (financial support), and reminder phone calls (logistical support). Other interventions identified in the Zeng et al., study included prescheduled ophthalmology appointments (logistical support), transportation assistance (logistical/financial support), patient education (communication), and patient navigators (logistical support). Rates of adherence ranged between 38 and 83%. The highest follow-up rate of 83% was reported in a study by Hark et al., who used patient navigators (logistical support) to improve follow-up to ophthalmology appointments.( 38 ) Patient navigators have been used widely in various medical specialties, including ophthalmology in adult populations ( 38 – 42 ) with no evidence of their effectiveness for vision screening programs in pediatric populations. Future studies should explore the effectiveness of the abundance of health interventions, including patient navigators, to improve referral adherence in vision screening programs targeted specifically to children. Strengths and Limitations Strengths of this study include its novelty, and its robust and systematic approach. To the best of our knowledge, it is the first study to identify strategies to improve referral adherence for children following abnormal vision screening tests, regardless of the screening setting or disease focus. Despite its strengths, the limitations of this study are consistent with JBI methodology and need to be considered. First, the quality of included studies was not assessed. Consequently, the risk of bias within individual studies cannot be commented on, which may affect the strength of the evidence synthesized. Also, had an assessment of the quality of included studies been conducted, additional gaps in knowledge may have been elucidated. Similarly, we cannot assess the effectiveness of strategies identified in prior studies without employing a systematic review or meta-analysis. Also, the heterogeneity of included studies, combined with the exclusion of non-English literature, may have led to gaps in the evidence captured. Finally, despite using a robust and systematic approach to search the literature, it is possible that some relevant studies may not have been selected for inclusion. Conclusion Many strategies—most commonly direct caregiver communication—have been implemented to enhance referral adherence among children flagged by vision screening programs. Future work should rigorously evaluate the effectiveness of these strategies using randomized controlled trials or in systematic reviews and meta-analysis. This knowledge will inform the development of scalable, evidence-based solutions that can prevent avoidable childhood vision loss. Abbreviations United States (US), Joanna Briggs Institute (JBI), Eye care professional (ECP), Wills on Wheels (WOW), Kids Vision for Life Foundation (KVLF), School Vision Program (SVP), Inter-rater reliability (IRR) Declarations Ethics approval and consent to participate : Ethical approval and informed consent were not required for this study, as it involved the analysis of previously published, de-identified data and did not involve interaction with human participants. As such, the study was deemed exempt from Institutional Review Board oversight Consent for publication: Consent for publication was not required for this study, as it involved the analysis of previously published, de-identified data and did not involve interaction with human participants. Competing Interests: The authors have no competing interests relevant to this article to disclose Funding/Support: This work was supported by the National Institutes of Health Core Grant (EY014800), and an Unrestricted Grant from Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology & Visual Sciences, Spencer Fox Eccles School of Medicine at the University of Utah. The work is also supported by the National Eye Institute (P30EY007003 and R01EY031337-03S1) and the National Institute of General Medical Sciences grant K12GM111725. The opinions, results, and conclusions reported in this paper are those of the authors and are independent of the funding sources. Funders had no role in the design and conduct of the study. Author Contribution AOA conceptualized and designed the study, acquired, analyzed and interpreted data, and drafted the article. AA, PMH, AR acquired, analyzed the data, made substantial contributions to conceptualizing and designing the study, interpreting data, and revised it critically for important intellectual content. AMH conceptualized and designed the study, acquired the data, and revised it critically for important intellectual content. TL made substantial contributions to conceptualizing and designing the study, interpreting data and revising it critically for important intellectual content. Acknowledgements: None Clinical trial number : Not applicable Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. References Mema SC, McIntyre L, Musto R. Childhood vision screening in Canada: public health evidence and practice. 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Zarnegar A, Cassidy J, Stone A, McGinnis-Thomas D, Wasser LM, Sahel JA et al. Effect of a Patient Navigator Program to Address Barriers to Eye Care at an Academic Ophthalmology Practice. J Acad Ophthalmol (2017). 2023;15(1):e106-e11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Oct, 2025 Reviews received at journal 14 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor invited by journal 19 Sep, 2025 Editor assigned by journal 28 Aug, 2025 Submission checks completed at journal 28 Aug, 2025 First submitted to journal 22 Aug, 2025 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-7436894","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":532733710,"identity":"5f7d979d-bebb-4f96-8e02-b34edaaff271","order_by":0,"name":"Afua O. 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19:31:20","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":157387,"visible":true,"origin":"","legend":"","description":"","filename":"2db551b2fa9d4ffc99bab4feed166dc01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7436894/v1/82ee8e215677db3d8ce21b92.xml"},{"id":94139044,"identity":"b6e39654-3122-4473-81ff-e4a85b822358","added_by":"auto","created_at":"2025-10-22 19:31:20","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":169571,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7436894/v1/86ff68793d6d893999a3a473.html"},{"id":94140793,"identity":"2c5ad2f9-a222-4724-9c39-77bbb33ba7f9","added_by":"auto","created_at":"2025-10-22 19:47:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":193077,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7436894/v1/2bf8c0ac2cfd45d57b70a5bb.png"},{"id":94139027,"identity":"0936cc93-148b-40ed-b38c-d31f31527bfc","added_by":"auto","created_at":"2025-10-22 19:31:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32971,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of Themes Addressed by Papers Included in the Scoping Review\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7436894/v1/94e1e489694a27828fd8ecad.png"},{"id":94141193,"identity":"5a010b9f-dd3e-4ec5-b2a2-0e87385d39db","added_by":"auto","created_at":"2025-10-22 19:55:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1554899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7436894/v1/73b1d282-4103-48e3-b329-ac74202e2dca.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strategies to Improve Adherence to Eye Care Referrals for Children following Vision Screening: A Scoping Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTo prevent long-term visual impairment, the early detection and treatment of vision disorders during childhood is essential.(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Vision screening enables the early identification of vision disorders through referrals to eye care professionals for a comprehensive eye examination.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) However, the effectiveness of vision screening programs is compromised when referrals to eye care professionals are not completed, preventing timely treatment for identified vision disorders. Vision screening is conducted in elementary schools, pediatric primary care, and/or other community-based settings in most countries.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn spite of the widespread use and established benefits of vision screening and comprehensive eye examinations, ensuring follow-up eye care after abnormal screening results remains a significant challenge. Studies show that as many as 60% of children do not attend recommended appointments with eye care providers following abnormal vision screening tests.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Lower adherence to eye care appointments disproportionally affects children from socially disadvantaged populations, including racial and ethnic minorities, underserved rural communities, people with low socioeconomic status, and sexual and gender minorities.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eEfforts to address low adherence to eye care appointments include developing evidence-based strategies and interventions. A previous study reviewed strategies to improve adherence to eye care professionals for adult populations.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Strategies reported in the study included patient navigation and prescheduled appointments. It is however unknown if these strategies have been used in pediatric populations and their impact on referral adherence for children.