Social Risk Factors of Referral Non-Adherence to Eye Care Referrals for Children: A Scoping Review

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Howard, and 2 more This is a preprint; it has not been peer reviewed by a journal.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-6804155/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Despite the importance and benefits of vision screening and comprehensive eye examinations, up to 60% of children with abnormal vision screenings do not attend recommended appointments with eye care providers. The purpose of this study is to identify social risk factors of and strategies to address referral non-adherence to eye care referrals following abnormal vision screening tests. Methods A scoping review was conducted following the Joanna Briggs Institute methodology. Bibliographic databases and gray literature were searched 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. Social risk factors were synthesized and thematically mapped using the Penchansky and Thomas's model of access, extended by Saurman. Results Seventeen studies reported social risk factors of referral nonadherence, and 16 studies assessed strategies to overcome social risk factors. The most frequently cited Penchansky and Thomas dimension was affordability (n = 14) and awareness (n = 14), while accessibility was the least cited (n = 5) in the data. None (n = 0) of the studies indicated the use of a conceptual framework to inform the organization of their extracted data. Most of the included studies targeted populations in high-income (as compared to low, lower-middle, upper-middle income) countries. Strategies to address social risk factors are reported in a separate manuscript. Conclusion Affordability and awareness are the most frequent social risk factors of non-adherence to eye care referrals for children following abnormal vision screening tests. Significant gaps remain in understanding social risk factors in resource-limited settings with high needs. Vision Screening Referral and Consultation Eye Care Services Health Services Accessibility Health Literacy Health Behavior Social Determinants of Health 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 Insurance Health Medically Underserved Area Vision health literacy Follow-up care Barriers to care Patient navigation School-based vision screening Figures Figure 1 Figure 2 Figure 3 Introduction Early detection and treatment of vision disorders is essential to prevent irreversible vision loss in children.( 1 – 3 ) Vision screening is aimed at identifying common vision disorders and facilitating diagnosis and treatment through referrals to an eye care professional for a comprehensive eye examination.( 4 ) Vision screening is a wasted effort without completed referrals to ensure treatment for detected vision disorders. In many countries, vision screening is conducted in schools, primary care, and/or other community-based settings.( 1 , 5 ) Despite the importance and benefits of vision screening and comprehensive eye examinations, up to 60% of children with abnormal vision screening tests do not attend recommended appointments with eye care providers.( 2 , 3 , 6 , 7 ) Lower rates of adherence to eye care appointments disproportionally impact socially disadvantaged populations, which include racial/ethnic minorities, underserved rural communities, people with low socioeconomic status, and sexual and gender minorities.( 4 , 8 – 11 ) Identifying the social risk factors of referral nonadherence to eye care appointments is important to design effective strategies to prevent irreversible vision loss and its long-term consequences. Previous studies have identified social risk factors of referral nonadherence to eye care. 18,19,20 However, these studies have focused on eye care for specific vision disorders, vision screening rather than specialist eye care, or were targeted to the United States (US) population or adult population. The objective of this study is to identify social risk factors of and strategies to address referral nonadherence for comprehensive eye exams by eye care professionals following abnormal vision screening tests for children. The results of this review will inform future studies aimed at implementing an evidence-based strategy to improve referral adherence for children after abnormal vision screening in primary care. Methods Protocol and registration This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology ( 6 ) for scoping reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.( 7 ) 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 in November 2024 The protocol for this review was registered with the Open Science Framework and can be accessed at: https://osf.io/kxn49/ . 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. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Search Strategy The review team met with a librarian (A.H.) in June 2023 to design the search strategy for PubMed and then adapted it for other electronic databases. The initial literature search was conducted in July 2023 (from the inception of the respective database to July 2023). An updated search was conducted in early November 2024. The search aimed to identify relevant studies that described social risk factors of and strategies to address referral nonadherence following abnormal vision screenings in children using the following combination of keywords, controlled vocabulary, where applicable, and their synonyms: “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 included based on the type of target population, outcomes and type of study. Eligibility criteria was applied at both the title/abstract and full-text levels, as detailed in Table 1 . Vision screening could occur in any setting, e.g., school, pediatric primary care, or another community-based setting. There were no restrictions on date of publication or country of publication; however, studies were excluded if they were not written in English (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 None Type of study Primary peer-reviewed studies, regardless of design Commentaries, letters to the editor, editorials, and review papers Information sources The electronic databases searched were 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 conducted. Evidence selection Search results were collected and deduplicated in EndNote and then uploaded into the Rayyan-Intelligent Systematic Review program (Rayyan Systems Inc., Cambridge, MA) to review retrieved articles. Article selection was based on the eligibility criteria outlined above and involved a two-step process, specifically, a review of titles and abstracts followed by a review of full-text articles. All reviewers (AOA, PMH, AA, and AR) were involved in a pilot test on a random 10% of articles retrieved from the initial search. The reviewer team screened the articles using the initial eligibility criteria outlined in our protocol and made minor changes to the inclusion criteria. Specifically, expanding it to include caregivers of children, and additional clarity on the type of vision screening programs. Screening commenced once 75% agreement had occurred between all four reviewers on pilot studies. During the screening process, two reviewers independently reviewed each source at each level (title, abstract, and full-article review), and disagreements were reconciled by consensus 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. Information extracted 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. Synthesis of findings Data extracted from full-text studies selected for inclusion were synthesized using a three-stage process consisting of inductive coding, theme generation, and theme mapping. Inductive Coding was conducted using descriptive coding labels created inductively by one reviewer (AA) and confirmed by another reviewer (AOA) to allow initial sub-themes of the social risk factors to emerge from existing published knowledge. Theme generation involved the identification, analysis, and interpretation of patterns within the data set (‘thematic synthesis’). One reviewer (AA) inputted the coded results in Excel where they were grouped based on the qualitative themes. Another reviewer (AOA) then reviewed the data to ensure consistency and consensus. This method of theme generation allowed the 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. Themes for social risk factors were mapped to the widely used the Penchansky and Thomas (P-T) Framework,( 12 ) expanded by Saurman to enable the review to elucidate gaps in knowledge on the social risk factors of access to vision care, in line with the study’s research objectives.( 13 ) Access is defined as a set of specific areas of fit between the patient and the health care system, similar to the ‘enabling factors’ in the Anderson model of Behavioral Use.( 14 , 15 ) To determine the level of fit, access was divided into six dimensions: ( 1 ) availability - volume and adequacy of supply of services; ( 2 ) accessibility – location of the service and the patient’s ability to commute; ( 3 ) accommodation – organizational abilities of the service to accept patients and patients ability to use the service; ( 4 ) affordability – financial costs of the service; ( 5 ) acceptability – mutual perceptions between the patient and the provider regarding each other and the service; ( 6 ) awareness – effective communication and spread of information to patients.( 12 , 13 ) The six independent dimensions are interconnected, and each is important to encourage access to health services. By organizing findings through the P-T Framework, dimensions of access that are lacking can be identified and addressed. In this study, patient-level data on the social risk factors related to referral nonadherence following abnormal vision screening tests are reported. Results The initial search identified 5,538 studies through databases and grey literature, with one additional record 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 with only 11 not available. 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. 17 studies assessed social risk factors (Fig. 1 ), and 16 studies assessed strategies to overcome social risk factors of referral non-adherence. The included studies targeted vision screening programs conducted at schools 5 (29%),( 16 – 20 ) pediatric primary care clinics 4 (24%), ( 21 – 24 ) and other community settings 8 (47%) (Table 2 ).( 25 – 32 ) Vision screening programs in 3 (18%) studies targeted preschool aged children (aged 3 to 5 years), ( 21 , 25 , 33 ) while 2 (12%) studies targeted school-age children 6 to 18 years only, ( 18 , 34 ) and 5 (29%) studies targeted school screening programs for both preschool and school-age children.( 22 , 26 , 27 , 29 , 31 ) Race was reported in 7 (41%) studies, ( 19 , 22 , 29 , 32 – 35 ) and ethnicity was reported in 5 (29%) studies.( 21 , 22 , 33 – 35 ) Study designs varied with most included studies using qualitative methods (focus groups and interviews) (n = 6, 35%) ( 16 , 19 – 21 , 32 , 35 ) compared to quantitative methods to assess social risk factors of nonadherence to referrals. Most studies employing quantitative methods (n = 11, 65%) ( 18 , 22 , 25 – 27 , 29 , 31 , 33 , 34 , 36 , 37 ) used surveys to assess referral nonadherence. The majority (n = 13, 76%) of studies were conducted in high income countries, ( 19 , 21 , 22 , 26 , 27 , 29 , 31 – 37 ) three studies (18%) were conducted in low- and middle-income countries (Nigeria and India), ( 16 , 20 , 25 ) and one study was conducted in an upper middle-income country (Brazil). ( 18 ) Table 2 Description of Included Studies Authors, Year Published Geographical Context WHO income level Target Population Screening setting Age range (children, years) Sex/gender distribution [Females/Girls n (%)] Race [Black, White, Asian, American Indian, Other; n (%)] Ethnicity [Hispanic, Non-Hispanic; n (%)] Lohfeld et al., 2021 Nigeria, Cross River State Lower-Middle Parents of school-aged children School Parents: 23 to 61 Parents (mothers): 28 (64%) - - Kemper et al., 2006 US, national cohort High Income Parents of pre-school children Primary care (pediatrician and family physician clinics) Parents: not specified Children: 3 to 5 Parents: not specified Children: 23 (51.1%) - Non-Hispanic white: 17 (62.2%); Hispanic or non-white: 28 (37.8%) Neville et al., 2015 US, New Jersey High Income Parents of school-aged children in an urban middle school Schools Parents: not specified Children: 11 to 14 Parents: not specified Children: 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., 2011 Brazil, Guarulhos, Sao Paulo Upper Middle Parents or guardians of elementary school children in grades 1–4 Schools Parents: not specified Children: 7 to 10 Parents: not specified Children: 50.8% - - Su et al., 2013 US, New Haven County, Connecticut High Income Parents of children with an abnormal visual acuity screening test Staff model university health center with an in-house eye department, a federally qualified community health center with an in-house eye department, a federally qualified community health center without an inhouse eye department, or a private pediatric primary care practice Parents: not specified Children: 3 to 14 Parents: not specified Children: 27 (47%) Black 4(7%), Asian 6(10%), White 17(29%), Mixed 6(10%) Hispanic − 25(43%) Slingsby et al., 2017 US, South Dakota High Income Parent or guardians