Abstract Background: Hearing loss is a significant yet underrecognized public health issue in low- and middle-income countries. In South Africa’s public healthcare sector, low awareness and inconsistent referrals from primary healthcare (PHC) providers delay diagnosis and limit audiology service utilization. This study explores barriers to awareness and referral pathways and identifies strategies to improve access. Aim: This study aimed to (1) assess public awareness of audiology services, (2) examine inefficiencies in referral pathways from PHC providers, (3) explore linguistic, cultural, and socioeconomic influences on service-seeking behaviors, and (4) propose strategies to enhance awareness and referrals. Methods: A secondary qualitative analysis was conducted on 15 deidentified interview transcripts from a prior study on public audiology service access in Johannesburg. Thematic analysis identified patterns in awareness, referral experiences, and service barriers. Results: Public awareness of audiology services was limited, with most participants learning about them only after significant hearing difficulties. Information was often obtained through word-of-mouth rather than healthcare providers. Referral inefficiencies resulted in multiple clinic visits before audiology referrals, while some never received referrals. Cultural and linguistic mismatches hindered service-seeking, with some participants initially consulting traditional healers. Financial and transport constraints further limited access, despite free hearing aids. Conclusions: Weak referral systems, low awareness, and socioeconomic barriers hinder audiology service utilization in South Africa. Strengthening public education, integrating hearing screening into PHC, decentralizing services, and training healthcare providers in audiology referrals are critical. Policy reforms, including task-shifting and mobile audiology clinics, are essential for equitable hearing health care.