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) These gaps highlight the need for a comprehensive synthesis of strategies for improving referral nonadherence in children. The objective of this study is to identify strategies from the existing literature to improve referral adherence for comprehensive eye exams by eye care professionals following abnormal vision screening tests for children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eProtocol and registration\u003c/h2\u003e\n \u003cp\u003eThis scoping review followed the methodology outlined by the Joanna Briggs Institute (JBI) (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) for scoping reviews and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.(\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) This review is part of a broader study exploring adherence to pediatric eye care referrals. A companion scoping review focusing on social risk factors of non-adherence has been submitted separately, with adaptations to address a distinct research objective focused on intervention strategies. Searches were conducted across bibliographic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, and Web of Science) and gray literature were searched from their inception to July 2023, with an updated search performed in November 2024. The protocol for this review was registered with the Open Science Framework. As this study involved analysis of previously published sources with de-identified data and did not involve interaction with human participants, ethical approval and informed consent were not required and was exempt from the University of Utah Institutional Review Board.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eThe review team met with a librarian (AMH) in June 2023 to develop a comprehensive search strategy for PubMed. The strategy was subsequently adapted for use across additional electronic databases. The initial literature search was conducted in July 2023 covering studies available from the inception of the respective databases up to July 2023. An updated search was conducted in early November 2024. The search aimed to identify relevant studies that examined social risk factors of and strategies to improve referral adherence following abnormal vision screenings in children. Search terms included keyword and controlled vocabulary, where applicable, and their synonyms for the following concepts: \u003cem\u003echild, vision screening, referral adherence, and eye care professional\u003c/em\u003e. The complete search strategy used for PubMed can be found in Appendix I.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eStudies were selected based on specific characteristics including the type of target population, outcomes and study design. Screening for eligibility criteria was conducted in two phases: an initial review of the title/abstract followed by a full-text assessment, as detailed in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Eligible studies included vision screening conducted in any setting, e.g., school, pediatric primary care, or another community-based setting. There were no limitations on date of publication or country of publication; however, studies not published in English were excluded (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInclusion and Exclusion Criteria\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInclusion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExclusion\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Parents or guardians of children requiring follow-up after vision screening\u003c/p\u003e\n \u003cp\u003e\u0026bull; Children aged 3 to 18 years at the time of their vision screening test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Exclusion: Children\u0026thinsp;\u0026lt;\u0026thinsp;2 years and \u0026gt;\u0026thinsp;18 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudy Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Patient social risk factors of referral nonadherence to eye care professionals following abnormal vision screenings in children and strategies to address them\u003c/p\u003e\n \u003cp\u003e\u0026bull; Strategies to improve referral nonadherence to eye care professionals following abnormal vision screenings in children and strategies to address them\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; None\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Primary peer-reviewed studies, regardless of design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Commentaries, letters to the editor, editorials, and review papers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic Characteristics of Target Populations in Included Studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFirst author,\u003c/p\u003e\n \u003cp\u003eYear Published\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGeographical Context\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eWHO Income Level\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTarget Population\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eScreening setting\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge range**, years\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex/gender distribution [Females/Girls n (%)]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChu et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Santa Ana, California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of at-risk students attending Title I schools*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTitle I school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClarke et al., 2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Southern California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of preschool children in a large, urban public-school system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 to 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents: not specified\u003c/p\u003e\n \u003cp\u003eChildren: 292 (48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLatino/Hispanic 516 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay et al., 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, New York City\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of students attending public school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 to 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChildren: 129,035 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic: 114, 696 (43.2%); Black: 62,603 (23.6%); Asian: 42,785 (16.1%); White: 42,141 (15.9%); Multiracial or Missing: 3,287 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic:114,696 (43.2%)\u003c/p\u003e\n \u003cp\u003eNon-Hispanic: 150,816 (56.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiao et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt-risk/socioeconomically disadvantaged elementary students\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElementary school***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDotan et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of children with low SES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWills Eye Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 to18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents: not specified\u003c/p\u003e\n \u003cp\u003eChildren: 471 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHark et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of children from underserved communities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElementary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 to 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChildren: 5,245 (49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKripke et al., 1970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUS, Iowa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of preschool children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eField clinics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 to 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLatorre-Arteaga et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeru, Abancay, Apurimac region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper Middle Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreschool, primary, and secondary school children; teachers and directors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 to 17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMusch et al., 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, Wayne County, Michigan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of children in grades 1 and 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eschools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 to 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeville et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, New Jersey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of school-aged children in an urban middle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool (urban middle school)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 to 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (54.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfrican American 36(41.4%), Caucasian 23 (26.5%), Multiracial 3 (3.4%), Asian 3 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic 22 (25.