An exploratory qualitative research design was employed to explore the perceptions of optometry district coordinators to gain insights into the patterns and outcomes of ECS in the public hospitals of Limpopo province. This approach was selected to facilitate the collection of rich data to elicit understanding into the experiences, challenges and effectiveness of ECS from the perspective of the optometry district coordinators based on their key roles and responsibilities within each district.

The study was conducted in public health facilities of Limpopo province. As of 2022, Limpopo province¹⁴ had an estimated population of 5.9 million, ranking as the fifth most populous province in South Africa, with a predominantly rural landscape. The province is administratively divided into five district municipalities: Capricorn, Mopani, Sekhukhune, Vhembe, and Waterberg. Each district municipality is served by one secondary-level hospital, which provides support to six or seven primary-level hospitals, health centres and clinics.¹² During the study period, ECS were available across 38 health facilities, comprising 30 primary hospitals, five secondary hospitals, two tertiary hospitals and one health centre. The two tertiary hospitals, including a health centre, were based in the same district.

At the time of the study, eye care services were offered by optometrists, ophthalmic nurses and ophthalmologists. Ophthalmology services were limited to three hospitals comprising one tertiary and two primary-level hospitals, each based in different districts across the province. Optometry services were accessible at all 38 health facilities. This study was conducted at selected public health facilities that had an optometry district coordinator in each district. Each district has one designated optometry district coordinator for ECS, responsible for overseeing and coordinating the delivery of ECS, as well as providing advisory support for ECS at both district and provincial level. This is a common practice across the districts within the country.¹⁵

During the study period (May 2023 – September 2023), five optometrists were responsible for coordinating ECS across the province, each based at a health facility within their respective district. The concept of ‘information power’ was applied to guide sampling decisions in this study.¹⁶ The information power concept emphasises that the adequacy of a sample is determined by the richness, relevance and depth of the data it yields rather than the number of participants. This approach is commonly recommended in exploratory qualitative studies.^17,18,19 Aligned with both the study objective and information power concept, a saturated sample comprising all five district coordinators was recruited to participate in this study through purposive sampling strategy. Participants exhibited relative uniformity regarding overseeing and coordinating ECS within their respective districts. The use of purposive sampling strategy ensured that participants were the key informants to provide data that would not be accessible through alternative sampling methods.

Only four district coordinators provided informed consent to participate and were subsequently included in the final sample. Data collected from the four participants were sufficiently rich to address the study objective and generate meaningful insight into the patterns and outcomes of ECS across the districts. Data redundancy was observed after the third participant, as continued data collection yielded no new insights and therefore data saturation. The point of saturation helped to confirm that the dataset was sufficiently rich, and the sample size, albeit small, was adequate for producing data to adequately address the study objective. This approach is recommended in the exploratory qualitative research designs, where the adequacy of the sample is determined based on the achievement of data redundancy than a predetermined number of participants.^17,18

All five optometry district coordinators were included in the study. One district coordinator declined to provide informed consent and was excluded from participation. The final sample included four district coordinators.

A semi-structured interview guide was used for data collection. The development of the interview guide was guided by a comprehensive review of relevant literature^20,21,22,23 to ensure methodological consistency and reproducible findings. A pilot study assessed content validity and the suitability of the interview guide for the intended study context. The pilot study was conducted in two phases, in public hospitals within Limpopo province. Conducting a pilot study in a similar setting to the main study enhances the validity of the data collection tool and its appropriateness for use within similar context.^24,25 During the first phase, two optometrists who were serving at supervisory levels in their respective hospitals from different districts within the province participated. Feedback from this phase informed adjustments to the interview guide, specifically re-organising and aligning three sub-questions with the pre-determined section items to enhance information coherence. Subsequently, the second phase involved one optometrist who often served as acting district coordinator, who was not part of the main study sample. Feedback from this phase indicated no need for further modifications to the interview guide or data collection procedures. Data obtained from the pilot study were excluded from the final analysis. The interview guide was designed to elicit participants’ perceptions of ECS within their respective districts.

The final interview guide was structured into nine sections addressing the following topics: (1) demographic information; (2) description, distribution and causes of VI; (3) leadership and governance; (4) service delivery and access; (5) eye care workforce; (6) technology, assistive devices and funding; (7) information management; (8) awareness and health promotion services and (9) barriers to accessing ECS. Face-to-face interviews were conducted using the interview guide. The participants were interviewed independently to allow for open, in-depth exploration of their personal experiences and perspectives without influencing one another and to ensure confidentiality during data collection. The researcher adopted an open and receptive approach during the interviews, actively engaging with participants’ reported experiences and perspectives.

