Facilitators and Barriers to Retinopathy of Prematurity Screening in a Tertiary Care Facility: A Mixed-Methods Study

In the delicate early weeks of life, some babies are born too soon. Their eyes, like the rest of their bodies, are not fully developed. For these infants, a condition called retinopathy of prematurity can take hold. It is a disorder where the blood vessels at the back of the eye grow in a chaotic, disordered way. If this growth is not spotted and treated quickly, it can lead to the retina pulling away from the back of the eye, causing permanent blindness. The good news is that this outcome is preventable. Doctors can examine the eyes of at-risk babies, find the problem early, and stop the damage before it becomes irreversible. However, this prevention relies on a chain of events: identifying the right babies, telling their parents, scheduling the exam, and ensuring the baby returns for follow-up visits. If any link in this chain breaks, a child who could have seen clearly may lose their sight.

In a major teaching hospital in southwestern Nigeria, a team of researchers set out to understand why this chain of care was breaking. They wanted to know not just how many babies were missing out on these vital eye exams, but why. They looked at records of premature infants and spoke with the doctors and nurses who care for them. Their goal was to map the journey of a baby from the neonatal unit to the eye clinic, finding exactly where the path gets blocked and what keeps it moving forward.

The researchers focused on a specific group of infants: those born before 34 weeks of pregnancy or weighing less than 1,500 grams at birth. These are the children most at risk for the eye condition. Over a four-year period, from 2016 to 2020, the hospital admitted 531 babies who fit this description. The team reviewed the medical records of every single one of them to see what happened. The numbers told a stark story. Only 180 of these 531 eligible infants, which is about one-third, actually received an eye examination. Among the few who did get checked, more than one in ten were examined later than the medical guidelines recommended, meaning they waited too long for the doctor to look at their eyes. The average time from birth to the first exam was seven weeks, a delay that can be critical for a condition that moves fast.

To understand the reasons behind these missed opportunities, the team conducted a series of interviews with twelve healthcare workers. These included senior doctors, nurses, and residents who work directly with the babies. They asked these professionals to describe their daily reality. The answers revealed that the problem was not a lack of knowledge. The staff knew exactly which babies needed checking and when. Instead, the barriers were practical and systemic. The hospital often faced shortages of trained staff. Experienced nurses were frequently transferred to other departments, leaving gaps that had to be filled by new, untrained personnel who needed constant retraining. There was no single person assigned to manage the eye screening program, so no one was specifically responsible for tracking which babies had been seen and which had not.

The equipment needed for the exams was also often insufficient or unavailable. But perhaps the most difficult hurdle involved the parents. Once a baby was stable enough to leave the hospital, the responsibility for the next steps fell to the family. Many parents did not understand the urgency of the eye exams because the babies looked fine and had no symptoms. Others faced financial difficulties or transport problems that made returning to the hospital for a follow-up visit impossible. The researchers found that when a baby was discharged early, the chance of them missing their appointment increased significantly. The system relied on parents to remember dates and navigate the healthcare system on their own, without a structured way to remind them or help them get there.

Despite these heavy obstacles, the study also highlighted what was working. The medical team was deeply committed. Doctors and nurses from different departments worked together, sharing information and supporting one another. They had established protocols and received some outside technical help that kept the program alive. The researchers noted that the dedication of these individuals was the main reason the service existed at all. However, they concluded that relying on the personal goodwill of staff is not a sustainable solution. When a dedicated nurse leaves or a doctor is overworked, the system falters.

The study suggests that to fix the problem, the hospital needs to take full ownership of the screening program. This means appointing a specific coordinator to track every baby, ensuring there are enough staff and working tools, and creating a system that actively follows up with families. The researchers proposed that parents should receive repeated counseling, not just once, but throughout their time in the hospital and after they go home. They suggested that the hospital should have a way to call or remind parents of upcoming appointments, rather than waiting for the parents to remember on their own.

The findings paint a picture of a system that is trying to do its best with limited resources. The gap between the number of babies who need care and the number who receive it is large, but the path to closing that gap is clear. It requires moving from a system that depends on chance and individual effort to one that is built on structure, coordination, and support for families. By addressing the shortages in staff and equipment, and by creating a safety net for parents who might otherwise lose track of their child's care, the hospital can ensure that more of these vulnerable infants get the chance to see their world clearly. The study does not claim to have solved the problem, but it has provided a detailed map of where the roadblocks are, offering a guide for how to clear the way forward.