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNoma et al., 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBrazil, Guarulhos, Sao Paulo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper Middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic elementary school children in grade 1 to 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 to 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5540 (50.70%) screened\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRodriguez et al., 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, San Jose, California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool nurses and parents of minority public school children with low income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 to 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLatino/Hispanic students in demonstration schools 81.1%, and 70.2% in comparison schools\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuchoff and Mozlin, 1991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, Bronx, New York\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of inner-city high school students (62% Hispanic, 27% Black)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 to 19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003cp\u003e47 (54.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYawn et al., 1996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUSA, Rochester, Olmstead County, Minnesota\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of kindergarten children in public and private schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic and private schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97% White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZeng et al., 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChina, Yudu county, Jiangxi province\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper Middle Income - Parts of China have been categorized as High Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents of preschool children with abnormal screening results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 to 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e535 girls (46.4%), 254 (42%) Control \u0026amp; 241 (50%) Intervention Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZhang et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChina, Shaanxi and Gansu Provinces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper Middle Income - Parts of China have been categorized as High Income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChildren in grade 4 to 6 living in poor, rural counties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 to 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,648 (48.5%) of children with visual impairment, 2718 (52.6%) of those complying with referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"918\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 918px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNOTES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 918px;\"\u003e\n \u003cp\u003e* Title I school = publicly funded school with a large portion of the surrounding attendance area are low-income families\u003c/p\u003e\n \u003cp\u003e** \u0026nbsp; \u0026nbsp; Refers to age range of children in the study sample\u003c/p\u003e\n \u003cp\u003e***Elementary school with more than 80% of students falling below the Federal Poverty Line (household income \u0026lt; $19,090 for family of three or \u0026lt; $23,050 for family of four)\u003c/p\u003e\n \u003cp\u003eABBREVIATIONS - US: United States of America; NA: Not Applicable \u0026ndash; study did not provide\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Identified Barriers and Interventions to Improve Referral Adherence to Eye Care Professionals\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"927\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst author, Year published\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry and local context\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to Referral Adherence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence (%) pre-strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterventions to Improve Referral Compliance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003epost- strategy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eChu et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Santa Ana, California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1,306 screened, 382 (29%) with abnormal screenings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Unable to afford cost of care\u003cbr\u003e\u0026nbsp;2) Need to travel to an ECP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Provided on-site eye exams via grant provided by KVLF at no cost to families with free glasses\u003cbr\u003e\u0026nbsp;2) In the event that the consent form was not returned, school personnel attempted to call the student\u0026rsquo;s parent/guardian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e52% (198/382) of parents consented to comprehensive eye exams\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eClarke et al., 2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Southern California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e592 screened, 42 (7%) with abnormal screenings, 29 (69.0%) answered follow-up calls\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Provided brochures to families following abnormal vision screenings detailing recommendations and low-cost/no-cost vision care options and the school nurse\u0026rsquo;s phone number for assistance\u003cbr\u003e\u0026nbsp;2) School nurses conducted follow-up calls to check in and emphasize importance of follow up if patient had not followed up within 2-3 months after an abnormal vision screening result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e- 17% (5/29) plans to follow-up after receiving brochure\u003c/p\u003e\n \u003cp\u003e- 83% (20/24) agreed to obtain a vision exam after follow-up calls\u003c/p\u003e\n \u003cp\u003e- 76% (19/25) contacted to obtain results of follow-up exam.\u003cbr\u003e\u0026nbsp;- 79% (15/19) with known follow up care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e- 17% (5/29) plans to follow-up after receiving brochure\u003c/p\u003e\n \u003cp\u003e- 83% (20/24) agreed to obtain a vision exam after follow-up calls\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eDay et al., 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, New York City\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e84% (n=229,834) of Pre-K to 1\u003csup\u003est\u003c/sup\u003e grade students enrolled from 2018-19 were screened; Of the total number of students screened, 22.2% (n=42,859) of Pre-K to 1\u003csup\u003est\u003c/sup\u003e grade students had abnormal vision screenings, 69.1% (n=29,615) received follow-up efforts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Difficulties accessing eye exam services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) SVP conducts follow-up calls immediately after screening, alerting parents to referral letters placed in the children\u0026rsquo;s backpack\u003cbr\u003e\u0026nbsp;2) Subsequent phone calls every two weeks to encourage and help parents find pediatric eye care. If family unreachable, letter mailed to parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eOf the 22.2% (n=42,827) of screened students with abnormal vision screenings in 2018\u0026ndash;19, 69.1% (n=29,598) received follow-up efforts, and 38.8% completed eye exams (n=16,617)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eDiao et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e132 referred, 72% (95/132) students with consent to receive care by the WOW Mobile Eye Unit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Lack of transportation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eWOW Mobile Eye Unit*\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e62% (CI: 54% to 70%) of patients (n= 82/132) were seen by the mobile unit. Historic rate of 53%. Statistically significant improvement in follow-up was noted (p = .036)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e62% (n=82/132)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eDotan et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e924 children examined, 10% (n=96) needed follow-up care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Lack of insurance or lack of awareness about how to use insurance/insurance benefits\u003cbr\u003e\u0026nbsp;2) Challenges with literacy\u0026nbsp;\u003cbr\u003e\u0026nbsp;3) Inconvenience of follow-up\u003cbr\u003e\u0026nbsp;4) Lack of understanding about the benefits of early intervention\u003cbr\u003e\u0026nbsp;5) Family priorities\u0026nbsp;\u003cbr\u003e\u0026nbsp;6) Concerns about costs\u003cbr\u003e\u0026nbsp;7) Transportation issues\u003cbr\u003e\u0026nbsp;8) Lack of effective communication methods\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Social worker was present during screening to ensure sufficient and accurate contact information was collected from parents (up to 5 telephone numbers were recorded for children needing follow-up)\u003cbr\u003e\u0026nbsp;2) Social worker helped arrange follow-up appointments, enrollment in insurance if needed, and vouchers for transportation to follow-up when needed\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e59% (n=57/96) received follow-up care\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e59% (n=57/96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eHark et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e10,726 screened, 5% (n=509) referred because of suspected nonrefractive eye disease , 215 scheduled for follow-up appointment, 82% (n=177/215) did not have an eye care provider.