of children referred for a comprehensive eye exam following a vision screening by CVSI vision screening event conducted by CVSI Parents: not specified Children: 3 to 11 Parents: not specified Children: 28 (44.5%) White 30(47.6%), American Indian 26(41.3%), Other 3(4.8%) - Ravindran et al., 2020 India, Tirunelveli, Tuticorin, Kannyakumari districts, South India Lower Middle Parents or guardians of children who did not complete referrals for eye care professionals within 60 days of screening test ICDS eye screening program in Tirunelveli, Tuticorin, and Kannyakumari districts of South India which lie 12–49 miles from the base hospital Parents: not specified Children: 0 to 5 Parents: not specified Children: 155 (47.8%) - - Tjiam et al., 2011 Netherlands, Rotterdam High Income Parents of children with incomplete referrals that participated in RAMSES Population based screening as part of RAMSES - - - - Wang et al., 2022 Canada, Catchment area of Kingston, Frontenac, Lennox, Addington Public Health, Ontario High Income Parents of children in senior kindergarten in the catchment area of KFL&A Public Health that were referred to an eye care professional Schools Parents: not specified Children: 4 to 6 - - - Wasserman et al., 1992 US, 23 states and the Puerto Rico High Income Parents of children receiving health care in pediatric primary care practices Pediatric practices Parents: not specified Children: 3 to 5 Parents: not specified Children: 3722 (48% female) Parents: not specified Children: 6668 (86%) White, 698 (9%) Black, and 775(1%) Asian Parents: not specified Children: 232(3%) Hispanic Williams et al., 2013 US, Philadelphia, Pennsylvania High Income Parents of inner-city children with low SES Wills Eye Institute and Jefferson Medical College of Thomas Jefferson University (GKSD) - - - - Yawn et al., 1998 US, Rochester, Minnesota High Income Parents, children, teachers, school and community health professionals and community leaders School - 66 (70.2%) Caucasian 69 (73.4%), African American 14 (14.9%), Southeast Asian (11.7%) - Bruce et al., 2018 UK, Bradford, England High Income Parents living in Bradford, England (5th highest deprived city in England) Not listed: just population-based program - Parents: (mothers) 17 (85%) 5 (25%) White British; 1 (5%) of African heritage; 14 (70%) S. Asian - Dotan et al., 2015 US, Philadelphia, Pennsylvania High Income Children living in urban areas with low-socioeconomic status (uninsured or underinsured) Wills Eye Hospital Children: 0 to 18 471 Girls − 51% - - Ebeigbe et al., 2016 Nigeria, Benin city, Edo state Lower-Middle Parents of school aged children (5 to 12 yrs) and eye care professionals - Parents: 38 to 54 years Eye care professionals: 30 to 45 years Parents (mothers): 26 (74.2%) Eye care professionals: 3 (30%) - - Gordon-Shaag et al., 2022 Israel, Jerusalem High Income Children - 3 to 6 613 (47.8) -- Referred: 135(22%) - - Kimel et al., 2006 US, Rockford, Illinois High Income Parents of elementary students in an urban, midwestern public school district Public school - Children included 48% boys and 52% girls Children: 42% White, 49% African American Children: 5.5% Hispanic ABBREVIATIONS: CVSI = Northern Plains Eye Foundation Western South Dakota Lions Children’s Vision Screening Initiative, RAMSES = Rotterdam Amblyopia Screening Effectiveness Study, KFL&A = Kingston, Frontenac, Lennox and Addington, ICDS = Integrated Child Development Centers, GKSD = Give Kids Sight Day, US = United States The most frequently reported social risk factors of referral non-adherence were related to the awareness ( 16 , 18 – 22 , 27 , 29 , 32 – 37 ) and affordability dimensions,( 16 , 18 , 19 , 21 , 22 , 25 – 27 , 29 , 31 , 34 – 37 ) present in 14 (82%) studies (Fig. 2 ). This was followed closely by social risk factors related to the accommodation dimension present in 12 (71%) studies.( 16 , 18 , 20 , 22 , 25 – 27 , 29 , 32 , 34 , 35 , 37 ) The least reported social risk factors of referral non-adherence were related to the dimension of accessibility (n = 5, 29%).( 18 , 22 , 25 , 32 , 35 ) Social risk factors that did not fit within the six dimensions of the P-T Framework extended by Saurman were predisposing characteristics in line with the Anderson model of Behavioral Use.( 38 ) Predisposing characteristics refer to patient-level factors that exist prior to the use of health services and influence a person’s likelihood to seek health care.( 38 ) A description of the social risk factors identified for each dimension of access is described below and in Table 3 . Strategies identified in included studies to overcome patient social risk factors of referral non-adherence following an abnormal vision screening test are reported in a separate manuscript. Table 3 Synthesis of Social risk factors of Referral Non-Adherence Identified in Included Studies Dimension Sub-Theme Social risk factors Study Citing Social risk factors Awareness Low Vision Health Literacy The caregiver does not believe there is an eye problem ( 16 ), ( 21 ), ( 34 ), ( 18 ), ( 29 ), ( 36 ), ( 27 ), ( 35 ) Misconceptions about seeking healthcare generally (children will get sick if they go to the hospital) ( 16 ), ( 36 ) Misconceptions about treatment, especially regarding the use of prescription eyeglasses ( 16 ), ( 20 ), ( 19 ) Misconceptions or lack of knowledge about the importance of eye conditions, such as lazy eye, and the need for timely eye exams ( 21 ), ( 22 ), ( 36 ), ( 32 ), ( 20 ), ( 27 ) Parents belief that vision exams and glasses covered by Medicaid insurance are substandard ( 35 ) Lack of knowledge about where and how to schedule appointments ( 21 ), ( 22 ), ( 29 ), ( 36 ), ( 19 ), ( 34 ), ( 37 ), ( 32 ) Language barriers* ( 34 ), ( 37 ), ( 32 ), ( 36 ) Low Literacy* ( 16 ) Fear of diagnosis or treatment ( 36 ) Concerns about cost or if insurance provided coverage for follow-up appointments with an eye care provider and glasses* ( 29 ), ( 37 ), ( 19 ) Parent inattention to school documentation ( 34 ), ( 16 ) Did not know about the referral ( 16 ), ( 34 ), ( 22 ), ( 29 ), ( 18 ), ( 33 ), ( 37 ), ( 36 ), ( 35 ) Lack of caregiver understanding difference between a screening and eye exam ( 16 ), ( 29 ), ( 37 ), ( 19 ) Affordability Unable to afford cost of care Lack of insurance coverage for eye exams ( 21 ), ( 34 ), ( 22 ), ( 26 ), ( 61 ), ( 27 ), ( 35 ) Low income* ( 18 ), ( 16 ), ( 25 ), ( 36 ), ( 19 ) Concerns about cost or insurance coverage for follow-up appointments with an eye care provider and glasses* ( 29 ), ( 37 ), ( 19 ) Predisposing Factors* Patient-level factors Parent negligence ( 16 ) Parent forgetfulness to attend or schedule appointments ( 16 ), ( 18 ), ( 22 ), ( 29 ), ( 36 ), ( 27 ) Parent preference for alternative medical treatment ( 36 ), ( 16 ) Lack of social acceptance regarding wearing glasses by teenage peers ( 19 ) Low education ( 25 ), ( 35 ) Difficulty obtaining food for the family (food insecurity) ( 29 ), ( 35 ), ( 16 ) Difficulty obtaining or instability of housing ( 29 ), ( 35 ) Sick or disabled family members requiring other family health appointments ( 18 ), ( 29 ), ( 35 ) Family conflicts ( 29 ) Acceptability Dissatisfaction with program/provider Parent belief that Medicaid vision exams and glasses substandard ( 35 ) Lack of confidence in screening results from school-based programs ( 19 ), ( 32 ), ( 27 ), ( 35 ), ( 16 ), ( 36 ) Physician lack of empathy for families ( 16 ) Racial and financial discrimination regarding prompt eye care ( 19 ) Accessibility Logistical challenges Lack of caregiver support ( 18 ), ( 35 ) Bad weather ( 18 ) Lack of transportation and long distance to eye care provider ( 22 ), ( 25 ), ( 32 ), ( 35 ) Does not own a phone to schedule appointments ( 35 ) Unpredictable family schedule due to having a large family ( 35 ) Not able to plan ahead due to family challenges e.g. obtaining food and housing, child does not live in a consistent home ( 35 ) Accommodation Lack of priority due to extraneous factors Parental time constraints due to work ( 16 ), ( 34 ), ( 18 ), ( 22 ), ( 29 ), ( 25 ), ( 26 ), ( 37 ), ( 32 ), ( 20 ), ( 27 ), ( 35 ) Disability ( 29 ), ( 35 ) COVID-19 pandemic ( 26 ) Inconvenient Medicaid scheduling system (limited appointments that could only be booked in the mornings) ( 35 ) Availability Healthcare system related factors Long wait times for eye care appointments ( 16 ), ( 19 ) Long in-person wait times to receive care at government facilities (walk-in appointments) ( 20 ), ( 16 ) Limited number of qualified eye care professionals or eye appointments ( 26 ), ( 27 ), ( 20 ), ( 35 ) *Adopted from Anderson’s Behavioral Model of Health Services Use Acceptability The most frequently cited social risk factors of poor acceptability were a lack of confidence in vision screening program conducted in lower-middle (Nigeria)( 16 ) and high-income countries (United Kingdom (UK),( 32 ) United States (US),( 19 , 35 ) Israel,( 27 ) Netherlands( 36 ). Particularly, caregivers doubted the accuracy of the screening tests. Yawn et al. reported that caregivers in Rochester, Minnesota doubted that training given to screeners (who were parent volunteers) was adequate and supervised.( 19 ) Other social risk factors of poor acceptability included caregiver beliefs that comprehensive eye exams and prescription glasses provided to beneficiaries of US, government-funded health insurance (Medicaid) were of poor quality.( 35 ) In Cross River State, Nigeria, Lohfeld et al. reported that caregivers’ past negative experiences with physicians in hospitals were a deterrent to adhering to referrals to eye care providers.( 16 ) Physicians were described as lacking empathy for patients.( 16 ) Other factors identified as social risk factors of poor acceptability were caregivers’ dissatisfaction with the use of the word ‘failure’ in parent notification slips, caregiver perceptions that vision screening was boring for children, and racial and financial discrimination preventing prompt care.( 16 ) Accessibility Social risk factors of poor accessibility were the result of logistical hurdles in five studies from lower-middle (India),( 25 ) upper-middle (Brazil),( 18 ) and high income countries (US) ( 22 , 35 ) and UK ( 32 ). The most frequently cited social risk factor of poor accessibility to care was the lack of transportation and long travel distances to an eye care provider in US,( 22 , 35 ) India,( 25 ) and UK-based studies.( 32 ) Additionally, lack of a caregiver at home to care for other children, in order to take another child to an eye care visit was identified as a determinant of poor accessibility for studies conducted in the US( 35 ) and Brazil.( 18 , 35 ) Other social risk factors included inclement weather,( 18 , 35 ) and no phone to schedule appointments.( 18 ) In their study of caregivers in the Illinois Rockford Public School district in the US, Kimel et al. reported that caregivers often experienced difficulties planning ahead due to uncertainties regarding their basic needs such as food and housing, and unpredictable family schedules.( 35 ) Large families found it especially difficult coordinating schedules.( 35 ) Accommodation Time constraints related to work were the most frequently cited social risk factors cited by 12 studies conducted in lower middle [Nigeria ( 16 , 20 ) and India ( 25 )), upper-middle (Brazil ( 18 )) and high income (US,( 22 , 29 , 34 , 35 , 37 ) Canada,( 26 ) Israel,( 27 ) and UK ( 32 )] countries. Other social risk factors for poor accommodation included an inconvenient appointment scheduling system for beneficiaries of US government health insurance (Medicaid) due to limited eye care appointments restricted to mornings, as reported in a study in Illinois, US.( 35 ) Also reported were restrictions due to the COVID-19 pandemic.( 26 ) In two US-based studies, caregivers reported that they did not adhere to referral eye exams because they were concerned that children with special needs would be unable to cooperate with an eye exam.( 29 , 35 ) Affordability Lack of affordability was reported as a social risk factor of nonadherence in 14 studies from lower-middle [India ( 25 ) and Nigeria ( 16 )), upper-middle (Brazil ( 18 )], and high-income countries [US,( 19 , 21 , 22 , 29 , 31 , 34 , 35 , 37 ) Canada,( 26 ) Israel,( 27 ) and Netherlands ( 36 )]. Lack of insurance coverage for comprehensive eye exams was the most frequently cited determinant related to affordability and was reported by studies conducted in US ( 22 , 31 , 34 , 35 , 39 ), Canada,( 19 , 21 , 22 , 26 , 29 , 34 , 37 ) and Israel ( 27 ). In addition to lack of insurance, caregivers in US-based studies reported that their decision to adhere to referral appointments was influenced by concerns of the cost of care; particularly, whether their insurance provided coverage for eye appointments and prescription glasses.( 19 , 29 , 37 ) Lack of insurance coverage was reported for a study based in Israel which has universal health insurance ( 27 ). Similarly, low income was reported in Brazil,( 18 ) India,( 25 ) Netherlands,( 36 ) US,( 19 ) and Nigeria ( 16 ) where out of pocket payments were the predominant means of paying for vision care. Availability Healthcare system-related social risk factors of poor availability were reported in studies from high-income and lower-middle-income countries. These social risk factors included long wait times for eye care appointments for studies conducted in US ( 19 ) and Nigeria.