“If I Wear Glasses, I Will Go Blind”: Misconceptions, Stigma, and Nonadherence to Spectacle Wear in Somalia’s Outpatient Eye Clinics

Introduction

Refractive error is a leading contributor to distance vision impairment worldwide and is among the most cost effective conditions to manage in eye care through accurate refraction and appropriate spectacle correction.¹ Global strategies increasingly emphasize effective outcomes rather than prescriptions alone, reflected in the adoption of effective refractive error coverage as a monitoring construct and in the WHO SPECS 2030 initiative, which calls for a 40 percentage point increase in effective coverage of refractive error by 2030.^2,3 In this context, a technically correct prescription has limited value if spectacles are not accepted, not worn, or are dispensed with poor fit and quality.

Somalia is a fragile health system setting where access to affordable, good quality refraction and dispensing services is uneven, and shortages of trained personnel and other barriers can constrain the delivery of refractive services and the provision of spectacles.⁴ Nationally compiled Somalia specific data on spectacle adherence remain limited in the accessible published literature; however, data from Somaliland show a high burden of visual impairment in school aged children with low spectacle use among those who need correction, underscoring the importance of strengthening the pathway from prescription to use.⁵ Against this background, clinicians frequently observe that misconceptions and stigma are decisive drivers of nonadherence to spectacle wear.

The purpose of this commentary is to describe commonly encountered beliefs and social barriers to spectacle wear in Somali outpatient practice, to situate these observations within the broader evidence base, and to propose feasible clinic and community actions that may improve acceptance and sustained wear without implying new empirical findings.

Commentary Method Approach

This evidence informed commentary draws on the authors’ clinical experience in outpatient eye care in Mogadishu and on illustrative narrative selection of relevant peer reviewed literature and WHO technical resources on refractive error services, spectacle use, misconceptions, stigma, and adherence. The intent is to synthesize practical themes and implementation considerations rather than to report a systematic review or primary data collection.

Clinical Observations in Somalia’s Outpatient Eye Clinics

In our clinical experience, a recurring pattern is the patient who presents with blurred vision, demonstrates substantial improvement during refraction, yet expresses reluctance to wear spectacles after the prescription is provided. Some patients state that spectacles weaken the eyes, create dependence, or will eventually cause blindness. Beliefs and misconceptions about spectacle related harm have been documented in other populations, suggesting that misinformation can persist even when refraction is available.^6,7

Stigma driven avoidance is also frequently encountered. Patients describe fear of being judged or labeled as blind or disabled if they wear spectacles publicly, and they may anticipate negative effects on social standing, employability, or marriage prospects. Studies report that spectacle wearers may be perceived as visually handicapped, that teasing is anticipated, and that fear and stigma can reduce uptake and continued use, including among females in some settings.^7–10

A further pattern is selective or concealed use. Some patients obtain spectacles but wear them only privately or only for specific tasks, even when consistent wear would provide greater functional benefit. This behaviour is commonly linked to social anxiety, cosmetic concerns, discomfort, or distrust in the long term safety of spectacle wear.

Why Misconceptions Persist

Misconceptions often follow a narrative that natural vision is weakened by spectacles. Several mechanisms sustain this belief. Refractive error progression over time, particularly during childhood and adolescence, may be misattributed to spectacle wear rather than expected biological change. Early adaptation symptoms such as headache, asthenopia, or spatial distortion can occur with first time wear or with astigmatic correction, anisometropia, or higher prescriptions; without anticipatory guidance, patients may interpret these symptoms as evidence of harm. In addition, low quality dispensing can produce discomfort and poor visual satisfaction, reinforcing community stories that spectacles cause problems. These dynamics align with evidence that knowledge and beliefs influence undercorrection and nonuse, and that misconceptions are common where eye health literacy is limited.⁶

For clinicians, this implies that misconceptions are best addressed through brief, specific explanations that separate refractive correction from blinding disease processes and through service quality that consistently produces comfortable, clear vision.

