Trust and Mistrust in Traditional and Modrn Ophthalmic Treatments: A Qualitative Study Among Somali Patients

Trust and Mistrust in Traditional and Modrn Ophthalmic Treatments: A Qualitative Study Among Somali Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Trust and Mistrust in Traditional and Modrn Ophthalmic Treatments: A Qualitative Study Among Somali Patients Mohamed Farah Ismail, Abdikarim Ahmed Warsame, Zakaria Omar Sheck, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8143403/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The prevalence of avoidable blindness is also high in the Somali population against the backdrop of a fragile health system and a widespread use of traditional eye remedies. What patients experience during transitions between modern ophthalmology and traditional eye practices remains unclear Methods The study used a qualitative exploratory approach and took place in Mogadishu, Somalia (June and September, 2025). Semi-structured interviews were undertaken with a sample of 30 participants (15 patients, 10 traditional eye healers, and 5 ophthalmic care providers), with additional data garnered through three formal focus group discussions stratified for the different categories of participants. The data consisted of translations into English and analyzed using the NVivo 12 program. Results Findings are presented in the form of three overarching themes. (1) “Cultural legitimacy of traditional eye care” : The herbal and Islamic treatments were presented as a cultural inheritance that is “divinely ordained,” thus creating a degree of authenticity and “externality” of the hospital modality. (2) “ Efficacy and distrust of modern eye care practices” : Participants showed concern over eye surgery and “powerful chemicals” used in eye drop formulations, and doubted the sincerity of the providers and the consistency of the system at the Somali hospital. (3) “Barriers and facilitators of eye care at the Somali hospital and beyond” : The distance, insecurity, and lack of capacity within Somali ophthalmology led to a persistence of local traditional practices even when patients were aware of the advantages of the modern system. Conclusions The final conclusions are that decisions relating to eye care for Somali patients are complex and interlink closely with cultural, religious, relationship, and structural issues. The following are required if avoidable blindness is to be alleviated: (i) traditional eye healers must be drawn into the early referral and diversion away from harmful practices, and (ii) culturally specific counseling must be undertaken, taking into account religion and custom but also seeking to demystify surgery and medications. Trust and infrastructure are essential and must be addressed if eye care success is to be achieved in Somalia. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Somalia Ophthalmology traditional medicine Eye health Qualitative researc Introduction Preventable blindness is also a significant healthcare issue in Somalia, as an estimated 1.2% of people in this nation find themselves blind, meaning more than 100,000 people in this population suffer from blindness because of cataracts as well as other eye-related infections [WHO]. However, in this population of just over 10–15 million people, there only remain less than 20 eye specialists in this nation, making cataract surgery as well as treatments for people suffering from glaucoma an impossibility in this nation, most importantly in rural parts of this nation. The healthcare systems in this nation find itself in a conflict zone, causing this healthcare system to find it relying simultaneously on traditional medicine as well as an ineffective healthcare system in this nation (1). For Somalis, traditional medicine is more than an alternative healthcare system; it is an essential component of their cultural heritage(1). Procedures such as using herbal eye drops, applying khal (also known as Kohl), as well as Quranic water, which is water treated by recitations from the Quran, appear to be more available, cheaper, and more acceptable to their beliefs than Western biomedicine in healthcare facilities(2). In several African countries, including Somalia, traditional medicine for eyes is even more significant in that it is endowed with spiritual values, including Quranic healing, which is believed to be divine, thus increasing patient confidence in this healthcare modality(3). For Somalis, healthcare is generally believed to be from God, and healthcare approaches accompanied by prayers, as well as the use of holy water, appear to be more credible, safe, and acceptable to them than other healthcare approaches, including those in biomedicine(3). While this healthcare modality is more acceptable to Somalis, overdependence on traditional eye care approaches could lead to delayed healthcare, which may result in further complications of conditions that require urgent attention(1). In fact, it is worth mentioning that in East Africa, cases of severe complications resulting from traditional eye medications, which include infections of the cornea, as well as blindness for life, have been documented(4). A general suspicion of present-day Western biomedical practices in Somalia is also a barrier to adopting hospital-based services(5). Present day eye treatments, for example, using