( 16 , 19 ) In Cross-River State Nigeria, government health care facilities were reported to only provide walk-in appointments necessitating long waits to be seen.( 16 , 20 ) Additionally, the limited numbers of qualified eye care professionals or appointments were reported for studies conducted in US,( 35 ) Canada,( 26 ) Nigeria ( 20 ) and Israel.( 27 ) Awareness The most frequently cited social risk factors of poor awareness were misconceptions about how vision disorders presented, were treated, and implications of vision disorders.( 16 – 22 , 24 , 27 – 29 , 36 , 40 ) These social risk factors were reported for studies conducted in lower-middle [Nigeria ( 16 , 20 )] and high income [Netherlands, ( 36 ) US, ( 19 , 21 , 22 ) UK, ( 32 ) and Israel ( 27 )] countries. Some caregivers did not adhere to referrals because they did not believe that their children had vision disorders.( 16 , 18 , 21 , 27 , 29 , 34 – 36 ) In Cross River State, Nigeria,( 16 ) and Michigan, US,( 21 , 34 ) caregivers of children who failed a school-based vision screening did not believe their children had a vision disorder or believed that the vision disorder was minor because of an absence of symptoms and signs, and did not warrant an urgent visit to an eye doctor. Also, Kimel et al. reported caregivers had the erroneous belief that follow-up eye exams and glasses covered by US government-funded insurance (Medicaid) were substandard.( 35 ) Eight studies conducted in the US (Michigan,( 21 ) Connecticut,( 22 ) South Dakota,( 29 ) Minnesota,( 19 ) New Jersey,( 34 ) and Pennsylvania( 37 )), Netherlands,( 36 ) and the UK ( 32 ) reported social risk factors due to caregivers’ lack of knowledge about where (place or type of eye care provider) and how to schedule follow-up appointments with an eye care professional. Nine studies from Nigeria,( 16 ) US ( 33 ) (New Jersey,( 34 ) Connecticut,( 22 ) South Dakota,( 29 ) Pennsylvania ( 37 ) and Illinois ( 35 ), Brazil,( 18 ) and Netherlands ( 36 ) reported social risk factors related to caregivers’ lack of knowledge about the vision screening programs. Specifically, caregivers were not aware that their children had an abnormal vision screening test and had been subsequently referred to an eye care professional. Also, caregivers did not understand the difference between a vision screening and comprehensive eye exams.( 16 , 19 , 29 , 37 ) Finally, language and illiteracy, fear of diagnosis and the consequent cost of care and prescription glasses, were additional social risk factors of poor awareness.( 16 , 19 , 29 , 32 , 34 , 36 , 37 ) Predisposing Factors A number of predisposing factors were reported as social risk factors of referral nonadherence in studies conducted in lower-middle,( 16 , 25 ) upper-middle,( 18 ) and high-income countries.( 19 , 22 , 27 , 29 , 35 , 36 ) The most frequently cited predisposing factor was forgetfulness to attend or schedule an appointment with an eye care professional.( 16 , 18 , 22 , 27 , 29 , 36 ) Families facing challenges with their basic needs such as food insecurity and instable housing were less likely to adhere to referrals to eye care professionals.( 16 , 29 , 35 ) A study conducted by Yawn et al. in the rural city of Rochester, Minnesota, reported that teenagers did not often want to attend appointments with eye care professionals because of the fear of being prescribed glasses.( 19 ) Also, caregivers of children in Rotterdam, Netherlands ( 36 ) and Cross River State, Nigeria ( 16 ) reported their preference for alternative medical treatment to Western medicine as their reasons for not adhering to referrals. Additional extraneous factors such as disability, illness, conflicts in the family, parent negligence, and low education were also identified as social risk factors of referral nonadherence.( 16 , 18 , 25 , 29 , 35 ) Discussion In this scoping review, we mapped the social risk factors of referral nonadherence to eye care professionals (following abnormal vision screening tests for children) identified in the existing literature. Social risk factors identified were synthesized thematically and organized using a framework from Penchansky and Thomas (based on the Framework of Access), extended by Saurman.( 12 , 13 ) We identified 17 studies that reported social risk factors of referral nonadherence.( 16 , 18 – 22 , 25 – 27 , 29 , 31 – 37 ) The most frequently cited social risk factors were the inability to afford the cost of vision care (including comprehensive eye exams and prescription glasses), and low vision health literacy. ( 16 , 18 – 22 , 25 – 27 , 29 , 31 – 37 ). In relation to the P-T Framework, these were social risk factors related to affordability and awareness. Gaps in the Existing Literature Only one of the included studies reported social risk factors across all six dimensions of access as described in the P-T Framework extended by Saurman.( 16 , 18 – 21 , 24 , 27 , 29 , 32 , 35 ) None of the 17 included studies used a conceptual framework such as the P-T Framework to inform the design of their data collections tools (i.e., interview guides, focus groups or surveys).( 12 ) This suggests that studies did not address all dimensions of access to care which highlights a critical gap in studies designed to address health disparities. In this study, social risk factors to accessibility were least represented in the data. Accessibility from the patient perspective is highly subjective and associated with other patient-level factors such as time constraints, a limited number of qualified eye care professionals and their inability to plan ahead which were represented in other access dimensions. Most of the included studies were based on studies conducted in high-income countries.( 19 , 21 , 22 , 26 , 27 , 29 , 31 – 37 ) This statistic highlights a significant gap in our understanding of social risk factors of referral nonadherence in settings where resources may be limited and needs high. Limited studies in low- and middle-income countries ( 16 , 18 , 20 , 25 ) may be due partly to limited population-based data sources compared to high-income countries, such as national population-based surveys, electronic health records systems, and administrative data. Other difficulties may relate to data collection in communities with low rates of literacy and languages that differ from that of researchers which may require significant resources and funding for translation and other related services. It is not surprising that affordability and awareness were the most frequently cited social risk factor of referral nonadherence. In the US and other high-income nations, most health insurance plans cover the cost of vision care for children to include vision screening, comprehensive eye exams, and a pair of prescription glasses per year. In the US, the Affordable Care Act (ACA) requires all health insurance plans cover vision care services for children which is one of 10 essential health benefits.( 41 – 43 ) The type of vision care coverage, however, varies by US state. Forty-two states cover annual comprehensive eye exams and one pair of prescription glasses per year.( 43 , 44 ) However, grandfathered health plans (established prior to passing the ACA) are exempt from ACA provisions such as these. Therefore, caregivers without or limited health insurance coverage for the cost of comprehensive eye exams and prescription glasses face challenges paying for these out of pocket.( 39 , 45 , 46 ) Also, some eye care professionals do not accept government-funded insurance such as Medicaid,( 40 , 41 ) perhaps due to the low reimbursement associated with Medicaid insurance compared to private insurance.( 47 ) Awareness as a determinant of referral nonadherence includes poor vision health literacy, and misconceptions and mistrust of health care systems. Vision disorders in childhood often present with no signs or symptoms and children are unable to express or even know that their vision is substandard. For this reason, caregivers may not believe the vision screening results and therefore the need for a comprehensive eye exam.( 24 ) Studies on Hispanic immigrant parents report a lack of knowledge about the importance of vision care and types of vision coverage for children.( 48 ) Few studies have reported social risk factors of referral nonadherence with eye care professionals.( 49 ) Zeng and colleagues conducted a study to review the literature on the social risk factors of attending ophthalmology eye exams following vision screening in the community and interventions to increase follow-up rates.( 49 ) The study population was patients with diabetic retinopathy, glaucoma, refractive error or cataract. Social risk factors reported were related to ophthalmology appointments. Of the social risk factors they found to not attending follow-up appointments, lacking a car or living farther away from the hospital (accessibility) would be most applicable to social risk factors in this current study. Zeng and colleagues identified the following strategies for improving attendance to ophthalmology appointments for adults: reminder phone calls by study staff, ( 50 – 53 ) providing prescheduled appointments, patient contracts, vouchers for free or subsidized follow-up eye exams, bus tokens for follow-up appointments, or patient education and resources such as printed exam results and written instructions for scheduling follow-up appointments. Other strategies included encouragement by a community health worker or patient navigator,( 54 , 55 ) Saturday hours in addition to weekday clinic hours,( 55 ) multiple phone calls and screening centers near referral clinics.( 52 ) Patient navigators have been used widely in various medical specialties including ophthalmology.( 56 – 60 ) Patient navigators are particularly useful for supporting individuals and families with poor vision health literacy to navigate challenges with scheduling and attending referral appointments, and understanding payment and other nuances of their health insurance. To cut down on the potentially high costs of hiring patient navigators, partnerships with community health programs to staff the patient navigator role could be helpful. Onsite specialist eye care could also reduce the burden on families, especially those with low vision health literacy to overcome challenges with accessing specialist care. Social risk factors of poor affordability, may be best mitigated through legislation for health insurance plans to cover the cost of annual eye exams and prescription glasses. Despite the abundance of strategies and interventions to improve referral adherence, it is unknown whether these strategies will be effective in pediatric populations referred from vision screening programs to specialist eye care. 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 social risk factors of referral nonadherence for children after abnormal vision screening tests, regardless of the screening setting. Relevant studies were identified using a robust and systematic approach. Knowledge of the social risk factors identified will better equip future research in the creation of strategic health interventions to improve access to specialist care. The application of P-T Framework extended by Saurman facilitated a systematic and thorough study of gaps in the literature. Despite its strengths, several limitations of this study need to be considered. We faced difficulties categorizing some social risk factors within the framework because they either crossed multiple dimensions of access or did not appear to be a good fit for any of the identified access dimensions. For instance, the perception that vision exams provided by Medicaid were substandard could indicate a determinant of poor acceptability, but also a determinant of poor awareness. To address this, we listed these social risk factors under all the access dimensions for which it appeared relevant. Parent negligence and sick family members were two social risk factors that did not appear to fit under any of the access dimensions. For these, we created a new theme based on the Anderson Model of Behavioral Use called ‘Predisposing Factors’. Also, social risk factors of referral nonadherence identified in this study may not be directly applicable or generalizable to all country contexts. For instance, concerns regarding insurance coverage for comprehensive eye exams, or the ability to afford co-pays or out-of-pocket payments, may be more relevant to the US context than other countries, such as Canada, and the UK which have universal health insurance programs. Also, social risk factors regarding long wait times in walk-in eye clinics may be more applicable to low-income countries where this system of care abounds. Finally, quality of included studies was not assessed, in line with the JBI methodology for conducting scoping reviews. Therefore, it is possible that there was bias in the selection of studies. Had an assessment of the quality of included studies been conducted, additional gaps may have been elucidated. Despite using a robust and systematic approach to search the literature, it is possible that some relevant studies may have not been selected for inclusion. Conclusion In conclusion, several social risk factors of referral nonadherence exist for children referred from vision screening programs to eye care professionals, with the most frequent being a lack of affordability and awareness. This knowledge will enable the development of strategic and targeted interventions to prevent irreversible vision loss in children. Abbreviations United States (US), Joanna Briggs Institute (JBI) Penchansky and Thomas (P-T), Affordable Care Act (ACA) 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. Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. 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. Authors' contributions: AA, AOA conceptualized and designed the study, acquired, analyzed and interpreted data, and drafted the article. 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. 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Howard","email":"","orcid":"","institution":"University of South Florida Health Libraries","correspondingAuthor":false,"prefix":"","firstName":"Allison","middleName":"M.","lastName":"Howard","suffix":""},{"id":498968941,"identity":"964a271f-115c-4f9d-ab95-ab2e6d2252c9","order_by":4,"name":"Teasha Luu","email":"","orcid":"","institution":"University of Utah","correspondingAuthor":false,"prefix":"","firstName":"Teasha","middleName":"","lastName":"Luu","suffix":""},{"id":498968942,"identity":"2f9b8883-e800-48f2-87c3-ea65ff093d73","order_by":5,"name":"Afua O. Asare","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDAC5gMoLBBOIKCFLQGJdYBELTwGxGnhb+Mx/MBQUydv3t7zTfpDzR0GfvYcA7xaJI7xGEswHDtsOOfM2W0SB449Y5DseYNfC8P9HgMJBrYDjDMkcoFa2A4zGNwgYIs80JYfDP/q7GfIv3kmceDfYQZ7QloMjvGYSTC2MSfOkOBhkzjYBrRFgoAWw2NsZRaJfYeTZ/CkGVuc7TvMI3HmWQFeLXLHmDff+PCtznYG++GHNyq+HZbjb0/egFcLGCQgsXkIKx8Fo2AUjIJRQBAAAC7jSJCk3BjjAAAAAElFTkSuQmCC","orcid":"","institution":"John Moran Eye Center, University of Utah","correspondingAuthor":true,"prefix":"","firstName":"Afua","middleName":"O.","lastName":"Asare","suffix":""}],"badges":[],"createdAt":"2025-06-02 16:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6804155/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6804155/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89230898,"identity":"708b7e89-27ca-41f3-87e7-bf408b10a55d","added_by":"auto","created_at":"2025-08-17 14:16:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":104692,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Diagram\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6804155/v1/59d70d722403b9ba377d4426.jpg"},{"id":89230900,"identity":"673f961b-0624-4651-87b3-515944f840e6","added_by":"auto","created_at":"2025-08-17 14:16:20","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41318,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of Social risk factors of Non-Adherence for Children Referred from Vision Screening\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6804155/v1/3429b514e69f8b7980498a55.jpg"},{"id":89232281,"identity":"8349f53a-19ee-4a0c-bfc6-6c6445774368","added_by":"auto","created_at":"2025-08-17 14:24:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":66874,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Dimensions of Access Across Included Studies\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6804155/v1/55da96fd1753373be3f7e685.jpg"},{"id":89232311,"identity":"253a36fa-05a3-44e7-84ad-87c6d176adaa","added_by":"auto","created_at":"2025-08-17 14:24:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1706606,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6804155/v1/24afe0d7-9a0e-4124-b8e4-2b4de7493f67.pdf"},{"id":89230946,"identity":"fbbb7bcb-c227-435f-8977-2319a4bcf5c2","added_by":"auto","created_at":"2025-08-17 14:16:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15957,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixI.docx","url":"https://assets-eu.researchsquare.com/files/rs-6804155/v1/c65e2e564981fad9b2fd946a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Social Risk Factors of Referral Non-Adherence to Eye Care Referrals for Children: A Scoping Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEarly detection and treatment of vision disorders is essential to prevent irreversible vision loss in children.(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Vision screening is aimed at identifying common vision disorders and facilitating diagnosis and treatment through referrals to an eye care professional for a comprehensive eye examination.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Vision screening is a wasted effort without completed referrals to ensure treatment for detected vision disorders. In many countries, vision screening is conducted in schools, primary care, and/or other community-based settings.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eDespite the importance and benefits of vision screening and comprehensive eye examinations, up to 60% of children with abnormal vision screening tests do not attend recommended appointments with eye care providers.(\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 rates of adherence to eye care appointments disproportionally impact socially disadvantaged populations, which include racial/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\u003eIdentifying the social risk factors of referral nonadherence to eye care appointments is important to design effective strategies to prevent irreversible vision loss and its long-term consequences. Previous studies have identified social risk factors of referral nonadherence to eye care. \u003csup\u003e18,19,20\u003c/sup\u003e However, these studies have focused on eye care for specific vision disorders, vision screening rather than specialist eye care, or were targeted to the United States (US) population or adult population. The objective of this study is to identify social risk factors of and strategies to address referral nonadherence for comprehensive eye exams by eye care professionals following abnormal vision screening tests for children. The results of this review will inform future studies aimed at implementing an evidence-based strategy to improve referral adherence for children after abnormal vision screening in primary care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eProtocol and registration\u003c/h2\u003e\u003cp\u003eThis scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) for scoping reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) 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 in November 2024 The protocol for this review was registered with the Open Science Framework and can be accessed at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/kxn49/\u003c/span\u003e\u003cspan address=\"https://osf.io/kxn49/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eThe review team met with a librarian (A.H.) in June 2023 to design the search strategy for PubMed and then adapted it for other electronic databases. The initial literature search was conducted in July 2023 (from the inception of the respective database to July 2023). An updated search was conducted in early November 2024. The search aimed to identify relevant studies that described social risk factors of and strategies to address referral nonadherence following abnormal vision screenings in children using the following combination of keywords, controlled vocabulary, where applicable, and their synonyms: \u0026ldquo;child\u0026rdquo;, \u0026ldquo;vision screening\u0026rdquo;, \u0026ldquo;referral adherence\u0026rdquo;, and \u0026ldquo;eye care professional\u0026rdquo;. The complete search strategy used for PubMed can be found in \u003cb\u003eAppendix I\u003c/b\u003e.\u003c/p\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eStudies were included based on the type of target population, outcomes and type of study. Eligibility criteria was applied at both the title/abstract and full-text levels, as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Vision screening could occur in any setting, e.g., school, pediatric primary care, or another community-based setting. There were no restrictions on date of publication or country of publication; however, studies were excluded if they were not written in English (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInclusion and Exclusion Criteria\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInclusion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExclusion\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePopulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Parents or guardians of children requiring follow-up after vision screening\u003c/p\u003e\u003cp\u003e\u0026bull; Children aged 3 to 18 years at the time of their vision screening test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExclusion: Children\u0026thinsp;\u0026gt;\u0026thinsp;18 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy Outcomes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient social risk factors of referral nonadherence to eye care professionals following abnormal vision screenings in children and strategies to address them\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary peer-reviewed studies, regardless of design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCommentaries, letters to the editor, editorials, and review papers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cp\u003eThe electronic databases searched were 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 conducted.\u003c/p\u003e\n\u003ch3\u003eEvidence selection\u003c/h3\u003e\n\u003cp\u003eSearch results were collected and deduplicated in EndNote and then uploaded into the Rayyan-Intelligent Systematic Review program (Rayyan Systems Inc., Cambridge, MA) to review retrieved articles. Article selection was based on the eligibility criteria outlined above and involved a two-step process, specifically, a review of titles and abstracts followed by a review of full-text articles. All reviewers (AOA, PMH, AA, and AR) were involved in a pilot test on a random 10% of articles retrieved from the initial search. The reviewer team screened the articles using the initial eligibility criteria outlined in our protocol and made minor changes to the inclusion criteria. Specifically, expanding it to include caregivers of children, and additional clarity on the type of vision screening programs. Screening commenced once 75% agreement had occurred between all four reviewers on pilot studies. During the screening process, two reviewers independently reviewed each source at each level (title, abstract, and full-article review), and disagreements were reconciled by consensus or by a third reviewer (AOA or PMH).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStudy selection and data collection process\u003c/h2\u003e\u003cp\u003eData from studies that were included in the review were extracted using a pilot-tested form. Information extracted 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.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSynthesis of findings\u003c/h3\u003e\n\u003cp\u003eData extracted from full-text studies selected for inclusion were synthesized using a three-stage process consisting of inductive coding, theme generation, and theme mapping.\u003c/p\u003e\u003cp\u003eInductive Coding was conducted using descriptive coding labels created inductively by one reviewer (AA) and confirmed by another reviewer (AOA) to allow initial sub-themes of the social risk factors to emerge from existing published knowledge.\u003c/p\u003e\u003cp\u003eTheme generation involved the identification, analysis, and interpretation of patterns within the data set (\u0026lsquo;thematic synthesis\u0026rsquo;). One reviewer (AA) inputted the coded results in Excel where they were grouped based on the qualitative themes. Another reviewer (AOA) then reviewed the data to ensure consistency and consensus. This method of theme generation allowed the 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\u003cp\u003eThemes for social risk factors were mapped to the widely used the Penchansky and Thomas (P-T) Framework,(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) expanded by Saurman to enable the review to elucidate gaps in knowledge on the social risk factors of access to vision care, in line with the study\u0026rsquo;s research objectives.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Access is defined as a set of specific areas of fit between the patient and the health care system, similar to the \u0026lsquo;enabling factors\u0026rsquo; in the Anderson model of Behavioral Use.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) To determine the level of fit, access was divided into six dimensions: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) availability - volume and adequacy of supply of services; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) accessibility \u0026ndash; location of the service and the patient\u0026rsquo;s ability to commute; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) accommodation \u0026ndash; organizational abilities of the service to accept patients and patients ability to use the service; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) affordability \u0026ndash; financial costs of the service; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) acceptability \u0026ndash; mutual perceptions between the patient and the provider regarding each other and the service; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) awareness \u0026ndash; effective communication and spread of information to patients.