Theme 1–1: Parental belief there is no eye problem.

When asked why parents do not bring their child to a follow-up exam, a key reason was the belief that there was no problem with the child’s eyes or vision. As one mother explained, “I felt there was nothing wrong with his eyes because he’s never complained to me [so] I didn’t take it serious” (FG4-F1). Another mother shared a similar view: “[It’s] disbelief … —not believing there’s a problem. They will say there’s no need for further testing because there’s no problem” (FG9-F1). Still another respondents labelled this as ignorance:

“Some ignorant parents may think that it is just ‘eehh’; [indicating not very important with a shrug]. It’s ignorance on the part of the parents; they’re unaware of what’s going on” (FG1-M1).

Some parents clearly stated they generally disregard what young children say: “[With a young child] you will not even take anything serious you will relax. That’s the reason” (FG8-F1).

Another reason parents do not take action about a problem is because it does not seem serious:

“Since my child wasn’t complaining about a physical problem, I felt it may not be important for me to go there. There wasn’t any eye drooping and he [referring to her child] was going about with his normal business so I felt it isn’t that serious and I overlooked it” (FG1-F1).

Theme 1–2: Issues with the referral letter.

A second key reason why parents do not bring eligible children for a follow-up eye exam is that the only information about the eye care programme is a referral letter that all children who fail the screening test are asked to bring home:

“What made me not go [to the eye clinic] with the child is that I didn’t receive any note from them [the school]” (FG10-F3).

In some cases the child may bring the letter home but not explain its contents to the parents. In other cases, parents reported that the referral letter did not look official so they ignored it:

“I didn’t get confirmation from the school authority to go for further test; that’s why I couldn’t go for the eye test” (FG10-M4).

This statement should be understood in the context of Nigeria:

“If something isn’t from the government … people will be afraid. Some people believe only government officials are supposed to go into schools for immunization or eye treatments, or anything to do with children’s health” (FG4-M1).

Theme 1–3: Parental belief they must pay for follow-up eye care.

Many parents had the misperception there was a cost associated with clinic-based eye exams. As one mother noted, many parents “think it’ll cost money, so they don’t want to go because of the possible financial costs” (FG5-F1). In part, this is because hospital care can be financially out of reach for many people and the CCEiN eye clinics are hospital-based:

“As far as Nigeria is concerned … less privileged people cannot go to hospital … they know that the nurses and the doctor won’t pay attention to them if they don’t bring money. First, they ask you to buy [a patient registration] card; then they prescribe drugs and ask you to buy [them]. They won’t even start treating you without you paying money!” (FG2-M1)

Theme 1–4: Parental beliefs about eyeglasses.

A few people also expressed negative views about eyeglasses, either because they believed “glasses are for adults and not children” (FG10-F2) or “wearing glasses can negatively affect one’s eyes” (FG10-M3).

Theme 2–1: Parental or household situation.

A major topic of discussion in each FG was the impact of deep poverty in each of the study sites. One woman bluntly stated, “poverty is an understatement” (FG10-F1). Another woman described how poverty resulted in her not adhering the referral: “At the time there wasn’t even food for us to eat … that’s why we didn’t go [to the eye clinic]” (FG7-F2). This was a common view, expressed by another FG participant:

“Simply put, a lot of our people are poor, and poverty affects our reasoning. You run around looking for things to eat and only later think about other problems that will bring them sorrow later” (FG5-M1).

In other groups, participants discussed both the need to postpone healthcare visits and the lack of affordable transport as barriers to attending follow-up eye exams.

Theme 2–2: Logistical problems.

A sizeable number of comments were made about time- and work-related factors as important reasons why parents cannot accompany their child to an eye clinic: “Money is not the only reason; some parents are too busy” (FG9-F1). Another parent echoed this view, stating, “It all boils down to time. Some parents have very tight schedules” (FG6-M3). This is closely linked to the inability to attend scheduled appointments:

“We know that when the time comes to do an eye check-up for children, some people won’t go. They’ll have an appointment scheduled but might not be available [at that time].” (FG10-F4)

Often this is because parents cannot take time off work: “My work didn’t permit me to—it didn’t give me free time to take him there” (FG4-F1).

Theme 2–3: Parental attitudes.

Participants also used generally negative terms to describe parents who do not bring their children for care, indicating they are ‘careless’, ‘negligent’, ‘forgetful’ or ‘disinterested in their children’. As one mother noted, “If a parent refuses to take their child for further care in this kind of situation, it’s probably due to carelessness” (FG5-F1).

In other instances, parents said “for some, it’s due to negligence” (FG4-M1) or forgetfulness:

“It escaped my memory. Even when I was thinking about it today, [I was wondering], will I be available to go? But before the day [of the appointment], it escaped my memory” (FG6-F2).

There was also a widespread perception that some parents do not take proper care of their children: “Some parents only give birth to their children, but don’t take care of them the way they’re supposed to.” (FG8-M2) Some participants went so far as to state there are parents who neglect their children and still expect to be taken care of:

“Ehh, some children suffer a lot. Their parents are only interested in their children helping them, not the parents helping their children… they don’t even eat well!” (FG5-M1).

In other cases, it was thought that some parents are just not interested in their children’s welfare:

“Some of them just take things for granted. Most of them actually have the money to take the child to the hospital but they just take everything for granted and just leave it alone.” (FG9-F1)

This was also linked to having a large family: “[Some parents] don’t value their children because they have so many” (FG5-F1). In other cases, it was attributed to a lack of empathy on the part of the parents: “Some people will be the end of their families. They don’t feel pain from things that don’t happen to them” (FG2-M1). In some instances, this was because the caretaker was not a biological parent:

“Some guardians don’t take their children there [referring to hospital] … because they’re not the person who gave birth to those children… they won’t spend their money on the child because it’s not their biological child… They’d prefer to leave such children like that and allow their eyes to get bad, which is very bad” (FG8-M2).