Stigma and the Social Meaning of Spectacles

Stigma reduces spectacle uptake through anticipated judgement and avoidance. In contexts where spectacle wear is not normalized, glasses may be interpreted as a visible marker of disability, weakness, or aging. Evidence shows that community attitudes, fear of teasing, and perceptions of spectacle wearers as visually handicapped can influence acceptance and continued use.^7–10

Gender related stigma deserves explicit attention. In some settings, girls and women face additional appearance related scrutiny and may experience stronger social penalties when wearing spectacles, which can reduce adherence even when correction is clinically beneficial.¹¹ In Somali communities where family and social networks strongly influence health decisions, patient acceptance may depend on whether close contacts endorse spectacle wear, making family engagement and culturally sensitive communication central to stigma reduction.

Health System Contributors That Amplify Nonadherence

Beliefs and stigma do not operate in isolation. In Somali outpatient settings, limited consultation time reduces opportunities for counselling and myth correction. Fragmented optical pathways can expose patients to variable quality and cost, and weak follow up allows adaptation issues, frame discomfort, or power errors to persist until the patient abandons spectacles. At the system level, shortages of trained personnel and service delivery barriers can constrain refraction and dispensing capacity, and counselling skills are often underemphasized relative to technical refraction steps.⁴ WHO has emphasized competency based approaches and team models for refractive services, including competency based refractive error teams, as practical resources to strengthen quality and consistency of care.¹²

These factors also matter for monitoring progress. Effective refractive error coverage focuses on whether people who need correction have correction that delivers adequate vision improvement.² When spectacles are not worn or are poorly made, nominal coverage may increase while effective coverage remains low.

Practical Actions for Somalia’s Outpatient Refractive Care

Improving spectacle adherence in Somalia requires interventions that fit real clinic workflows and address both social drivers and quality related drivers. Counselling should be a standardized clinical step. A brief myth focused message can clarify that spectacles do not damage the eyes, that they correct the focusing error to restore clarity, and that vision changes over time are usually due to the underlying condition or aging rather than spectacle wear. Demonstration based counselling can be persuasive because it links correction to immediately valued functions, such as reading, recognizing faces, or performing work safely. Dispensing quality should be treated as an adherence intervention, because accurate lens power, appropriate centration, and comfortable frame fitting reduce early discontinuation. Family inclusive counselling can reduce conflicting advice at home, and early follow up for first time wearers can identify adaptation and fit problems before spectacles are abandoned.

A suggested 60–90 second counselling script and first time spectacle wearer checklist are provided in (Box 1).

Box 1 Suggested 60–90 second Counselling Script and First Time Wearer Checklist

Low cost community strategies can complement clinic based counselling. Posters in clinics and schools, brief radio messages, and peer normalization through teachers, religious leaders, and respected health workers can help shift social meaning and reduce stigma. Systematic reviews indicate that adherence can remain suboptimal even when spectacles are provided, reinforcing the need for combined educational and service quality interventions.^13,14

Implications for Research and Service Evaluation in Somalia

Somalia can strengthen local evidence on spectacle nonadherence and link service improvement with publishable implementation learning. Cross sectional outpatient surveys can quantify misconceptions and stigma and identify predictors of nonuse. Qualitative studies can map dominant narratives, sources of health information, and perceived social consequences. Prospective audits can measure the proportion of patients wearing spectacles at follow up and document reasons for discontinuation. Implementation evaluations can test brief counselling scripts, family engagement, dispensing quality improvements, and low cost community messaging using outcomes aligned with effective correction and real world wear.^2,3,12

Limitations

This manuscript is a commentary grounded in clinical observations and illustrative narrative use of published literature rather than a formal quantitative or qualitative study in Somalia. As nationally compiled Somalia specific evidence on spectacle adherence remains limited in accessible literature, the proposed actions should be evaluated prospectively through implementation studies that measure real world wear, comfort, and patient reported barriers in Somali communities.

Conclusion

In Somalia’s outpatient eye clinics, spectacle nonadherence is commonly shaped by misconceptions that spectacles cause harm and by stigma that equates spectacle wear with blindness or disability. These barriers interact with limited counselling time, variable dispensing quality, affordability constraints, and weak follow up, leading to avoidable persistence of functional vision impairment. A practical response is available within routine clinical practice through brief myth focused counselling, demonstration of functional benefit, attention to comfort and dispensing quality, family engagement, structured early follow up, and low cost community normalization. Because this is an evidence informed commentary rather than a formal study, the effectiveness of these approaches should be tested locally using implementation designs that measure sustained wear and functional outcomes.