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The six independent dimensions are interconnected, and each is important to encourage access to health services. By organizing findings through the P-T Framework, dimensions of access that are lacking can be identified and addressed. In this study, patient-level data on the social risk factors related to referral nonadherence following abnormal vision screening tests are reported.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe initial search identified 5,538 studies through databases and grey literature, with one additional record 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 with only 11 not available. 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. 17 studies assessed social risk factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and 16 studies assessed strategies to overcome social risk factors of referral non-adherence.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe included studies targeted vision screening programs conducted at schools 5 (29%),(\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) pediatric primary care clinics 4 (24%), (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and other community settings 8 (47%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).(\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Vision screening programs in 3 (18%) studies targeted preschool aged children (aged 3 to 5 years), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) while 2 (12%) studies targeted school-age children 6 to 18 years only, (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and 5 (29%) studies targeted school screening programs for both preschool and school-age children.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Race was reported in 7 (41%) studies, (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and ethnicity was reported in 5 (29%) studies.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Study designs varied with most included studies using qualitative methods (focus groups and interviews) (n\u0026thinsp;=\u0026thinsp;6, 35%) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) compared to quantitative methods to assess social risk factors of nonadherence to referrals. Most studies employing quantitative methods (n\u0026thinsp;=\u0026thinsp;11, 65%) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) used surveys to assess referral nonadherence. The majority (n\u0026thinsp;=\u0026thinsp;13, 76%) of studies were conducted in high income countries, (\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 citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) three studies (18%) were conducted in low- and middle-income countries (Nigeria and India), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and one study was conducted in an upper middle-income country (Brazil). (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescription of Included Studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthors, Year Published\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeographical Context\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWHO income level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTarget Population\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eScreening setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAge range (children, years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSex/gender distribution [Females/Girls n (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eRace [Black, White, Asian, American Indian, Other; n (%)]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eEthnicity [Hispanic, Non-Hispanic; n (%)]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLohfeld et al., 2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNigeria, Cross River State\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower-Middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of school-aged children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSchool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: 23 to 61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents (mothers): 28 (64%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKemper et al., 2006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, national cohort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of pre-school children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary care (pediatrician and family physician clinics)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 3 to 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 23 (51.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNon-Hispanic white: 17 (62.2%); Hispanic or non-white: 28 (37.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeville et al., 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, New Jersey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of school-aged children in an urban middle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSchools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 11 to 14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 47 (54.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eAfrican American 36(41.4%), Caucasian 23 (26.5%), Multiracial 3 (3.4%), Asian 3 (3.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eHispanic 22 (25.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoma et al., 2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBrazil, Guarulhos, Sao Paulo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUpper Middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents or guardians of elementary school children in grades 1\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSchools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 7 to 10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 50.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSu et al., 2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, New Haven County, Connecticut\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of children with an abnormal visual acuity screening test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStaff model university health center with an in-house eye department, a federally qualified community health center with an in-house eye department, a federally qualified community health center without an inhouse eye department, or a private pediatric primary care practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified \u003c/p\u003e\u003cp\u003eChildren: 3 to 14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 27 (47%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eBlack 4(7%), Asian 6(10%), White 17(29%), Mixed 6(10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eHispanic \u0026minus;\u0026thinsp;25(43%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSlingsby et al., 2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, South Dakota\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParent or guardians of children referred for a comprehensive eye exam following a vision screening by CVSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003evision screening event conducted by CVSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 3 to 11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified \u003c/p\u003e\u003cp\u003eChildren: 28 (44.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWhite 30(47.6%), American Indian 26(41.3%), Other 3(4.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRavindran et al., 2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia, Tirunelveli, Tuticorin, Kannyakumari districts, South India\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower Middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents or guardians of children who did not complete referrals for eye care professionals within 60 days of screening test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICDS eye screening program in Tirunelveli, Tuticorin, and Kannyakumari districts of South India which lie 12\u0026ndash;49 miles from the base hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 0 to 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 155 (47.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTjiam et al., 2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNetherlands, Rotterdam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of children with incomplete referrals that participated in RAMSES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePopulation based screening as part of RAMSES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWang et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCanada, Catchment area of Kingston, Frontenac, Lennox, Addington Public Health, Ontario\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of children in senior kindergarten in the catchment area of KFL\u0026amp;A Public Health that were referred to an eye care professional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSchools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 4 to 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWasserman et al., 1992\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, 23 states and the Puerto Rico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of children receiving health care in pediatric primary care practices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePediatric practices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: not specified \u003c/p\u003e\u003cp\u003eChildren: 3 to 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 3722 (48% female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 6668 (86%) White, 698 (9%) Black, and 775(1%) Asian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eParents: not specified\u003c/p\u003e\u003cp\u003eChildren: 232(3%) Hispanic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWilliams et al., 2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of inner-city children with low SES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWills Eye Institute and Jefferson Medical College of Thomas Jefferson University (GKSD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYawn et al., 1998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, Rochester, Minnesota\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents, children, teachers, school and community health professionals and community leaders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSchool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e66 (70.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eCaucasian 69 (73.4%), African American 14 (14.9%), Southeast Asian (11.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBruce et al., 2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUK, Bradford, England\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents living in Bradford, England (5th highest deprived city in England)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNot listed: just population-based program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents: (mothers) 17 (85%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5 (25%) White British; 1 (5%) of African heritage; 14 (70%) S. Asian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDotan et al., 2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, Philadelphia, Pennsylvania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChildren living in urban areas with low-socioeconomic status (uninsured or underinsured)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWills Eye Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eChildren: 0 to 18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e471 Girls \u0026minus;\u0026thinsp;51%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEbeigbe et al., 2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNigeria, Benin city, Edo state\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower-Middle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of school aged children (5 to 12 yrs) and eye care professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eParents: 38 to 54 years\u003c/p\u003e\u003cp\u003eEye care professionals: 30 to 45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eParents (mothers): 26 (74.2%)\u003c/p\u003e\u003cp\u003eEye care professionals: 3 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGordon-Shaag et al., 2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIsrael, Jerusalem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChildren\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 to 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e613 (47.8) -- Referred: 135(22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKimel et al., 2006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUS, Rockford, Illinois\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParents of elementary students in an urban, midwestern public school district\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePublic school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eChildren included 48% boys and 52% girls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eChildren: 42% White, 49% African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eChildren: 5.5% Hispanic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eABBREVIATIONS: CVSI\u0026thinsp;=\u0026thinsp;Northern Plains Eye Foundation Western South Dakota Lions Children\u0026rsquo;s Vision Screening Initiative, RAMSES\u0026thinsp;=\u0026thinsp;Rotterdam Amblyopia Screening Effectiveness Study, KFL\u0026amp;A\u0026thinsp;=\u0026thinsp;Kingston, Frontenac, Lennox and Addington, ICDS\u0026thinsp;=\u0026thinsp;Integrated Child Development Centers, GKSD\u0026thinsp;=\u0026thinsp;Give Kids Sight Day, US\u0026thinsp;=\u0026thinsp;United States\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe most frequently reported social risk factors of referral non-adherence were related to the awareness (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34 CR35 CR36\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and affordability dimensions,(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\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=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) present in 14 (82%) studies (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This was followed closely by social risk factors related to the accommodation dimension present in 12 (71%) studies.