All participants provided consent for the interviews to be audio-recorded, with their responses concurrently documented in written form. Data saturation was observed in the third participant, as responses became increasingly repetitive, indicating redundancy. However, all four participants were interviewed to enhance the credibility of the findings. All participants opted to be interviewed in English. The same interview guide was used across all study sites to maintain consistency in data collection processes and enhance comparability of participants’ responses.

The verbatim transcription of all audio-recorded interviews was conducted using the Microsoft 365 transcription programme, which incorporated verbal cues. Participants’ gestures during the interviews were noted and diarised. Following the transcription and data-cleaning process, the transcripts were meticulously reviewed. To ensure methodological rigour and accuracy, the interview transcripts were cross-referenced with the diarised responses, and participants were contacted to verify and clarify specific statements made during the interviews. Subsequently, the researcher applied Braun and Clarke’s six-phase framework for inductive thematic analysis: (1) familiarisation with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes and (6) producing the final report.²⁶ Consequently, data were analysed using thematic analysis, a method involving identifying, analysing and reporting themes within the dataset to elucidate participants’ perceptions and uncover patterns of ECS in the public hospitals in Limpopo province. This approach was selected for its methodological rigour and alignment with the study objective. Participants’ responses served as the primary data source for this analysis.

To enhance the trustworthiness of the findings, Lincoln and Guba’s criteria for credibility, transferability, dependability and confirmability, as outlined by Stahl and King,²⁷ were applied. Specifically, district coordinators were purposefully sampled to facilitate data source triangulation across districts, to enhance the credibility of the study. The study setting and participants were described in detail. Investigator triangulation was achieved through the independent analysis and interpretation of data by the research team comprising the principal investigator and supervisors. This process was further strengthened by peer debriefing and the integration of diverse perspectives and viewpoints from the research team, to reduce potential bias associated with a single-researcher interpretation. Coding frameworks were developed and subjected to inter-coder verification among the research team to ensure transferability and dependability. These codes and categories were iteratively refined in response to emerging data and feedback from debriefing sessions. Illustrative quotes from participant interviews were incorporated to maintain a clear linkage between the findings and the raw data. A blended approach of deductive and inductive data analysis was employed to facilitate a nuanced understanding of the patterns and outcomes associated with ECS in the public hospitals within Limpopo province. The study’s findings and recommendations will be made available upon request to promote confirmability.

Ethical approval for this study was obtained from the Humanities and Social Science Research Ethics Committee of the University of KwaZulu-Natal (Reference: HSSREC/00004472/2022). Gatekeeper permission was granted by the Limpopo Provincial Department of Health (Reference: LP_2022-12-004), authorising the use of departmental facilities for data collection. To ensure participants’ anonymity, unique identification codes were assigned to each participant.

Three female and one male district coordinators participated in this study. Their ages ranged between 48 and 52 years. All participants had a Bachelor’s degree in optometry and a post-graduate diploma in related fields. In addition, two participants had completed Master’s degrees in disciplines related to their work, although not specifically in optometry. The three female participants each had a minimum of 16 years of professional experience as district coordinators, while the male participant had 9 years of experience in the same role. Their primary responsibilities included coordinating clinical optometry services and providing ongoing support to ECS within their respective districts. Furthermore, all participants served as the primary provincial advisors for ECS, contributing to the planning, management and distribution of eye care resources.

The findings were organised into eight primary themes, each with corresponding subthemes, as detailed in Table 1: (1) description, distribution and causes of VI; (2) leadership and governance; (3) service delivery and access; (4) eye care workforce; (5) technology, assistive devices and funding; (6) information management; (7) awareness and health promotion services and (8) barriers to eye care services.

In this study, VI was described as a partial or complete loss of vision that significantly impacted ADL. Participants’ shared responses reflected both a quantified understanding of VI, described in terms of visual acuity, and its impact on an individual’s ability to participate in daily activities, regardless of the severity of vision loss. The use of visual acuity to characterise VI aligns with the World Health Organization (WHO)-recommended classification standards.⁶ This description of VI encompasses functional vision, which relates to how an individual functions when performing ADL.^28,29 Participants reported a high number of VI cases among individuals aged 50 years and older, females in the adult population and males in the paediatric population. Similar findings were reported in an earlier study conducted in the province, where individuals aged 50 years and older showed a higher risk of VI.¹⁰ This may be attributed to the increased risk of age-related eye diseases associated with increasing age among this population.^1,2,6,30 In addition, VI was perceived as more common among females in the adult population, a finding consistent with the reports of other studies.^1,2,31,32,33 The higher prevalence of VI among females might be attributed to their higher life expectancy, predisposing them to increased risk of developing age-related eye diseases, lack of prioritisation of women’s health because of cultural beliefs, limited access to ECS for women and poverty.³⁴ The increased number of VI among the males for the paediatric population may be because of complications associated with ocular surface diseases such as VKC that commonly affect male children.^1,35,36,37