medicinal drops in eyes, as in surgery, could be feared as suspicious(5). A lack of investment, as well as intermittent provision of eye treatments, has led to a loss of trust, including the idea of viewing a hospital as an establishment which is strange to, as well as having no relation to, Somali culture(1). Trust is an essential criterion in healthcare choice(3). Trust in this case also encompasses adjusted effectiveness, understanding, as well as expectations of safe conditions(3). Though other African research has been able to demonstrate that traditional beliefs also affect healthcare choice, little is known about trust in, as well as lack of trust in, healthcare, in this case eye treatments, in Somali clients in specific(1). A recent study in Somalia showed patient preferences between using herbal medicine and hospital care to treat infections, in which cultural acceptability as well as infrastructure contributed to patient choice(1). This paper seeks to fill this gap by exploring in-depth the views of Somali patients toward conventional eye treatments as opposed to traditional remedies for eyes. This paper seeks to look at cultural issues, structural impediments, as well as trust/mistrust issues that shape whether to get this kind of healthcare at a hospital facility as opposed to sticking to local healing practitioners in the community. This paper seeks to highlight issues connected to traditional healing methods, which in turn provides an avenue for suggesting an efficient integration of Somali culture into conventional ophthalmological work. Methods Study design and setting For this qualitative explorative study, individual interviews as well as focus group discussions were conducted to examine community views of traditional versus modern approaches to eye care in Mogadishu, Somalia. A total of thirty individuals participated in this study, which took place from June to September of 2025 in Mogadishu. The reason for selecting this location is that it is Somalia’s capital, which is home to people from different backgrounds; also, this location provides an avenue where traditional practitioners coexist alongside different hospitals/medical facilities, including an eye hospital, in addition to having a high burden of ocular diseases such as cataracts, glaucoma, trachoma, etc., in a region suffering from poor facilities for eye care. Participant selection and sample size justification The respondents were purposively sampled to include views of three groups of people who participate in eye care decisions: Patients (n = 15) : These include adults who are at least 18 years old, who in the past year have sought either traditional medicine treatments or hospital-based eye care because of an eye condition, which could be cataracts, an ongoing eye infection, or symptoms of glaucoma, regardless of whether they are men or women, including persons of different ages to ensure that different patient experiences are incorporated. Tradition eye healers (n = 10) : Those who have practiced for more than five years in providing community-based traditional eye care treatments. These include herbalists and religious healing practitioners who specialize in traditional treatments of eye disorders using approaches such as herbal eye drop treatments, spiritual healing, amongst others. Ophthalmic care providers (n = 5) : These include healthcare providers like ophthalmologists, ophthalmic clinical officers, or ophthalmic nurses working in eye clinics or in hospitals in Mogadishu. A planned target sample size of 30 individuals is informed by principles of thematic saturation, in which enough data is collected to answer our research question in such a way as to preclude the identification of substantially new information by further interviews[10]. In fact, upon analysis, enough data appeared to have been gained by the 25th interview as well as in our second focus group, in which few novel thoughts began to appear, suggesting an adequate sample size to draw upon for this research study. Data Collection The data for this study were gathered using 30 in-depth interviews and 3 Focus Group Discussions (FGDs). One of the authors, who is Somali, spoke Somali and English, conducted all interviews in Somali to minimize language barriers. The interviews took place in a location of convenience to the respondent (e.g., for healthcare practitioners at the eye hospital, for clients and practitioners at community facilities or respondent’s residence). Interviews took approximately 45–60 minutes per respondent, and all interviews were tape-recorded with individual respondent consent to participate in being interviewed, which would also give consent to have interviews taped. An open-ended interviewing guide was employed to guide interviews (see examples of open-ended questions below). Issues discussed using this guide included, but did not limit to, recent personal experience with eye treatments, criteria for choice between healer provider versus hospital provider, beliefs about effectiveness (e.g. herbal drops versus antibiotic drops, versus surgery) and safety of treatments, source of trust versus source of distrust in healer providers, cultural versus religious beliefs about eye disease and healing, as well as challenges encountered (e.g. money, accessibility, family involvement). Some examples of open-ended