It is important to determine who is the usual decision-maker regarding children’s health. Although parents often stated that it is the father who decides, probing revealed both parents often jointly make decisions affecting a child’s health and the household budget. However, they also admitted that the father is the ultimate authority. As one woman stated, “In a family if your husband says ‘No’ … the child won’t go to the hospital” (FG9-F1).

Theme 2–4: Parental beliefs about care.

Participants provided several examples of parents’ beliefs about hospitals that can prevent them from seeking care for their child. This includes a belief that “going to the hospital is taboo” or that the hospital is only “for big people [or] people that inherit sickness” (FG2-F3). Another belief is that once a health problem is named, the person will become ill with that condition. One father explained that situation as follows:

“A main reason why some people don’t go to the hospital is they don’t think they’re sick. But once they go to the hospital and they [the hospital staff] tell them they have a disease, then they become sick… they believe that if someone mentions a sickness of some kind, they will get it so that makes some people afraid to go to the hospital” (FG5-M1).

In another FG, one of the participants described knowing someone whose vision worsened after receiving treatment. He ended his story by stating that “some [parents] could be afraid of further damaging their children’s sight.” (FG10-M3)

In Nigeria, spiritual beliefs strongly shape health-seeking behaviors. It is very common for people to believe in the power of prayer as well as in allopathic or modern biomedicine, choosing to pray before seeking medical care:

“Some parents are like me. When something happens, I first will handle the spiritual aspects before getting medical attention because I know there are some cases that were resolved that like in the past… some of us believe that the spirit controls the physical. It’s not that we don’t believe in the power of modern medicine, but sometimes it [the problem] can be a spiritual attack” (FG10-M4).

In many communities, several people attend Apostolic churches that forbid the use of modern medicine. Members of one FG acknowledged this, stating “It may be because of their religion. Like the Apostolic faith. They tell you, ‘Don’t use Western medicine’” (FG2-F1). Many Pentecostal or charismatic churches also do not endorse the use of allopathic medicine and instead exhort members to rely on the power of prayer or laying on of hands to cure health problems. As another participant explained, “Some of them [parents] don’t believe in medical treatment, [because of] their orthodox church” (FG1-M1). Instead, they expect that divine intervention will heal a person. Another reason for avoiding biomedical facilities is a belief that health problems are due to witchcraft, which is overcome through prayer:

“Sometimes it’s not a financial issue [that prevents people from attending an eye clinic] but [a belief that] a problem is due to attack [witchcraft]. Then we need to fasten up in prayers [seriously pray]” (FG10-F4).

Some families rely traditional remedies to treat eye or vision problems:

“I was taking care of a blind man and asked him, ‘How did you become blind?’ He said, ‘It’s because of measles.’ He had measles when he was young and his parents put drops of a traditional remedy in his eyes. ‘Why?’, I asked him. He said, ‘They didn’t know they should’ve taken me to the hospital’.” (FG10-F1)

Theme 2–5: Illiteracy.

The lack of proactive care of children’s vision was also attributed to low levels of literacy or health literacy. One man explained, “We still have a lot of illiteracy in town” (FG4-M1). This presents a problem when schoolchildren who fail the screening bring home the referral letter for a follow-up exam:

“They [referring to his children] bring home letter for their mother, who can’t read. And she says, ‘Give me the letter and when your father comes [home] I’ll give it to him to read.’ By the time the father comes home, she’s forgotten so she doesn’t give the letter to him!” (FG7-M1).

Theme 2–6: Hospital-related issues.

There were also complaints about hospitals which could result in parents not adhering to referrals to a hospital-based eye clinic. Two key issues were negative attitudes from staff: “Doctors have to show sympathy. Some doctors, they don’t have that human sympathy” (FG2-F1) and long wait times to be seen by a doctor:

“You go there [to the hospital] but don’t get to see the doctor… That’s stressful for parents because they have things to do at home rather than going to the hospital and wasting the whole day [waiting]” (FG2-F1).

Theme 3–1: educate people about the importance of child eye care.

There was also some discussion on how to increase awareness and acceptance of the child eye care programme in Cross River State. A lack of knowledge or information was something that participants thought the CCEHiN programme could address: “I think it [not seeking follow-on care] may be due to the lack of information … a parent may not be informed on how serious the issue of that child is” (FG4-F1).

In some cases families are uninformed because they lack access to information: “They [referring to poor families] may not have a radio or a television … [which is]where they would hear information like this” (FG1-F2).

Theme 3–2: correct parental misconceptions about the eye care programme.

The other recommendation, to increase awareness and uptake of the eye programme, would be to address common misconceptions, such as thinking that both vision screening tests and follow-up care are provided at local schools. As one father explained, “I didn’t go [to the clinic] because [I thought] the team will come back to the school for further care” (FG10-M4). A woman explained this was why she did not bring her children for a follow-up exam:

“My children brought the referral letters to me, but I didn’t follow their advice. I followed up with [an appointment at the] General Hospital where my doctor promised me that the people [offering eye care] will come back [to the school] by September. So, I let the children wait.” (FG10-F1).

Some parents also noted it is important to ensure that parents are given an official referral letter because “some people believe only government officials are supposed to go into schools for immunisation or eye treatments–anything to do with children’s health” (FG4-M1).