The main causes of VI among children were refractive errors, corneal disorders, complications associated with eye allergies, albinism and retinal diseases. Among adults, the main oculocutaneous of VI included refractive error, cataracts, glaucoma, albinism, corneal disorders, retinal diseases, sequelae oculocutaneous trauma and complications arising from systemic diseases. The causes of VI among children and adults in this study are similar to those reported earlier within the country³⁸ and in LMICs.^1,9 The majority of the causes of VI reported by participants were avoidable or treatable. Some of the factors that explain the high prevalence and causes of VI in LMICs include poor access, availability and affordability of comprehensive ECS, low eye care literacy levels, high poverty rates, limited access to ophthalmology services and a lack of sustainable refractive error coverage in public hospitals in these regions.^1,9 The use of traditional medicine for treatment of eye diseases was reported as a common occurrence in both children and adults. This finding is similar to those reported in other African countries, including South Africa.^39,40,41 The use of traditional medicines to treat eye diseases was attributed to cultural factors, a lack of eye health education, poor access, affordability and failure of the healthcare system to deliver comprehensive ECS.^{22,23,42,43,44}

Findings from this study highlight gaps in the prevention and management of VI at the national level, emanating from limited eye health guidelines, policies and plans. The absence of such policies, plans, coupled with partial implementation of the guidelines, and the lack of monitoring mechanisms likely contribute to compromised ECS delivery in the public hospitals of the province. These factors further highlight underlying health system weaknesses that hinder efforts to eliminate avoidable blindness. Similar findings of fragmentation and lack of integration of ECS within health policy documents in South Africa that accounted for the lack of comprehensive ECS in public hospitals in the country were reported.^15,45,46 The gaps in the national policies, programmes and plans may have hindered effective implementation of the recommended strategies, including guidelines aimed at preventing avoidable blindness at provincial and district levels.³⁸ The development, implementation and monitoring of integrated national eye health policies, plans and programmes into health systems to enhance eye health outcomes are necessary to reduce the burden and impact of VI.^22,23,47 The inadequate integration of ECS into national health policies adversely impacts the majority of individuals who rely on public hospitals for ECS.

Findings from this study showed that the management of VI in Limpopo province included the provision of spectacles, disease management and referrals for further management to the ophthalmologists, schools for individuals with low vision, and the university. However, prolonged waiting lists for cataract surgery services, poor access, non-sustainable provision of spectacles and lack of low vision and rehabilitation care centres may contribute to the poor uptake of ECS in the public hospitals within the province. Similar factors were reported as barriers to the utilisation of ECS in other studies.^48,49 The variations in patient referral practices may be attributed to the absence of standardised referral guidelines, undermining continuity of patient care. Consequently, patients may be prompted to seek alternative or informal care such as unregulated medicines, which may worsen their eye health outcomes. Other factors contributing to the variations in referral practices and inadequate management of patients with irreversible VI may be the lack of recognition of specialised services, such as low vision rehabilitation care, and the lack of equipment for diagnosis and management of certain eye conditions, such as keratoconus cases. These factors may hinder practitioners’ ability to provide appropriate diagnostic and therapeutic interventions for optimal outcomes.⁴⁸ There are persistent gaps for low vision and rehabilitation services access across the public hospitals within Limpopo province despite early recommendations for the establishment of such clinics at primary and/or secondary hospital levels.³⁸ Strengthening the partnership between governmental departments, NPOs and academic institutions may provide a better strategy for improving the provision of comprehensive ECS and referral pathways, particularly in resource-constrained settings.⁵⁰