questions asked during an interview include: “Can you tell me about what you did when you last had an issue with your eyes, and why did you choose that particular option?” “What is your opinion of the effectiveness as well as safety of the traditional remedies for eyes, in relation to hospital treatments such as eye drops, surgery, etc.?” “What are the main issues or concerns for you in relation to going to a hospital for an eye problem?” “How much do you trust the local eye healer (or eye doctor), and why?” “Do religious beliefs or family traditions affect how you treat eye problems?” "Have you, or does someone you know, experienced a poor or excellent result from either conventional care or hospital eye care?" FGD organization: A total of three FGDs were organized – patient FGD (n = 6 FGD participants), healer FGD (n = 5 FGD participants), and provider FGD (n = 4 FGD participants). The FGDs were organized by type of participant to allow for open, homogeneous discussion, thus allowing patients, healers, and providers to freely discuss without issues of dominance in inter-group discussions. The FGDs took approximately 90 to 120 minutes to complete, as in the patient FGD, for example, where issues of community attitudes and examples of patient discussions, including debate about herbal versus hospital treatments, took place. The healer FGD allowed for understanding of collective healer views of hospital collaboration, and in provider FGDs, examples of views of providers towards patient use of traditional medicine use could be understood. Additionally, all FGDs were audio-taped for ease of transcription. Translation process All interviews, as well as group discussions, took place in Somali language, which underwent transcription in Somali as well. A two-pronged approach to translating transcripts into English for analysis also took place here. First, this involved translating all Somali transcripts into English by the principal researcher here. Finally, for ascertaining meaning in English, this project utilized a bi-lingual research assistant to check English translations of transcripts for correctness against original Somali transcripts. Phrases expressing subtler meanings in cultures, such as references to healing in religious customs, for instance, also received collaborative consideration between the translators to identify an appropriate English equivalent in this study. Data Analysis For this study, a thematic analysis methodology is employed, combining manual coding processes as well as using data analysis computer software (NVivo12). First, at this stage, the researchers manually engaged in multiple readings of all available transcripts to familiarze themselves, recording insights at this level. Subsequent development of an inductive codebook involved line-wise open coding of transcripts for principal ideas in phrases, which in turn were increasingly clustered to carry wider concepts suitably expressed as categories. These categories in turn underwent several cycles of refinement, subsequent merging into wider concepts suitably expressed as overarching themes, in an iterative manner[11]. For ease of coding, data management, as well as facilitated easy location of data for a code afterward, computer-assisted software (NVivo12) is used here as well. For increasing validity of this analysis, coding of randomly selected transcripts by both authors (who speak Somali fluently, as well as have prior experience in this area of analysis) is independently undertaken, for comparison of this coding, any discrepancies at code assignment phases being suitably addressed via consensus-building, modifying coding as needed here as well(6). Throughout analyses, measures of trustworthiness were incorporated, including peer debriefing (the research team discussed insights collectively, including whether interpretations appeared accurate to those who understood the context) and member checking to a moderate level of involvement, where a compilation of results was presented to representatives of study participants, including one healer and one patient, to check whether results accurately reflected insights from those perspectives). The results of thematic analysis included identification of three key themes, several of which fall under sub-themes, as follows, including recommendations from experts in addition to quotes from source material (participants, quotes of which are in English to provide clarity). While maintaining anonymity for individuals, actual identifying markers removed either entirely to ensure protection of confidentiality). Results Three major themes emerged from interviews and FGDs in respect to trust, mistrust of current ocular treatments in relation to more traditional treatments available to Somali patients in Mogadishu. These include (1) The validity of traditional care for eyes, (2) efficacy of current ocular treatments in respect to mistrust of hospital-based ocular treatments, and (3) Structural issues of expectancy to formal ocular care. These include further subthemes, which include quotes for exemplification, as follows. Table 1 Participant characteristics Participant group n Gender (M/F) Mean age, years (range) Key inclusion criteria Patients 15 8 / 7 43 (19–70) Adults who sought either traditional or hospital-based ophthalmic care within the past year Traditional