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Social worker contacted parents and assisted with scheduling an appointment with pediatric ophthalmology at Wills Eye Hospital, which offered expedited appointments in reserved slots\u003cbr\u003e\u0026nbsp;2) Two movie tickets to incentivize parents to attend the follow-up appointment\u003cbr\u003e\u0026nbsp;3) Liaison with the school district conducted up to 3 phone call reminders to parents who did not return completed consent forms within 4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eReferral adherence was 72% (n=127/177)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e72% (n=127/177)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eKripke et al., 1970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUS, Iowa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1233 screened (585 in 1967, 648 in 1968)\u003c/p\u003e\n \u003cp\u003e92 referred (49 in 1967, 43 in 1968)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e22.4% (n=11/49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Parents and physicians encouraged to arrange full eye examinations for student with abnormal vision screening tests\u003cbr\u003e\u0026nbsp;2) Shortened time between abnormal vision screening and sending report letters to parents\u003cbr\u003e\u0026nbsp;3) Forms requesting replies were enclosed with report letters to parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e63% (n=27/43) of children referred in 1968 completed an eye examination vs 22.4% (n=11) in 1967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e62.8% (n=27/43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eLatorre-Arteaga et al., 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003ePeru, Abancay, Apurimac region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1,522 screened, 259 (17%) referred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e66% (n=45/68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Develop health education materials for families\u003cbr\u003e\u0026nbsp;2) Provide logistic support (i.e., transportation)\u003cbr\u003e\u0026nbsp;3) Provide outreach clinic in remote locations, free eye exams, and financial subsidies for patients who could not afford the cost of glasses, medical treatment or transport to the eye hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e237 received an eye exam representing a 39% increase in attendance rate at eye clinic [from 66% (45/68) to 92% (237/259)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e92% (n=237/259)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eMusch et al., 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUSA, Wayne County, Michigan\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e162 with abnormal screening tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e48% (n=39/82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Coordinator contacted parents within 3 weeks of mailing the initial letter to check if the follow-up examination has been scheduled or was completed\u003cbr\u003e\u0026nbsp;2) Coordinator provided reminders and a list of ECPs in the area willing to examine the child, including designation of those who accept Medicaid as well as those who would see the child at no cost\u003cbr\u003e\u0026nbsp;3) If no completed ECP form was received within 6 weeks of abnormal screening, coordinator made a second phone call to ensure follow-up care is being pursued\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e65% (52/80) children had a documented ECP exam within 16 weeks in the enhanced group vs 47.6% (39/82) in the standard group (p=0.025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e65% (n=52/80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eNeville et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUSA, New Jersey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e341 screened, 87 abnormal screens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Didn\u0026apos;t receive or lost referral letter\u0026nbsp;\u003cbr\u003e\u0026nbsp;2) Financial concerns\u003cbr\u003e\u0026nbsp;3) Lack of insurance\u003cbr\u003e\u0026nbsp;4) Language barriers\u003cbr\u003e\u0026nbsp;5) Lack of time/busy/procrastination\u003cbr\u003e\u0026nbsp;5) Do not believe vision screening results\u0026nbsp;\u003cbr\u003e\u0026nbsp;6) Inattention to school documentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e17% (n=17/100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eWithin 2 weeks of mailing an informative letter, school nurses conducted follow-up telephone calls\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e84% (71/85) either returned referrals documenting follow-up from an exam or made an appointment with the enhanced protocol vs 20% (20/100) in the standard protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e54% returned eye specialist report or has appointment (n=47/87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eNoma et al., 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eBrazil, Guarulhos, Sao Paulo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e51,509 screened, 14,651 referred, \u0026nbsp;5,968 invited for second round of ophthalmology eye exams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Financial constraints\u003cbr\u003e\u0026nbsp;2) Weather changes\u003cbr\u003e\u0026nbsp;3) Child or family member sick\u003cbr\u003e\u0026nbsp;4) Logistical challenges, including transportation challenges, scheduling challenges with school, finding someone to stay with younger children, challenges with work schedules, and absent caregiver\u003cbr\u003e\u0026nbsp;5) Lack of confidence in program\u003cbr\u003e\u0026nbsp;6) Parents do not believe screening results\u003cbr\u003e\u0026nbsp;7) Lack of awareness\u003cbr\u003e\u0026nbsp;8) Fear\u003cbr\u003e\u0026nbsp;9) Caregiver forgetfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e59% (n=8,683/14,651)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eA second round of ophthalmology eye exams for children with abnormal vision screening test who missed a first round.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e37% (2,228/5,968) attended second round of ophthalmology eye exams [compared to 59% (8,683/14,651) at first round]. Second round resulted in coverage increment of 15% (59 to 75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e75% (n=10,911/14,651)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eRodriguez et al., 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUSA, San Jose, California\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e6,067 screened in demonstration schools, 7,014 students screened in comparison schools between 2007 and 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003eFull-time school nurses at demonstration schools made additional efforts to contact parents (3 times on average) to adhere to referrals to eye care professionals for eye exams, compared to part-time nurses at comparison schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eFollow-up rates in demonstration schools ranged between 96% (2011-12) and 98% (2010-11) vs 69% in the pre-intervention year \u0026nbsp; \u0026nbsp; (2007-2008). Follow-up rates were between 41% and 67% in comparison schools\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e96%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eSuchoff and Mozlin, 1991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUSA, Bronx, New York\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e37 identified in screening as priority cases (hyperopia, myopia or astigmatism \u0026ge; 2D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Hired paraprofessional called parents of priority students on phone\u003cbr\u003e\u0026nbsp;2) If parents could not be reached, a family worker visited the home in the evening\u003cbr\u003e\u0026nbsp;3) Appointments were made for parents to speak to the optometrist at school to emphasize the importance of addressing their child\u0026apos;s visual problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e50% (7/14) attended the scheduled appointment with an optometrist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e50% (n=7/14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eYawn et al., 1996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eUSA, Rochester, Olmstead County, Minnesota\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e2,887 screened, 820 with an abnormal vision screening test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;NA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Multiple referral cards sent home and parents asked to sign referral cards to acknowledge receipt\u003cbr\u003e\u0026nbsp;2) Public health nurses made telephone calls and home visits to families not returning the cards to ensure that each card was received\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e80% (657/820) had records of optometric or ophthalmologic evaluation after referral. Another 11% (91/820) were wearing lenses for the first time on a subsequent school vision screening.