Caregivers’ and teachers’ inability to identify children’s visual challenges, compounded by children’s failure to report such challenges, facilitated the perpetuation of uncorrected refractive error (URE) (Alrasheed 2021). This failure was attributed to poor eye care literacy by school community members (Alrasheed 2021; Alrasheed, Mohamed & Alluwimi 2024; Alsaqr 2023; Du et al. 2022). Du et al. (2022) found that the uptake of eye care services depended on caregivers being informed by either their children or teachers; however, neither teachers nor children were wiser about eye-related problems. Therefore, when poor vision is neither reported nor noticed, URE treatment may be delayed, causing heightened cognitive and emotional stress, academic and non-academic frustration, such as playing in groups (Chan, Singer & Naidoo 2020; Magakwe, Hansraj & Xulu-Kasaba 2022; Ntodie et al. 2025; Zhou et al. 2024). Consequently, URE is associated with increased chances of dropping out of school, resulting in limited education, which adversely impacts employment opportunities, socioeconomic status, psychological well-being, and the quality of life (Asare & Morjaria 2021; Cao et al. 2022; Chan et al. 2020; Govender-Poonsamy et al. 2023; Huda, Ramzan & Imran 2021; Latif et al. 2022; Magakwe et al. 2022; Yang et al. 2021; Zhou et al. 2024). These consequences are plausible because vision is used up to 80% of the time during learning activities (Chan et al. 2020; Onyeahiri, Omere & Kyamru 2024). The URE has the greatest burden of disease among ocular conditions; hence, it is classified as a public health concern (Govender-Poonsamy et al. 2023; Magakwe et al. 2022; Magakwe, Xulu-Kasaba & Hansraj 2020; Yang et al. 2021; Zhou et al. 2024).

Teachers’ knowledge and/or awareness of common eye problems is indispensable in the eradication of preventable and avoidable blindness (Alemayehu, Belete & Adimassu 2018). Teachers’ well-established role as health educators, based on their contact time with children and positive attitudes, especially in under-resourced communities, can initiate a referral for eye examination (Alemayehu et al. 2018). The uptake of eye care services is well-documented to be imperative for the elimination of avoidable blindness among the litany of problems associated with compromised vision (Alrasheed, Naidoo & Clarke-Farr 2016; Alrasheed et al. 2018b; Li et al. 2010). However, caregivers’ perceptions, beliefs, and attitudes towards spectacles, which are influenced by their bias, are critical in the acquisition and use of spectacles (Alrasheed 2021; Alrasheed et al. 2016, 2024; Alrasheed, Naidoo & Clarke-Farr 2018a; Li et al. 2010).

Enabling factors, not exhaustive of healthcare insurance, income, wealth, and urban residence, were associated with eye care services uptake in South Africa (Akuffo et al. 2020). Children who were not covered by healthcare insurance were five times more likely to be at risk of unmet eye care needs (Alrasheed et al. 2016). Conversely, only 15.7% of the South African population had healthcare insurance in 2024, which enabled the accessibility of private health and eye care healthcare (Wolvaardt, Stein & Mumbauer 2025). According to Malakoane et al. (2020), healthcare in South Africa is divided into private and public sectors, with the latter funded by the government. Moreover, about 80% of the Free State province population is dependent on the failing public health sector (Malakoane et al. 2020). This dependence on the unavailable public healthcare services was attributed to the remnants of apartheid (Malakoane et al. 2020). Apartheid ensured that the country’s majority and native groups were socially, politically, and educationally segregated, and economically excluded; hence, the high unemployment rate (Malakoane et al. 2020; Statistics South Africa 2021, 2025).

Even though South Africa is ranked as an upper-middle-income country (World Bank 2025), it has arguably the worst inequality in the world and high unemployment rates (Makgetla 2020; Statistics South Africa 2021, 2025).

The cost of spectacles in developing countries was reported by several studies as the main barrier to the uptake of spectacles (Alrasheed 2021; Alrasheed et al. 2018a, 2024; Dhirar et al. 2020; Ezinne et al. 2020). It was established that the cost of the actual eye care services and cost-related factors make spectacles unaffordable, thus inaccessible (Alrasheed 2021; Alrasheed et al. 2018a, 2024; Magakwe et al. 2022). This is despite URE being the simplest and most affordable anomaly to diagnose and manage (Govender-Poonsamy et al. 2023; Magakwe et al. 2020). Figure 1 illustrates the barriers to the uptake of eye care services; however, the literature is limited regarding barriers from teachers’ perspectives.

In South Africa, there was an increase in the number of registered optometrists, from 3697 in 2016 to 4040 in 2024 (Health Professions Council of South Africa 2024; Maake & Moodley 2018). However, the number of these practitioners working in the public sector, which serves an estimated 80% of South Africans, has remained obstinately low (Maake & Moodley 2018; Makgetla 2020). Anecdotal evidence revealed that some government hospitals in the Free State operate with only ophthalmic nurses, some with no optometric services, while others do not dispense spectacles. This anecdotal evidence was corroborated by Malakoane et al. (2020) who discovered the exodus of healthcare professionals, inadequate financing, and dilapidated infrastructure. In addition, the public healthcare sector in the Free State province had poor healthcare quality because of fragmented service delivery and poor leadership (Malakoane et al. 2020). This resulted in a lack of trust and the non-utility of public health facilities by communities (Malakoane et al. 2020). To supplement the shortage of healthcare services and alleviate the burden of illness among learners by offering, among others, vision screening, the Integrated School Health Programme (ISHP) was launched (Department of Health & Department of Basic Education 2012). Literature is void of barriers to the uptake of spectacles among learners from the perspective of parents/ guardians and teachers in the Free State, hence this study.