eye healers 10 8 / 2 55 (33–76) Practitioners providing herbal or Quranic eye treatments for ≥ 5 years Ophthalmic care providers 5 3 / 2 37 (29–45) Ophthalmologists, ophthalmic nurses, or clinical officers working in Mogadishu eye units Total 30 19 / 11 — — Caption Participants were purposively selected to capture perspectives from patients, traditional healers, and biomedical eye-care professionals. All were residents of Mogadishu, Somalia, at the time of data collection (Nov–Dec 2024). Theme 1: Cultural Legitimacy of Traditional Eye Care This topic emphasizes the strong cultural and religious foundations of traditional eye healing in Somalia, as well as how this contributes to trust in traditional medicine for eyes. Forum contributors from both patient and practitioner perspectives discussed how traditional approaches to eye healing carry strong meanings of ancestral and religiously validated know-how, which makes them more acceptable than Western medicine to the community at large in Somalia. Two sub-topics to support this include traditional eye healing as ancestral wisdom, as well as Islamic healing in eye care. Subcategory 1.1 “Our Ancestral Wisdom” - Herbal remedies as heritage. Both patients and healthcare practitioners often spoke of traditional eye care remedies as an aspect of heritage passed down from previous generations. The use of such remedies is a statement of Somali identity, an indigenous link to the past, to her traditions, customs, and beliefs passed down from previous generations. For instance, this healthcare practitioner, a 54-year-old man, explained, “The know-how I possess to treat eyes has been passed down to me by my grandfather. His father passed it down to him before him. It is our family’s heritage. I get sought after because I possess the collective wisdom of our forefathers.” Likewise, this patient, a 30-year-old woman who suffers from frequent infections in her eyes, explained, “I resorted to using those herbal drops from leaves because that’s what my mother and grandmother always did for my red eyes when I suffered from them as a child. That’s what bonded me to them . ” According to our culture, if it’s been of benefit to our ancestral generations past, then it must work for them as well.” As such, this heritage makes traditional remedies appear as far from alternative as possible, as they appear to be in line as the only natural choice for everyone concerned as they appear to be more naturalized to everyone concerned because, to them, going to a hospital to get such remedies constituting compelling commonality, they feel they require crossing an internal barrier in which they feel they’re going against their cultures as they say, for instance, this patient, a 45-year-old man, observed, “Our hospital is brand new for us; but herbs run in our bloodstream.” Subcategory 1.2: Spiritual healing and Quranic legitimacy. Many participants discussed the use of Quranic practices of treating eye conditions reflect the important role religion plays in health. Traditional healers often recited Quranic verses over water to create “Quranic water” to be used as eye drops, or gave taweez (amulets) with prayers for protection of eyesight. Such practices instill the treatment with spiritual authority. One 41-year-old female patient recounted the following experience with an eye healer: “When my eye was swollen, I went to a sheikh. He read Quran on water and told me to wash my eye with it. I felt comfort because it wasn't just medicine, it was Allah's words healing me." The perception that faith-driven treatment invites divine healing was a common thing. Several patients said that using Quranic remedies made them feel safe. Because “God’s cure has no side effects.” By implication, hospital treatments sometimes were perceived to lack this spiritual dimension. One young male participant from the patient FGD remarked: “Doctors just give you chemical drops or operations. They don’t pray for you. For us, healing is from Allah, so I trust something with Quran on it more than someth­ing from a pharmacy.” Traditional healers themselves empha­sized that their success depended on both the herbs and God’s blessing - a healer (male, 60) said, “I always recite Bismillah (in the name of God) during the application of medicine to the eye, and "no treatment works without God's will." This subtheme That is to say, religious legitimacy increases trust in traditional eye care. In predominantly Muslim Somalia, society, such an approach that incorporates spiritual care feels more holistic and therefore more trustworthy for many patients than A purely biomedical intervention. It is important to note that, although cultural legitimacy strongly favors traditional eye care, not all participants were completely dismissive of modern care. Some patients acknowledged that for certain serious conditions, such as mature cataracts or severe trauma, the “old ways” may not suffice. They indicated they would still combine both; for instance, undergoing surgery but also seeking prayers for success. The general feeling behind Theme 1 is, however, one of traditional practices being culturally "ours “they possess a certain trustworthiness inherently derived from tradition and faith that modern means do not have in the eyes of many Somalis. Theme 2: Perceived Efficacy and Mistrust of Modern