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e91% (n=748/820)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eZeng et al., 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eChina, Yudu county, Jiangxi province\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e9,936 screened (5,053 in intervention and 4,883, in control), 1,114 with abnormal screening results (513 intervention and 601 control)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1) Lack of awareness about eye disease\u003cbr\u003e\u0026nbsp;2) Longer travel time to the hospital and lack of access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e37% (n=225/601)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Pre-arranged appointments at local hospital for follow-up care were made\u003cbr\u003e\u0026nbsp;2) Parents were reassured that doctors at the referral center had received professional training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eIntervention children had significantly higher compliance than controls (60% [308/513] vs.37% [n=225/601], P\u0026lt;0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e60% (n=308/513)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eZhang et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eChina, Shaanxi and Gansu Provinces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e15,763 screened, 5,361 had visual impairment, 5,163 were referred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e18% (n=962/5,361)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e1) Community-based vision center that provides free eye exams and free spectacles following abnormal vision screening\u003c/p\u003e\n \u003cp\u003e2) Follow-up phone calls to schools and families to encourage parents to bring their children for vision care services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003eVisitation rate for referred students was 43% (2,237/5,163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e43% (n=2,237/5,163)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eABBREVIATIONS\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eECP = eye care professional\u003c/p\u003e\n\u003cp\u003eWOW = Wills on Wheels, a mobile unit that provides free ophthalmology care at school to low income children with an abnormal vision screenings following optometric exams through Eagles Eye Mobile\u003c/p\u003e\n\u003cp\u003eKVLF = Kids Vision for Life Foundation\u003c/p\u003e\n\u003cp\u003eSVP = School Vision Program\u003c/p\u003e\n\u003cp\u003eUS: United States of America; NA: Not Applicable \u0026ndash; study did not provide\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cp\u003eSearches were conducted across multiple electronic databases, including PubMed (NLM), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Scopus (Elsevier), and Web of Science (Clarivate). Sources of grey literature were OAIster, NIH RePORTER, Trials Register of Promoting Health Interventions (TRoPHI), National Center for Children\u0026apos;s Vision and Eye Health website, American Association for Pediatric Ophthalmology and Strabismus website, Conference Proceedings Citation Index, and Cochrane CENTRAL Register of Controlled Trials. Additionally, a review of citations in included studies and relevant reviews was performed.\u003c/p\u003e\n\u003ch3\u003eEvidence selection\u003c/h3\u003e\n\u003cp\u003eSearch results were initially collected in EndNote for deduplication and then uploaded into the Rayyan-Intelligent Systematic Review program (Rayyan Systems Inc., Cambridge, MA) to review retrieved articles. The article selection process followed a two-step approach: a review of titles and abstracts, followed by a review of full-text articles. Eligibility was assessed according to the criteria described earlier. All reviewers (AOA, PMH, AA, and AR) were involved in a pilot test on a random 10% of full-text articles retrieved from the initial search to ensure inter-rater reliability (IRR). The reviewer team screened the articles using the initial eligibility criteria outlined in our protocol and made minor changes to the inclusion criteria, such as the addition of studies involving caregivers of children, and clarity on the type of vision screening programs. Screening began once at least 75% agreement had occurred between all four reviewers on the pilot test. Each study was independently assessed at both stages by two reviewers at each level (title, abstract, and full-article review). Discrepancies were resolved through discussion or by a third reviewer (AOA or PMH).\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy selection and data collection process\u003c/h2\u003e\n \u003cp\u003eData from studies that were included in the review were extracted using a pilot-tested form. Key variables collected included author, year of publication, geographical context (i.e., city/state, country), World Health Organization income level, target population, screening setting, age range, and sex/gender, race, and ethnicity distributions (Appendix II)\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSynthesis of findings\u003c/h3\u003e\n\u003cp\u003eData extracted from full-text studies selected for inclusion were synthesized following a three-stage process: inductive coding, theme generation, and theme mapping. Inductive coding was conducted using descriptive coding labels created inductively by one reviewer (AA) to allow patterns and preliminary subthemes related to social risk factors and strategies to emerge from existing published knowledge. The codes were reviewed and confirmed by a second reviewer (AOA) to ensure accuracy.\u003c/p\u003e\n\u003cp\u003eTheme generation involved the identification, analysis, and interpretation of patterns within the data set (\u0026lsquo;thematic synthesis\u0026rsquo;). Coded data was organized in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) by one reviewer (AA) into thematic groups, which were subsequently reviewed by another reviewer (AOA) to confirm consistency. The approach of theme generation facilitated the synthesis of findings to extend beyond the original studies, offering analytic insights. During the generation of themes, the reviewers consistently considered the study\u0026rsquo;s overarching research question and objectives.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe initial search identified 5,538 studies through databases and grey literature, with 26 additional records identified through citation searching. After 2,308 duplicates were excluded, 3,230 studies were screened at the level of the abstract and title. An additional 2,893 citations were removed in the title and abstract screening as not relevant. During the full-text screening stage, 337 articles were required for retrieval, of which 11 were not available for retrieval. Of the 326 full-text articles assessed for eligibility, 31 studies met the inclusion criteria and were included in the review. Citations of included studies were searched to identify any additional studies, and two were subsequently included, making a total of 33 included studies. Overall, 16 studies assessed strategies to improve rates of referral adherence (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Seventeen studies assessed social risk factors following an abnormal vision screening test and have been reported in a separate manuscript.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOf the included studies that assessed strategies to overcome referral nonadherence, 14 (88%) studies targeted vision screening programs conducted in schools (\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and two (13%) studies targeted programs in health care settings. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eVision screening programs in two studies (13%) targeted preschool-aged children (2 to 5 years) [16]; four studies (25%) targeted school-aged children (6 to 19 years) [22, 23, 25, 26]; and nine studies (56%) targeted both preschool- and school-aged children (2 to 19 years).(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Race was reported in three (19%) studies, (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and ethnicity was reported in four (25%) studies.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Nine studies targeted underserved or socially disadvantaged populations.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Study designs varied with 10 included studies being intervention (63%) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) compared to three descriptive (19%) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) designs to assess strategies to improve referral adherence. Retrospective design was used in two (13%) studies (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and one (6%) study implemented a cluster-randomized controlled trial. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) In total, 12 studies (75%) were conducted in high income countries [United States (US) (\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)], and four (25%) studies were conducted in an upper middle-income country [(Peru, (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Brazil, (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) China (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)]. The most frequently reported strategy for improving referral adherence was enhanced direct communication reported in 13 studies (81%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This was followed by logistical support (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) in nine (56%) studies and financial support (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) in eight studies (50%). The least reported strategy was related to information and resources (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) in five studies (31%).