Findings from this study showed that ECS in public hospitals of Limpopo province were mainly provided by optometrists, ophthalmic nurses, ophthalmic medical registrars and ophthalmologists. Participants found a shortage of staff, such as ophthalmic nurses, and the absence of other essential eye care personnel, such as mobility orientation officers, whose roles are critical for vision rehabilitation. These findings are consistent with those reported earlier in the province.^11,46 The existing shortages of eye care staff may be attributed to the growing population size, increased service demand and expanded geographical coverage. Despite that Limpopo province has commendable coverage of optometrists in public hospitals compared with other provinces in the country,⁵¹ the severe shortage of ophthalmic nurses in the surveyed districts may compel optometrists to assume ophthalmic nurse duties, thereby limiting their ability to focus on key optometry services such as low vision care, orthoptics vision therapy and keratoconus management. Similar findings of shortage of eye care staff were reported as barriers to increasing cataract surgery rates in the country, with surgeons mostly performing non-surgical services such as screening, refractions and administration.⁵² The shortage of practitioners in public hospitals, including remote areas, may be because the majority of eye care practitioners opt for employment in the cities or the private sector, and this results in inadequate coverage in public hospitals.⁵³ The shortage of ophthalmic nurses might be because of a lack of continuous training, the replacement of those who exit the health system because of retirement and misallocated ophthalmic nurses in pursuit of flexible working conditions in hospitals.⁴⁶ The number of eye care practitioner-to-population in this study is below the national health recommended targets, with this being 1: 100 000 for ophthalmic nurses, 1:250 000 for optometrists and 1:1 000 000 for ophthalmic medical registrar or ophthalmologist in South Africa.³⁸ This suggests the need to re-evaluate the recommended human resource targets for ECS per population size in health facilities within the country, considering population growth and eye care service demand, as the majority of the population in the country relies on public hospitals for healthcare services.^13,38 It also hints a broader challenge in eye healthcare in the country, likely emanating from inadequate integration of eye health policies within the overall health system. The shortage of eye care staff has been associated with high magnitude of VI, suggesting the need for health authorities to increase the staff compliment and integrate ECS within the health system to reduce the burden of VI.⁵³

The majority of public hospitals from surveyed districts were equipped with basic eye care equipment; however, hospitals faced significant challenges regarding equipment maintenance, including maintaining an adequate supply of consumables required for their proper functioning. As a result, the lack of adequate and functional equipment means that many hospitals fail to meet the minimum equipment standards for comprehensive eye examinations recommended by the Professional Board for Optometry and Dispensing Opticians.⁵⁴ Similar findings have been reported in the country,^46,55 where minimum standards of optometric care were not practised because of outdated technology and a lack of equipment. These could be attributed to poor prioritisation of eye health services by the health authorities.^6,19

An early report¹⁰ showed a substantial decrease in VI after optical correction, and an increased presence of cataracts, suggesting that the majority of causes of VI among patients in the Limpopo province were treatable through optical and surgical intervention. Despite these findings, this study highlights that the provision of spectacles was often interrupted because of constraints in the procurement processes, contact lens care services were limited to only one tertiary-level hospital, and there were prolonged cataracts waiting lists. Additionally, no health facility offered low vision care. This suggests the need for health authorities to prioritise the provision of optical devices such as spectacles, contact lenses, low vision devices and increase cataract surgery coverage.

The eye care awareness initiatives were frequently organised to promote ocular health education and provide vision screening services in Limpopo province. This assertion is supported by Masemola et al.,⁴⁶ wherein it was also found that eye care practitioners in Limpopo province actively engaged in outreach services for vision screening and eye health promotion. Such initiatives are notable as early identification and intervention of ocular diseases and injuries may prevent the development of complications and impairments.

The barriers to ECS were attributed to the lack of support and national policies for eye health, limited budgetary allocation, lack of assistive devices, inadequate equipment, consumables and working space and insufficient personnel, particularly low vision rehabilitation professionals. Other barriers included erosion of professional skills and interest, inadequate training opportunities, limited knowledge, scarcity of educational materials, limited optometry services and insufficient ophthalmologists. These findings are similar to those reported in South Africa.^45,46,52,55 The main barriers to access and uptake of services were poverty, lack of financial support, limited transportation, low literacy levels, inadequate eye health–seeking behaviours, a lack of awareness, cultural beliefs, denial of VI and insufficient family support. These socio-demographic characteristics have been shown to impact access and uptake of ECS in previous studies.^{1,2,10,22,56,57,58}

The strength of this study includes use of an interview guide that was designed based on review of relevant literature to ensure methodological consistency, reproducible findings and comparability with other studies. Furthermore, the inclusion of participants with relevant experiences provided richer insights on ECS in public hospitals within the Limpopo province. While the study may be susceptible to information bias because of participants being optometrists, ECS in the province are primarily coordinated by optometrists, making them apt sources of information regarding these services and outcomes thereof. Nevertheless, these findings should be interpreted with caution, as they may not be representative of the other district coordinator’s perceptions, particularly in district not included in the study. In addition, the researcher works as an optometrist at a public hospital and, therefore, participants’ responses may have been influenced by the researcher’s subjective perspective. Although this is possible, the interpretation and analysis of the study findings were performed by a research team to reduce potential bias associated with a single-researcher interpretation. Additionally, adherence to the interview guide may have limited the extent of the exploration on certain topics. Despite these limitations, this study provides valuable insights for policymakers, health authorities and eye care professionals, facilitating the effective planning of comprehensive ECS. This study also offers a foundation for future research.