The aim of this study was to determine the barriers to the uptake of spectacles from the perspective of caregivers and teachers in the Free State province. In summary, affordability, which is the ability of people to incur the cost of the actual healthcare services and the cost of other services incurred while seeking healthcare, influences the accessibility of eyecare services (Alrasheed et al. 2016, 2018a; Dhirar et al. 2020; Ezinne et al. 2020). Furthermore, accessibility of eyecare services is noted as the travel time to reach the nearest eyecare facility, closely linked to the residence, and the availability of transportation, including roads to access facilities (Alrasheed 2021). The existence of well-maintained infrastructure and practitioners who offer eyecare services is termed availability (Alrasheed 2021). Not exhaustive of compliance with spectacle wear, cultural beliefs, perceptions, practitioner behaviour and mistrust, gender, stigmas, and misconceptions formed part of the acceptability (Alrasheed et al. 2016, 2018a; Ezinne et al. 2020). Eye care literacy, that is, knowledge and awareness of eye-related signs and symptoms, what eye care services are available, and where they are available, which would enable communities to seek eye care expeditiously (Ezinne et al. 2020).

Participants in this study are unaware of eye problems. Only 61% of teachers identified blurry vision, 22% indicated squinting as an eye-related problem, while 40% failed to associate the struggle to see the blackboard with poor academic performance. Behavioural anomalies such as poor academic performance, limited attention span, low self-confidence/ esteem, and not writing in straight lines are exhibited by learners with URE (Chan et al. 2020). However, only 4.4% and 8.7% of teachers correlated spectacle non-compliance with substandard academic performance and low self-esteem/confidence, respectively. This highlighted that teachers in this study do not fulfil their role as health educators (Alemayehu et al. 2018). Not absolving parents/guardians from their responsibility towards their children, but teachers are better positioned to notice eye-related signs, symptoms, and behaviour (Chan et al. 2020; Govender-Poonsamy et al. 2025). This is because of the contact time they have with learners engaging in visually demanding tasks (Chan et al. 2020; Govender-Poonsamy et al. 2025).

Notwithstanding the above, a quarter of caregivers did not correlate the use of spectacles with alleviating visual challenges, and 13% were unaware of what could relieve eye problems. Some parents indicated good sleep, nutritious meals, and spontaneous resolution as remedies to eye problems, similar to other studies (Alrasheed et al. 2016; Li et al. 2014). The lack of awareness of eye-related signs and symptoms was one of the leading barriers in several studies (Alrasheed 2021; Alrasheed et al. 2016, 2018a, 2024). Poor health literacy is attributed to several factors, including the lack of eye care services and interventions such as health education programmes (Paudel et al. 2019, 2022). In the current study, these factors, together with rural residency and affordability, contributed to the poor health literacy.

In this study, about 10% of caregivers perceived spectacles as bad for the eyes, citing that spectacles would deteriorate eyes; however, this was less than the 78.6% in Sudan (Alrasheed et al. 2018a).

According to Alrasheed et al. (2016), 21.4% of parents sought eye care from traditional doctors compared to 1% in this study, possibly due to cultural differences in the studies. Caregivers indicated that they would allow their children to wear their spectacles, demonstrating high acceptability of spectacles. Conversely, caregivers in other studies dissuaded their children from wearing their spectacles, especially in public, as spectacles were perceived as signs of disability (Alrasheed et al. 2018a; Ezinne et al. 2020).

The mistrust of healthcare workers by the public did not emerge as a barrier to the uptake of eyecare services in this study unlike in South Sudan (Alrasheed et al. 2018a). Furthermore, teacher participants demonstrated an interest in being trained to conduct vision screening similar to Ethiopian teachers (Alemayehu et al. 2018). Elsewhere in South Africa, teachers demonstrated good skills in conducting vision screening when trained (Govender-Poonsamy et al. 2025).

Dlamini and Mbonigaba (2024) found that low maternal education and low family socioeconomic status result in unmet health needs of a child. In this study, 96.2% caregivers, the majority of whom were female and without tertiary education, did not have healthcare insurance, in contrast to the 39% in Sudan (Alrasheed et al. 2016). A total of 72.7% parents did not have the financial ability to take their children for an eye examination. This study highlighted that learners in the Free State province are unlikely to have their eye care needs met because of affordability. Similarly, the cost involved in the utility of eye care services and the acquisition of spectacles was reported as the main barrier by several studies (Alrasheed et al. 2016, 2018a; Dhirar et al. 2020; Ezinne et al. 2020).

About 70% of parents never took their children for an eye examination, despite 82.4% of parents being aware of their children’s visual challenges. This could be attributed to the inaccessibility of eye care services, as only 10% and 30% of parents and teachers indicated proximity to eye care services. Also, almost 40% of parents would not take their children to an optometrist, i.e. a primary eye care provider (Willie 2023), possibly because of the unavailability of optometrists in their communities or local clinics. Together with the unaffordability of eye care services because of unemployment and no healthcare insurance, among others, eye care services were inaccessible and unavailable in the Free State province.

The poor eye care knowledge, together with inaccessible, unavailable and unaffordable eye care services, were displayed as barriers to the uptake of spectacles among learners in the Free State by the participants. This study highlighted that learners from no fee-paying schools in the Free State are prone to suffer the burden of URE, making them more susceptible to visual impairment and other eye care problems. Both parent and teacher participants presented a high acceptability of eye care services; however, poor eye care knowledge prevented what could otherwise be a much higher acceptability rate.