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDirect Communication\u003c/h2\u003e\u003cp\u003eEnhanced direct communication was implemented in vision screening programs reported by 13 studies (81%), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) that were conducted in upper-middle [Brazil, (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) China (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)] and high-income countries [United States (US), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)]. Particularly, organizers of vision screening programs in nine studies reported the placement of phone calls to caregivers to notify them of referrals after a vision screening test and encourage adherence. Another popular strategy reported in five studies was helping caregivers to schedule referral appointments (e.g., answering caregivers\u0026rsquo; questions about covering the cost of the follow-up appointment, type of eye care provider to see, and where to find these providers), and coordinating these appointments. In some cases, pre-arranged appointments with eye care professionals were provided. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\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\u003eSynthesis of Strategies to Improve Adherence to Eye Care Referrals for Children following Abnormal Vision Screening Tests\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention Theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterventions Identified\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudies Adopting This Intervention\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eCommunication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhone calls to notify and encourage follow-up eye exams*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParent resources to assist follow-up (list of pediatric eye care providers, their health insurance, and other low-cost/no-cost vision care options) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssistance with scheduling and coordinating follow-up appointments including pre-arranged appointments*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultiple contact numbers collected at screening for follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDetailed informative letter for parents by mail\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver- optometrist interaction at school*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReferral letters encourage parents and family physicians to arrange exams and forms for eye care professional requesting replies*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHome visits to inform parents about abnormal test, if the parent is not available by phone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eInformation and Resources\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver resources to assist follow-up (list of pediatric eye care providers, their health insurance, and other low-cost/no-cost vision care options) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAppointments scheduled for caregivers to meet optometrists at school*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeveloped health education materials for families\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver reassurance of the provider training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eFinancial Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFree comprehensive eye exams and prescription glasses within proximity of vision screening location*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCaregiver resources to assist follow-up (health insurance accepted, and other low-cost/no-cost vision care options) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial workers assist with enrollment in relevant health insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransportation support \u0026ndash; vouchers *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFree movie tickets to incentivize follow-up eye exams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFinancial subsidies for glasses and treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eLogistical Support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFree comprehensive eye exams and prescription glasses within proximity of vision screening location*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssistance with scheduling and coordinating follow-up appointments including pre-arranged appointments*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransportation support \u0026ndash; vouchers *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReserved slots to expedite referral appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Stars represent interventions that were represented in more than one theme.\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\u003eInformation and Resources\u003c/h2\u003e\u003cp\u003eFive studies (31%) conducted in high [US (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)], and upper-middle income [Peru,(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) China (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)] countries reported the provision of additional information and resources to motivate caregivers to adhere to referrals, and simplify the process of referral adherence. The resources and information included lists of pediatric eye care professionals, the insurance the provider accepted, and contact information to facilitate appointment scheduling. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Suchoff et al. created opportunities for optometrists to meet one-on-one with caregivers of children identified with severe vision impairment to amplify the importance of adhering to the referral. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) A vision screening program in China offered comprehensive eye examinations for referred children, delivered by local nurses, ocular technicians, and ophthalmologists. These providers were trained by specialists from the Zhongshan Ophthalmic Center, a renowned eye clinic affiliated with Sun Yat-sen University. To promote caregiver adherence to referrals, program organizers emphasized the training received by these providers from Zhongshan experts, who would also be present at the referral clinic to oversee the management of any diagnosed eye conditions.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eFinancial Support\u003c/h2\u003e\u003cp\u003eVision screening programs reported in eight studies (50%) provided financial support (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) to improve adherence to referral eye exams. The vision screening programs were conducted in high-income (US) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and upper-middle-income [China, (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Peru (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)] countries. To overcome the financial constraints related to referral eye exams for families, the most popular strategy of financial support was free comprehensive eye exams in the same location or within proximity to the vision screening. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) A study conducted in rural Peru trained teachers to perform basic vision screening of students. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Children with abnormal vision screening tests were examined onsite by an optometrist at school. Adherence rates were not reported, but a high follow-up rate with onsite eye exams was implied. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Other strategies to provide financial support include the use of social workers to assist families in enrolling in affordable health insurance programs, (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) vouchers for transportation to referral appointments, (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and financial subsidies for glasses and treatment of eye disorders. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) A novel approach by Hark et al. was to provide two free movie tickets to caregivers who adhered to referral appointments with eye care professionals for their children. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLogistical Support\u003c/h2\u003e\u003cp\u003eLogistical support was used to improve adherence in nine studies (56%) from upper-middle [China, (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Peru (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)] and high-income countries [US, (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)]. The most frequently used method was assistance with scheduling and coordinating referral eye appointments to include providing pre-arranged appointments with eye care professionals. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Also mentioned in five studies was the provision of comprehensive eye exams on the same site as (or within close proximity to) the vision screening to encourage adherence to referral eye appointments. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) In addition to this, support for transportation (vouchers and covering cost of transportation), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and reserved slots at eye clinics to expedite referral appointments had been strategies employed in prior studies. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eRates of Referral Adherence\u003c/h2\u003e\u003cp\u003eIn total, 10 studies (63%) reported rates of adherence pre- and post-strategy intervention, (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) while four studies reported rates of adherence post-intervention only. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) The highest rates of adherence were 96% (an increase from 67% pre-intervention) in the US-based study by Rodriguez et al., followed by 92% (an increase from 82% pre-intervention) in the Peru-based study by Latorre-Arteaga et al, and 91% in the study by Yawn et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The lowest rate of adherence of 43% in a study by Zhang et al. conducted in China. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Rodriguez et al. and Latorre-Arteaga et al. used multiple strategies to improve rates of referral adherence. Specifically, Rodriguez et al. used direct communication (i.e., phone calls to notify and encourage adherence to follow-up appointments) and logistical support (i.e., assistance with scheduling and coordinating follow-up appointments) strategies. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Latorre-Arteaga used information and resources (i.e., written health education materials for caregivers), and financial/logistical support (i.e., social workers\u0026rsquo; assistance with enrolling in health insurance, transport vouchers, and subsidies for treatment and glasses). (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Yawn et al., on the other hand, used one communication strategy, i.e. phone calls to notify and encourage adherence to follow-up appointments. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) In the screening program conducted in China reported by Zhang et al., the lowest rate of referral adherence (43%) was reported despite the use of multiple strategies to improve referral adherence, specifically, financial/logistical support (i.e., free comprehensive eye exams and prescription glasses within proximity of vision screening) and communication strategies (i.e., phone calls to notify and encourage follow-up eye exams).\u003c/p\u003e\u003cp\u003eThe highest increase in the rates of adherence to referrals post-intervention was 57% reported in the study by Dotan et al., (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) followed by a 40% increase in adherence in the study by Kripke et al., (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and a 37% increase in the study by Neville et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) The vision screening programs described in these studies employed different strategies to improve rates of referral non-adherence. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) For instance, in the study by Dotan et al., they used communication, financial, and logistical support strategies, specifically, social workers, transportation vouchers, and the collection of multiple contact numbers for the caregivers of children who were referred. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) In the study by Kripke et al., they used a single communication strategy, specifically, sending letters to parents and family physicians to inform them of the referral and need for a comprehensive eye exam. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) The program in the study by Neville et al. also used two communication strategies; specifically, follow-up phone calls to caregivers and a detailed informative letter (separate from the standard referral notification). (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This scoping review synthesized published evidence on strategies designed to increase adherence to pediatric eye care referrals following abnormal vision screening results. Across the 16 included studies, (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) direct communication with caregivers emerged as the most frequently implemented approach to improve referral adherence, (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) often combined with logistical or financial supports to address common barriers.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eGaps in the Literature\u003c/h2\u003e\u003cp\u003eNone of the included studies reported strategies to improve referral adherence in lower-middle and low-income countries. This lack of studies highlights a significant gap in our understanding of the availability and types of strategies in settings where resources may be limited despite the high burden of vision impairment. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) The limited research in eye care topics in lower-middle and low-income countries. (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) may reflect the overall lower investment in global health research. (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eFree Comprehensive Eye Exams\u003c/h2\u003e\u003cp\u003eFree comprehensive eye exams were frequently offered as a means of financial and logistical support to improve referral adherence. However, the impact of free comprehensive eye exams on referral adherence was mixed. In the study by Chu et al., which provided on-site free comprehensive eye exams in low-income schools by an optometrist, only 52% of children returned consent forms, and adherence rates were reported as similar to traditional referrals. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The Wills on Wheels Mobile Eye Unit provided follow-up eye exams by pediatric ophthalmologists at school for children referred by an optometrist with positive feedback from school nurses. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) The presence of the mobile eye unit led to a statistically significant improvement in follow-up rate from a historical rate of 53% to an improved rate of 62%. However, in rural China, vision centers established to offer free eye exams and a pair of glasses for children while increasing access to comprehensive eye exams, resulted in only 43% of referred students visiting vision centers.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eImpact of Strategies on Referral Adherence\u003c/h2\u003e\u003cp\u003eStrategies implemented had varying impact on adherence to referrals for children with the rates of adherence ranging from 43\u0026ndash;96%. The highest increase in adherence pre and post implementation of a new strategy was 57%. The rate of adherence did not appear to be additive based on the number of strategies employed. That is, employing more than one strategy did not translate to higher rates of adherence. While communication strategies were the most frequently used, it remains unclear whether it had greater impact on rates of adherence compared to other strategies. Improvements in the rates of adherence may depend on the target population and confounding factors such as race and ethnicity, geography, and socioeconomic status. Causal inferences of the effect of strategies on adherence to referrals cannot be drawn using scoping review methodology. To draw inferences and therefore assess the effectiveness of strategies on referral adherence, alternative methodologies such as systematic reviews, meta-analyses or randomized controlled trials are needed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eComparisons to Prior Studies\u003c/h2\u003e\u003cp\u003eOur companion study indicated that the most common social risk factor for referral nonadherence is a lack of affordability and awareness. Therefore, the results of this current study reflect that of the prior, given that communication, financial, and logistical support were the most frequently reported strategies. The study results also closely reflect that of Zeng et al. who reported health interventions to increase follow-up rates for ophthalmology eye exams following vision screening in the community. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The study population in the study by Zeng et al. was adult patients with diabetic retinopathy, glaucoma, refractive error, or cataract, and the most frequently reported interventions were free or subsidized follow-up eye exams (financial support), and reminder phone calls (logistical support). Other interventions identified in the Zeng et al., study included prescheduled ophthalmology appointments (logistical support), transportation assistance (logistical/financial support), patient education (communication), and patient navigators (logistical support). Rates of adherence ranged between 38 and 83%. The highest follow-up rate of 83% was reported in a study by Hark et al., who used patient navigators (logistical support) to improve follow-up to ophthalmology appointments.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Patient navigators have been used widely in various medical specialties, including ophthalmology in adult populations (\u003cspan additionalcitationids=\"CR39 CR40 CR41\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) with no evidence of their effectiveness for vision screening programs in pediatric populations. Future studies should explore the effectiveness of the abundance of health interventions, including patient navigators, to improve referral adherence in vision screening programs targeted specifically to children.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eStrengths of this study include its novelty, and its robust and systematic approach. To the best of our knowledge, it is the first study to identify strategies to improve referral adherence for children following abnormal vision screening tests, regardless of the screening setting or disease focus. Despite its strengths, the limitations of this study are consistent with JBI methodology and need to be considered. First, the quality of included studies was not assessed. Consequently, the risk of bias within individual studies cannot be commented on, which may affect the strength of the evidence synthesized. Also, had an assessment of the quality of included studies been conducted, additional gaps in knowledge may have been elucidated. Similarly, we cannot assess the effectiveness of strategies identified in prior studies without employing a systematic review or meta-analysis. Also, the heterogeneity of included studies, combined with the exclusion of non-English literature, may have led to gaps in the evidence captured. Finally, despite using a robust and systematic approach to search the literature, it is possible that some relevant studies may not have been selected for inclusion.