(\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=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) The least reported social risk factors of referral non-adherence were related to the dimension of accessibility (n\u0026thinsp;=\u0026thinsp;5, 29%).(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Social risk factors that did not fit within the six dimensions of the P-T Framework extended by Saurman were predisposing characteristics in line with the Anderson model of Behavioral Use.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Predisposing characteristics refer to patient-level factors that exist prior to the use of health services and influence a person\u0026rsquo;s likelihood to seek health care.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) A description of the social risk factors identified for each dimension of access is described below and in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Strategies identified in included studies to overcome patient social risk factors of referral non-adherence following an abnormal vision screening test are reported in a separate manuscript.\u003c/p\u003e\u003cp\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 Social risk factors of Referral Non-Adherence Identified in Included Studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-Theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSocial risk factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStudy Citing Social risk factors\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e\u003cp\u003e\u003cb\u003eAwareness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"12\" rowspan=\"13\"\u003e\u003cp\u003e\u003cb\u003eLow Vision Health Literacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe caregiver does not believe there is an eye problem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMisconceptions about seeking healthcare generally (children will get sick if they go to the hospital)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMisconceptions about treatment, especially regarding the use of prescription eyeglasses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\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=\"c3\"\u003e\u003cp\u003eMisconceptions or lack of knowledge about the importance of eye conditions, such as lazy eye, and the need for timely eye exams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\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=\"c3\"\u003e\u003cp\u003eParents belief that vision exams and glasses covered by Medicaid insurance are substandard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLack of knowledge about where and how to schedule appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLanguage barriers*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow Literacy*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\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=\"c3\"\u003e\u003cp\u003eFear of diagnosis or treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConcerns about cost or if insurance provided coverage for follow-up appointments with an eye care provider and glasses*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\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=\"c3\"\u003e\u003cp\u003eParent inattention to school documentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\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=\"c3\"\u003e\u003cp\u003eDid not know about the referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLack of caregiver understanding difference between a screening and eye exam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\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=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAffordability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eUnable to afford cost of care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLack of insurance coverage for eye exams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow income*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\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=\"c3\"\u003e\u003cp\u003eConcerns about cost or insurance coverage for follow-up appointments with an eye care provider and glasses*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\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=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e\u003cb\u003ePredisposing Factors*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e\u003cb\u003ePatient-level factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParent negligence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\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=\"c3\"\u003e\u003cp\u003eParent forgetfulness to attend or schedule appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\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=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\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=\"c3\"\u003e\u003cp\u003eParent preference for alternative medical treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\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=\"c3\"\u003e\u003cp\u003eLack of social acceptance regarding wearing glasses by teenage peers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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=\"c3\"\u003e\u003cp\u003eLow education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDifficulty obtaining food for the family (food insecurity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\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=\"c3\"\u003e\u003cp\u003eDifficulty obtaining or instability of housing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSick or disabled family members requiring other family health appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFamily conflicts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\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=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eAcceptability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eDissatisfaction with program/provider\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParent belief that Medicaid vision exams and glasses substandard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLack of confidence in screening results from school-based programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysician lack of empathy for families\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\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=\"c3\"\u003e\u003cp\u003eRacial and financial discrimination regarding prompt eye care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eAccessibility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eLogistical challenges\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLack of caregiver support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBad weather\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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=\"c3\"\u003e\u003cp\u003eLack of transportation and long distance to eye care provider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDoes not own a phone to schedule appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnpredictable family schedule due to having a large family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot able to plan ahead due to family challenges e.g. obtaining food and housing, child does not live in a consistent home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\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\u003e\u003cb\u003eAccommodation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eLack of priority due to extraneous factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParental time constraints due to work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDisability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCOVID-19 pandemic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInconvenient Medicaid scheduling system (limited appointments that could only be booked in the mornings)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAvailability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eHealthcare system related factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLong wait times for eye care appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\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=\"c3\"\u003e\u003cp\u003eLong in-person wait times to receive care at government facilities (walk-in appointments)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\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=\"c3\"\u003e\u003cp\u003eLimited number of qualified eye care professionals or eye appointments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Adopted from Anderson\u0026rsquo;s Behavioral Model of Health Services Use\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAcceptability\u003c/h2\u003e\u003cp\u003eThe most frequently cited social risk factors of poor acceptability were a lack of confidence in vision screening program conducted in lower-middle (Nigeria)(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and high-income countries (United Kingdom (UK),(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) United States (US),(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Israel,(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Netherlands(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Particularly, caregivers doubted the accuracy of the screening tests. Yawn et al. reported that caregivers in Rochester, Minnesota doubted that training given to screeners (who were parent volunteers) was adequate and supervised.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Other social risk factors of poor acceptability included caregiver beliefs that comprehensive eye exams and prescription glasses provided to beneficiaries of US, government-funded health insurance (Medicaid) were of poor quality.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) In Cross River State, Nigeria, Lohfeld et al. reported that caregivers\u0026rsquo; past negative experiences with physicians in hospitals were a deterrent to adhering to referrals to eye care providers.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Physicians were described as lacking empathy for patients.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Other factors identified as social risk factors of poor acceptability were caregivers\u0026rsquo; dissatisfaction with the use of the word \u0026lsquo;failure\u0026rsquo; in parent notification slips, caregiver perceptions that vision screening was boring for children, and racial and financial discrimination preventing prompt care.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAccessibility\u003c/h2\u003e\u003cp\u003eSocial risk factors of poor accessibility were the result of logistical hurdles in five studies from lower-middle (India),(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) upper-middle (Brazil),(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and high income countries (US) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and UK (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The most frequently cited social risk factor of poor accessibility to care was the lack of transportation and long travel distances to an eye care provider in US,(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) India,(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and UK-based studies.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Additionally, lack of a caregiver at home to care for other children, in order to take another child to an eye care visit was identified as a determinant of poor accessibility for studies conducted in the US(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and Brazil.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Other social risk factors included inclement weather,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and no phone to schedule appointments.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) In their study of caregivers in the Illinois Rockford Public School district in the US, Kimel et al. reported that caregivers often experienced difficulties planning ahead due to uncertainties regarding their basic needs such as food and housing, and unpredictable family schedules.