Ophthalmic Treatments The second dominant theme is focused on how study participants feel about contemporary eye treatments as practiced in hospitals, including skepticism about their safety/effectiveness as well as comparisons to traditional treatments. A common theme is a lack of trust in conjunction with fear of eye surgery, consequences of taking medicine, and providers' motives/intent. This lack of trust served to tip the scales in support of using traditional remedies as a first course of action in dealing with eye problems. Of course, many study volunteers did express awareness of the safety/effectiveness of contemporary treatments, but they conflict in themselves in this respect by having ambivalence toward them. There are a number of sub-themes which are listed below: Subcategory 2.1 Fear of surgery and "the knife." Eye surgery, particularly cataract surgery, is another intervention people feared intensely. There’s a strong association with high risk, which is attributed to a lack of understanding as well as community stories of botched procedures passed down by association. In a patient FGD, consensus emerged quickly that "no one goes for eye surgery unless they’re desperate." A 63-year-old patient presenting for cataract in his eye confessed to having postponed his surgery for two years, stating, "I was informed at the hospital that I have to do cataract surgery, but I feared going to the doctor because I'd heard of people coming back worse, even blind, in case of failure to recover. I have used an herbal paste in my eyes every day, praying that it would cure this cataract in my eyes." A woman presenting because of her child having an issue in her eyes explained, in a similar vein, "Because I'm afraid of having doctors damage my child’s eyes in surgery; they’re only going to cut eyes, which is quite scary to a parent." The mistrust is further increased by questions as to whether Somali facilities possess competent specialists, as well as safe conditions for surgical repairs, as several of them asked whether anything really worth doing is possible in these standards of surgical facilities in Somalia, as follows from this healer’s statement, "Our hospitals here aren’t like those in other countries; they probably lack the adequate equipment for repairs to work as they’re supposed to in better-versed countries in locations like ours; that’s why I give them advice first to try our medicine. Surgery should be a last option." These attitudes better demonstrate a pervasive distrust of surgical intervention, often for reasons of horror stories as well as an awareness of an underserved goal of eye refractions in Somalia in general, even to including personnel, as explained by an ophthalmic nurse during a provider-conducted FGD, "Many of our patients end up in our office having cataracts because they didn’t know what to do to get them cured at first; they feared going to surgery because they feared what is commonly known as ‘the knife,’ as they didn’t trust the facility to provide competent specialists in either case, going so far as to try to avoid at all costs by using consultants at a coucher to cure them, which is much more dubious in that they only employ an obsolete technique of further pushing a thumb against what’s left of an eye to force out an optic lens to help restore full sight to an otherwise sightless patient, which is far more hazardous than our more complex surgeries." Subcategory 2.2 Concerns regarding medications, as well as possible side effects. Apart from surgery, another area of apprehension is using pharmaceutical eye drops, as well as tablets, from hospital pharmacies. A common understanding here is that current medications contain "strong chemicals" that may prove harmful to health. For instance, a 28, glaucoma patient, stated, "The doctor gave me eye drops for my high pressure, but I didn’t find them safe after going through the accompanying leaflet—many possible complications! I only took them for a week, which made my eye burn, so I stopped using them altogether and turned to my traditional remedies." Being apprehensive is partly due to past negative reactions to using medications and partly because of unfamiliarity with them in general. Herbal medicine is more natural, as well as safe, in comparison to pharmaceutical medication, which is associated more with harsh "chemicals." For example, a healer explained, "Our medicine is from plants,, so they should be safe as long as people use them properly. Hospital eye drops contain chemicals that might harm an eye or give people pain." Some individuals raised another issue, which is receiving low-quality, as well as counterfeit, medication from pharmacies of medicinal products in local markets who deal in medications, further increasing people’s apprehension towards "modern" medication in general, as another patient expressed, who bought antibiotic eye drops but didn’t work at all, suspecting it to be a low-quality, maybe even fake, product, stating, "How do I even trust what they give to me from the hospital pharmacy? At least I know what I'm taking from my herbs." This further shows people’s lack of confidence in using "modern" medication in general. Moreover, healthcare practitioners in this study have understood this kind of thinking, including, as an ophthalmologist explained, "Sometimes, we’re working