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMany strategies\u0026mdash;most commonly direct caregiver communication\u0026mdash;have been implemented to enhance referral adherence among children flagged by vision screening programs. Future work should rigorously evaluate the effectiveness of these strategies using randomized controlled trials or in systematic reviews and meta-analysis. This knowledge will inform the development of scalable, evidence-based solutions that can prevent avoidable childhood vision loss.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUnited States (US), Joanna Briggs Institute (JBI), Eye care professional (ECP), Wills on Wheels (WOW), Kids Vision for Life Foundation (KVLF), School Vision Program (SVP), Inter-rater reliability (IRR)\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eEthical approval and informed consent were not required for this study, as it involved the analysis of previously published, de-identified data and did not involve interaction with human participants. As such, the study was deemed exempt from Institutional Review Board oversight\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was not required for this study, as it involved the analysis of previously published, de-identified data and did not involve interaction with human participants.\u003c/p\u003e\n\u003ch2\u003eCompeting Interests:\u003c/h2\u003e\n\u003cp\u003eThe authors have no competing interests relevant to this article to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support: \u003c/strong\u003eThis work was supported by the National Institutes of Health Core Grant (EY014800), and an Unrestricted Grant from Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology \u0026amp; Visual Sciences, Spencer Fox Eccles School of Medicine at the University of Utah. The work is also supported by the National Eye Institute (P30EY007003 and R01EY031337-03S1) and the National Institute of General Medical Sciences grant K12GM111725. The opinions, results, and conclusions reported in this paper are those of the authors and are independent of the funding sources. Funders had no role in the design and conduct of the study.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAOA conceptualized and designed the study, acquired, analyzed and interpreted data, and drafted the article. AA, PMH, AR acquired, analyzed the data, made substantial contributions to conceptualizing and designing the study, interpreting data, and revised it critically for important intellectual content. AMH conceptualized and designed the study, acquired the data, and revised it critically for important intellectual content. TL made substantial contributions to conceptualizing and designing the study, interpreting data and revising it critically for important intellectual content.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMema SC, McIntyre L, Musto R. Childhood vision screening in Canada: public health evidence and practice. Can J public health = Revue canadienne de sante publique. 2011;103(1):40\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchuster AK, Elflein HM, Diefenbach C, Gr\u0026auml;f C, K\u0026ouml;nig J, Schmidt MF, et al. 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JAMA Ophthalmol. 2015;133(5):527\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489\u0026ndash;551.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlanchet K, Gilbert C, de Savigny D. Rethinking eye health systems to achieve universal coverage: the role of research. Br J Ophthalmol. 2014;98(10):1325\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWong B, Singh K, Everett B, O'Brien KS, Ravilla T, Khanna RC, et al. The case for investment in eye health: systematic review and economic modelling analysis. Bull World Health Organ. 2023;101(12):786\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoundation S. Eye health: A best buy in global health and development [Policy brief]. 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A randomized, controlled trial to test the effectiveness of a glaucoma patient navigator to improve appointment adherence. Patient Prefer Adherence. 2016;10:1739\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHark L, Waisbourd M, Myers JS, Henderer J, Crews JE, Saaddine JB, et al. Improving Access to Eye Care among Persons at High-Risk of Glaucoma in Philadelphia\u0026ndash;Design and Methodology: The Philadelphia Glaucoma Detection and Treatment Project. Ophthalmic Epidemiol. 2016;23(2):122\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrinks M, Zaback T, Park DW, Joan R, Cramer SK, Chiang MF. Community-based vision health screening with on-site definitive exams: Design and outcomes. Cogent Med. 2018;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWasser LM, Bear TM, Sommers M, Cassidy J, Muir KW, Williams AM. Barriers to Care Among Glaucoma Patients With a Missed Appointment and Interest in a Navigator Program. J Glaucoma. 2024;33(4):297\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZarnegar A, Cassidy J, Stone A, McGinnis-Thomas D, Wasser LM, Sahel JA et al. Effect of a Patient Navigator Program to Address Barriers to Eye Care at an Academic Ophthalmology Practice. J Acad Ophthalmol (2017). 2023;15(1):e106-e11.\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":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Vision Screening, Referral and Consultation, Eye Care Services, Health Services Accessibility, Health Literacy, Health Behavior, Health Services Needs and Demand, Health Services Research, Child, Socioeconomic Factors, Health Disparities, Delivery of Health Care, Access to Health Care, Scoping Review, Public Health, Medically Underserved Area, Vision health literacy, Follow-up care, Barriers to care, Patient navigation, School-based vision screening, Health Knowledge, Attitudes, Practice, Health Education, Intervention Studies, Community Health Services, Preventive Health Services","lastPublishedDoi":"10.21203/rs.3.rs-7436894/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7436894/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eVision screening plays a critical role in identifying potential vision disorders; however, its effectiveness is compromised when follow-up with eye care professionals is not completed. Up to 60% of children with abnormal vision screenings do not attend recommended appointments with eye care providers. This study aims to identify and synthesize the strategies to improve adherence to eye care referrals following abnormal vision screening tests.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The Joanna Briggs Institute methodology was followed to conduct the scoping review. This review is part of a broader study exploring adherence to pediatric eye care referrals. A companion scoping review focusing on social risk factors of non-adherence has been submitted separately. Searches for relevant literature were performed across bibliographic databases and gray literature from their inception to July 2023, with an updated search in November 2024. The review protocol was registered with Open Science Framework. Four reviewers screened and extracted data from the included studies. Strategies were synthesized, and themes developed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSixteen studies assessed strategies to overcome social risk factors. The most frequently reported strategy was enhanced direct communication such as phone calls and mailed notifications (n\u0026thinsp;=\u0026thinsp;13), and logistical support, including transportation and pre-scheduled appointments (n\u0026thinsp;=\u0026thinsp;9).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA variety of strategies have been implemented to improve adherence to pediatric eye care referrals, with communication and logistical support being the most common strategies used. Significant gaps, however, remain in evaluating the effectiveness of these strategies, especially in low-income countries.\u003c/p\u003e","manuscriptTitle":"Strategies to Improve Adherence to Eye Care Referrals for Children following Vision Screening: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 19:31:15","doi":"10.21203/rs.3.rs-7436894/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-30T14:42:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-14T11:59:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227734643567845059183536948280563007567","date":"2025-10-13T23:22:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248814020404005734492581059759815779168","date":"2025-10-09T19:48:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296821119769067248892387369036729477612","date":"2025-10-09T10:41:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T08:10:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-19T07:34:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T14:03:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-28T14:02:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-22T18:31:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e336d78-e07b-408b-ba6a-b1647cdd5931","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-22T19:31:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 19:31:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7436894","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7436894","identity":"rs-7436894","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}