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Large families found it especially difficult coordinating schedules.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAccommodation\u003c/h2\u003e\u003cp\u003eTime constraints related to work were the most frequently cited social risk factors cited by 12 studies conducted in lower middle [Nigeria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and India (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)), upper-middle (Brazil (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)) and high income (US,(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Canada,(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) Israel,(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and UK (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)] countries. Other social risk factors for poor accommodation included an inconvenient appointment scheduling system for beneficiaries of US government health insurance (Medicaid) due to limited eye care appointments restricted to mornings, as reported in a study in Illinois, US.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Also reported were restrictions due to the COVID-19 pandemic.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) In two US-based studies, caregivers reported that they did not adhere to referral eye exams because they were concerned that children with special needs would be unable to cooperate with an eye exam.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eAffordability\u003c/h2\u003e\u003cp\u003eLack of affordability was reported as a social risk factor of nonadherence in 14 studies from lower-middle [India (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and Nigeria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)), upper-middle (Brazil (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)], and high-income countries [US,(\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 citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Canada,(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) Israel,(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and Netherlands (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)]. Lack of insurance coverage for comprehensive eye exams was the most frequently cited determinant related to affordability and was reported by studies conducted in US (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), Canada,(\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 citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and Israel (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In addition to lack of insurance, caregivers in US-based studies reported that their decision to adhere to referral appointments was influenced by concerns of the cost of care; particularly, whether their insurance provided coverage for eye appointments and prescription glasses.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Lack of insurance coverage was reported for a study based in Israel which has universal health insurance (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Similarly, low income was reported in Brazil,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) India,(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Netherlands,(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) US,(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and Nigeria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) where out of pocket payments were the predominant means of paying for vision care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAvailability\u003c/h2\u003e\u003cp\u003eHealthcare system-related social risk factors of poor availability were reported in studies from high-income and lower-middle-income countries. These social risk factors included long wait times for eye care appointments for studies conducted in US (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and Nigeria.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) In Cross-River State Nigeria, government health care facilities were reported to only provide walk-in appointments necessitating long waits to be seen.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Additionally, the limited numbers of qualified eye care professionals or appointments were reported for studies conducted in US,(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Canada,(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) Nigeria (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and Israel.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eAwareness\u003c/h2\u003e\u003cp\u003eThe most frequently cited social risk factors of poor awareness were misconceptions about how vision disorders presented, were treated, and implications of vision disorders.(\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\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=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) These social risk factors were reported for studies conducted in lower-middle [Nigeria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)] and high income [Netherlands, (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) US, (\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) UK, (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and Israel (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)] countries. Some caregivers did not adhere to referrals because they did not believe that their children had vision disorders.(\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=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) In Cross River State, Nigeria,(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and Michigan, US,(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) caregivers of children who failed a school-based vision screening did not believe their children had a vision disorder or believed that the vision disorder was minor because of an absence of symptoms and signs, and did not warrant an urgent visit to an eye doctor. Also, Kimel et al. reported caregivers had the erroneous belief that follow-up eye exams and glasses covered by US government-funded insurance (Medicaid) were substandard.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Eight studies conducted in the US (Michigan,(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Connecticut,(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) South Dakota,(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Minnesota,(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) New Jersey,(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and Pennsylvania(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)), Netherlands,(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and the UK (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) reported social risk factors due to caregivers\u0026rsquo; lack of knowledge about where (place or type of eye care provider) and how to schedule follow-up appointments with an eye care professional. Nine studies from Nigeria,(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) US (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) (New Jersey,(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Connecticut,(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) South Dakota,(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Pennsylvania (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and Illinois (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), Brazil,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and Netherlands (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) reported social risk factors related to caregivers\u0026rsquo; lack of knowledge about the vision screening programs. Specifically, caregivers were not aware that their children had an abnormal vision screening test and had been subsequently referred to an eye care professional. Also, caregivers did not understand the difference between a vision screening and comprehensive eye exams.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Finally, language and illiteracy, fear of diagnosis and the consequent cost of care and prescription glasses, were additional social risk factors of poor awareness.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePredisposing Factors\u003c/h2\u003e\u003cp\u003eA number of predisposing factors were reported as social risk factors of referral nonadherence in studies conducted in lower-middle,(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) upper-middle,(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) and high-income countries.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) The most frequently cited predisposing factor was forgetfulness to attend or schedule an appointment with an eye care professional.(\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=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) Families facing challenges with their basic needs such as food insecurity and instable housing were less likely to adhere to referrals to eye care professionals.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) A study conducted by Yawn et al. in the rural city of Rochester, Minnesota, reported that teenagers did not often want to attend appointments with eye care professionals because of the fear of being prescribed glasses.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Also, caregivers of children in Rotterdam, Netherlands (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and Cross River State, Nigeria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) reported their preference for alternative medical treatment to Western medicine as their reasons for not adhering to referrals. Additional extraneous factors such as disability, illness, conflicts in the family, parent negligence, and low education were also identified as social risk factors of referral nonadherence.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e In this scoping review, we mapped the social risk factors of referral nonadherence to eye care professionals (following abnormal vision screening tests for children) identified in the existing literature. Social risk factors identified were synthesized thematically and organized using a framework from Penchansky and Thomas (based on the Framework of Access), extended by Saurman.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) We identified 17 studies that reported social risk factors of referral nonadherence.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) The most frequently cited social risk factors were the inability to afford the cost of vision care (including comprehensive eye exams and prescription glasses), and low vision health literacy. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In relation to the P-T Framework, these were social risk factors related to affordability and awareness.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eGaps in the Existing Literature\u003c/h2\u003e\u003cp\u003eOnly one of the included studies reported social risk factors across all six dimensions of access as described in the P-T Framework extended by Saurman.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\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=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) None of the 17 included studies used a conceptual framework such as the P-T Framework to inform the design of their data collections tools (i.e., interview guides, focus groups or surveys).(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) This suggests that studies did not address all dimensions of access to care which highlights a critical gap in studies designed to address health disparities. In this study, social risk factors to accessibility were least represented in the data. Accessibility from the patient perspective is highly subjective and associated with other patient-level factors such as time constraints, a limited number of qualified eye care professionals and their inability to plan ahead which were represented in other access dimensions.\u003c/p\u003e\u003cp\u003eMost of the included studies were based on studies conducted in high-income countries.(\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 citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35 CR36\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) This statistic highlights a significant gap in our understanding of social risk factors of referral nonadherence in settings where resources may be limited and needs high. Limited studies in low- and middle-income countries (\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=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) may be due partly to limited population-based data sources compared to high-income countries, such as national population-based surveys, electronic health records systems, and administrative data. Other difficulties may relate to data collection in communities with low rates of literacy and languages that differ from that of researchers which may require significant resources and funding for translation and other related services.\u003c/p\u003e\u003cp\u003eIt is not surprising that affordability and awareness were the most frequently cited social risk factor of referral nonadherence. In the US and other high-income nations, most health insurance plans cover the cost of vision care for children to include vision screening, comprehensive eye exams, and a pair of prescription glasses per year. In the US, the Affordable Care Act (ACA) requires all health insurance plans cover vision care services for children which is one of 10 essential health benefits.