with inappropriate medication consumers who stop using medication prematurely because they’re afraid of complications from medications, as they believe more in traditional treatments, thinking they’re more complete than regular approaches, which is difficult to convince them that using an antibiotic drop in an appropriate manner is sufficient to protect an eye from infections." Subcategory 2.3: Trust in providers - "Doctor or herbalist, who cares? " The topic of trust in caregivers also came up as another important consideration for many of the patients interviewed. Of course, they confessed to trusting an established healer from among them more than an unknown doctor in hospital settings for several reasons, including that established caregivers know them well enough to even treat them for free, as they have enough trust in them to respect them as close relatives, whereas hospital staff, in contrast, appear impersonal, only after money, but an established caregiver expressed this for a patient as follows: "If I go to a hospital, I might see a different doctor every time, and they barely have time to talk to me. The doctor barely has time to talk to them." A patient expressed better his understanding of this in this manner as well, "But my healer in my village knows me, my family, knows me, my children, everyone in my family. He follows up to see if I'm better, maybe even asks about whether I'm better from time to time to check if I'm recovering from what he treated me for. I trust him because he cares for me." One traditional healer said "People come to me first because they know I won't turn them away for not having money, and I treat them like my own children We have earned trust over many generations. " However, some respondents talked about unpleasant hospital experiences that made them less trusting, like impolite staff, lengthy wait times without a reason, or a previous incorrect diagnosis. "I went to the clinic for a painful red eye; the doctor gave me drops but didn't explain anything, my eye grew worse. After losing faith in them, I turned back to the herbal healer, who at least gave me consolation . " Recalled a female patient. Notably, some participants had a high level of trust in specific medical professionals, particularly if the provider had successfully treated a family member or demonstrated cultural sensitivity. According to one of the FGD providers, Somali patients are more likely to trust their doctors when they take the time to talk to them and, more intriguingly, when they accept traditional practices rather than completely rejecting them. I occasionally advise my patients to "I know Quran is a healer so continue washing with Quran water, but also use these drops to clear the infection," he said. They are more inclined to believe my advice when they perceive that I respect their beliefs. In conclusion, trust—or lack thereof—in the professionals providing contemporary ophthalmic care is inextricably linked to trust in that care. Unless the clinic experience is moderated by culturally sensitive care, many people find the community-based, compassionate approach of traditional healers to be more reliable than the formal, system-driven approach of clinics. Subcategory 2.4: Balancing both worlds – emerging openness to integration. While most of them are polarized in their attitudes, some showed an emerging awareness of the complementarity of both worlds. For example, a patient, who is a young 31-year-old man, observed, “When I had a corneal ulcer, I went to hospital for treatment because I knew it was serious. Even in hospital, I was doing my Quranic verses to recover from it, as well as an herbal solution at home to speed up healing. I think both work because Allah is in both treatments.” A traditional healer in his FGD also explained, "If I find a cataract person who cannot see because his cataract is very dense, I tell them, 'Surgery is available; get it.' I tell them, 'After I've prayed for them, I give them something to use at home for support.’ Of course, things which only a hospital can provide, they cannot get here.” While this is an indication of a willingness to combine approaches if needed, what is most interesting is that this inclination to combine approaches is welcomed by eye specialists, who declared, "I myself do hot mind them using harmless traditional treatments like rinsing eyes using certain herbs, holy water, for example, as long as they don’t completely forget Western methods for more natural approaches which only harm in the long run." While this is only an indication of an opening to combining approaches if needed, this is an indication, of course, of an interest in complementing approaches if needed—and assuming they, in turn, have better trust in biomedicine, they might find ways to complement approaches between biomedicine and traditional healing, as they otherwise reject biomedicine per se because of whence it came, to which, of course, they attribute holiness as well, which they also attribute to traditional healing, which, by definition, is also holiness, Holiness they attribute to both because they themselves attribute holiness to both by definition, by beliefs." In general, Theme 2 suggests that perceived efficacy and safety depend entirely on who is looking, as it is only a matter of time before many, if not all, of the current