(\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) The type of vision care coverage, however, varies by US state. Forty-two states cover annual comprehensive eye exams and one pair of prescription glasses per year.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) However, grandfathered health plans (established prior to passing the ACA) are exempt from ACA provisions such as these. Therefore, caregivers without or limited health insurance coverage for the cost of comprehensive eye exams and prescription glasses face challenges paying for these out of pocket.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) Also, some eye care professionals do not accept government-funded insurance such as Medicaid,(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) perhaps due to the low reimbursement associated with Medicaid insurance compared to private insurance.(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAwareness as a determinant of referral nonadherence includes poor vision health literacy, and misconceptions and mistrust of health care systems. Vision disorders in childhood often present with no signs or symptoms and children are unable to express or even know that their vision is substandard. For this reason, caregivers may not believe the vision screening results and therefore the need for a comprehensive eye exam.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Studies on Hispanic immigrant parents report a lack of knowledge about the importance of vision care and types of vision coverage for children.(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eFew studies have reported social risk factors of referral nonadherence with eye care professionals.(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) Zeng and colleagues conducted a study to review the literature on the social risk factors of attending ophthalmology eye exams following vision screening in the community and interventions to increase follow-up rates.(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) The study population was patients with diabetic retinopathy, glaucoma, refractive error or cataract. Social risk factors reported were related to ophthalmology appointments. Of the social risk factors they found to not attending follow-up appointments, lacking a car or living farther away from the hospital (accessibility) would be most applicable to social risk factors in this current study.\u003c/p\u003e\u003cp\u003eZeng and colleagues identified the following strategies for improving attendance to ophthalmology appointments for adults: reminder phone calls by study staff, (\u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) providing prescheduled appointments, patient contracts, vouchers for free or subsidized follow-up eye exams, bus tokens for follow-up appointments, or patient education and resources such as printed exam results and written instructions for scheduling follow-up appointments. Other strategies included encouragement by a community health worker or patient navigator,(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) Saturday hours in addition to weekday clinic hours,(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) multiple phone calls and screening centers near referral clinics.(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) Patient navigators have been used widely in various medical specialties including ophthalmology.(\u003cspan additionalcitationids=\"CR57 CR58 CR59\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) Patient navigators are particularly useful for supporting individuals and families with poor vision health literacy to navigate challenges with scheduling and attending referral appointments, and understanding payment and other nuances of their health insurance. To cut down on the potentially high costs of hiring patient navigators, partnerships with community health programs to staff the patient navigator role could be helpful. Onsite specialist eye care could also reduce the burden on families, especially those with low vision health literacy to overcome challenges with accessing specialist care. Social risk factors of poor affordability, may be best mitigated through legislation for health insurance plans to cover the cost of annual eye exams and prescription glasses. Despite the abundance of strategies and interventions to improve referral adherence, it is unknown whether these strategies will be effective in pediatric populations referred from vision screening programs to specialist eye care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" 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 social risk factors of referral nonadherence for children after abnormal vision screening tests, regardless of the screening setting. Relevant studies were identified using a robust and systematic approach. Knowledge of the social risk factors identified will better equip future research in the creation of strategic health interventions to improve access to specialist care. The application of P-T Framework extended by Saurman facilitated a systematic and thorough study of gaps in the literature.\u003c/p\u003e\u003cp\u003eDespite its strengths, several limitations of this study need to be considered. We faced difficulties categorizing some social risk factors within the framework because they either crossed multiple dimensions of access or did not appear to be a good fit for any of the identified access dimensions. For instance, the perception that vision exams provided by Medicaid were substandard could indicate a determinant of poor acceptability, but also a determinant of poor awareness. To address this, we listed these social risk factors under all the access dimensions for which it appeared relevant. Parent negligence and sick family members were two social risk factors that did not appear to fit under any of the access dimensions. For these, we created a new theme based on the Anderson Model of Behavioral Use called \u0026lsquo;Predisposing Factors\u0026rsquo;. Also, social risk factors of referral nonadherence identified in this study may not be directly applicable or generalizable to all country contexts. For instance, concerns regarding insurance coverage for comprehensive eye exams, or the ability to afford co-pays or out-of-pocket payments, may be more relevant to the US context than other countries, such as Canada, and the UK which have universal health insurance programs. Also, social risk factors regarding long wait times in walk-in eye clinics may be more applicable to low-income countries where this system of care abounds. Finally, quality of included studies was not assessed, in line with the JBI methodology for conducting scoping reviews. Therefore, it is possible that there was bias in the selection of studies. Had an assessment of the quality of included studies been conducted, additional gaps may have been elucidated. Despite using a robust and systematic approach to search the literature, it is possible that some relevant studies may have not been selected for inclusion.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, several social risk factors of referral nonadherence exist for children referred from vision screening programs to eye care professionals, with the most frequent being a lack of affordability and awareness. This knowledge will enable the development of strategic and targeted interventions to prevent irreversible vision loss in children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUnited States (US), Joanna Briggs Institute (JBI) Penchansky and Thomas (P-T), Affordable Care Act (ACA)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u0026nbsp;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\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eConsent for publication was\u0026nbsp;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\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors have no competing interests relevant to this article to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support:\u0026nbsp;\u003c/strong\u003eThis work was supported by the National Institutes of Health Core Grant (EY014800), and an\u0026nbsp;Unrestricted\u0026nbsp;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\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eAA, AOA conceptualized and designed the study, acquired, analyzed and interpreted data, and drafted the article. 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.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMema SC, McIntyre L, Musto R. Childhood vision screening in Canada: public health evidence and practice. Canadian journal of public health = Revue canadienne de sante publique. 2011;103(1):40-5.\u003c/li\u003e\n\u003cli\u003eSchuster AK, Elflein HM, Diefenbach C, Gr\u0026auml;f C, K\u0026ouml;nig J, Schmidt MF, et al. Recommendation for ophthalmic care in German preschool health examination and its adherence: Results of the prospective cohort study ikidS. PLoS One. 2018;13(12):e0208164.\u003c/li\u003e\n\u003cli\u003eUwemedimo OT, Arpadi SM, Chhagan MK, Kauchali S, Craib MH, Bah F, et al. 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JAMA Ophthalmol. 2015;133(5):527-32.\u003c/li\u003e\n\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, Social Determinants of Health, 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; Insurance, Health, Medically Underserved Area, Vision health literacy, Follow-up care, Barriers to care, Patient navigation, School-based vision screening","lastPublishedDoi":"10.21203/rs.3.rs-6804155/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6804155/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\u003eDespite the importance and benefits of vision screening and comprehensive eye examinations, up to 60% of children with abnormal vision screenings do not attend recommended appointments with eye care providers. The purpose of this study is to identify social risk factors of and strategies to address referral non-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 A scoping review was conducted following the Joanna Briggs Institute methodology. Bibliographic databases and gray literature were searched 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. Social risk factors were synthesized and thematically mapped using the Penchansky and Thomas's model of access, extended by Saurman.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeventeen studies reported social risk factors of referral nonadherence, and 16 studies assessed strategies to overcome social risk factors. The most frequently cited Penchansky and Thomas dimension was affordability (n\u0026thinsp;=\u0026thinsp;14) and awareness (n\u0026thinsp;=\u0026thinsp;14), while accessibility was the least cited (n\u0026thinsp;=\u0026thinsp;5) in the data. None (n\u0026thinsp;=\u0026thinsp;0) of the studies indicated the use of a conceptual framework to inform the organization of their extracted data. Most of the included studies targeted populations in high-income (as compared to low, lower-middle, upper-middle income) countries. Strategies to address social risk factors are reported in a separate manuscript.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAffordability and awareness are the most frequent social risk factors of non-adherence to eye care referrals for children following abnormal vision screening tests. Significant gaps remain in understanding social risk factors in resource-limited settings with high needs.\u003c/p\u003e","manuscriptTitle":"Social Risk Factors of Referral Non-Adherence to Eye Care Referrals for Children: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:16:15","doi":"10.21203/rs.3.rs-6804155/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-17T08:30:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T15:08:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T16:49:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48250617362960344164993839922426108606","date":"2026-01-23T10:20:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T21:25:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-24T06:07:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298006098968500448032274336325171164317","date":"2025-08-21T17:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59423311072936303391758053446222666326","date":"2025-08-13T20:53:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192810254002553538423512847557068767024","date":"2025-08-11T15:51:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65491780986700793815857798379002635262","date":"2025-08-09T01:07:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T14:22:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T21:07:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-05T19:54:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-05T16:55:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-06-05T16:51:50+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":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T07:25:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-17 14:16:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6804155","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6804155","identity":"rs-6804155","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}