Somali patient population recognize traditional methods of dealing with eye problems as being more safe and trustworthy, in comparison to more modern approaches, which are met with a fair amount of suspicion. Theme 3: Structural Barriers to Hospital-Based Eye Care Access The third theme is focused on the challenges faced by people in seeking eye care services from hospitals or health facilities. These challenges cut across all facets of health, including the culture discussed earlier, making it difficult for people to present themselves to the biomedical sector for services. In Somalia, even if a patient desires to benefit from current medicine over traditional medicine, challenges such as costs, accessibility, and infrastructure work against them. Cost of care, infrastructure, and resource constraints in healthcare emerged as strong subthemes. Subcategory 3.1 High cost of treatment and poverty. Financial issues were a great hindrance to seeking eye treatments from hospitals, as said by almost all of the informants. This is because healthcare in Somalia is mostly out of pocket, including specialist healthcare such as eye care, which could be quite expensive[13]. A fifty-year-old patient who is a maleness informant diagnosed with cataracts in both eyes said, “The doctor told me I needed to have surgery to be able to see again. I won’t be able to afford even for one eye, which costs more than what my family makes in a month. I haven’t been able to do anything about it; I decided to treat myself using traditional methods, which is cheaper even if it won’t bring back my sight.” One of the informants also expressed her sentiments when she said that even to get to the hospital for receiving regular injections, including check-ups (e.g. in relation to diabetic eye disease) is expensive in terms of transport costs as well as lost workdays, which they cannot afford. For traditional practitioners, as they charge little to nothing, this is an even more economical solution as they even demand for payment in kind (at a later date). A young mother who took part in patient FGD explained, “When my kid fell sick in the eyes, the hospital fees as well as medication would have set me back $20, which I did not have at the time of going for medication. I took him to a local healer who treated his eyes using a paste of herbs; I owed them a small amount for this sort of services, which costs nothing to get.” The end result is that even if trust exists to level of scarcity in healthcare, people would end up in traditional because of finances anyway. Subcategory 3.2: Distance, transportation, and security challenges. Physical access to eye care facilities is another structural hurdle, especially for those outside Mogadishu. Several patient participants were actually from rural areas or smaller towns who traveled to Mogadishu’s eye hospital as a last resort. They described arduous journeys and, in some cases, insecurity on the roads. One elderly patient who eventually went to Mogadishu for treatment said: “I lived for years with poor vision because going to the city was difficult. There is fighting on the roads sometimes, and it costs a lot to travel. So I relied on a local healer. Only when I nearly went blind did my sons take me to the capital.” Even within Mogadishu, transportation can be difficult due to traffic, cost of fuel, and for women, needing a family member to accompany them for safety. A female participant noted: “I cannot go alone to the hospital – it’s too far and my husband has to take time off work to bring me. It’s not easy, so we try other remedies first.” These logistical issues mean that convenience and proximity strongly influence care-seeking. Traditional healers, by contrast, are typically embedded in local communities (often “just a walk away” as one participant put it). They also may offer flexible hours – some healers will see patients in the evenings at home – whereas hospital clinics have limited hours. Additionally, participants mentioned that hospitals in Somalia can be chaotic or require long waiting times once you get there, which is another deterrent for someone who has traveled far. The structural challenges of distance and transport therefore reinforce the preference to “try something nearby” before undertaking a burdensome trip to a formal eye clinic. Subcategory 3.3: Limited capacity and quality of eye care services. Underlying many of the above issues is the stark reality that Somalia’s formal eye care capacity is extremely limited. Participants pointed out systemic problems, such as the country having a very few number of trained ophthalmologists, intermittent supplies of medical equipment and medications, and no widespread primary eye care programs. One of the hospital-based providers in our study frankly said: “We are only a handful of eye doctors in the entire country. The waitlist for surgery at our hospital is long. We do what we can, but we’re overwhelmed.” Patients themselves are aware of these limitations. One patient who had tried seeking care at a government hospital explained: “They told me the machine to check my eyes was broken and I should come back in a month. That made me gives up on them. Meanwhile, the healer in my village was at least doing something for me right away.” Others mentioned either medicines are never available in the hospital pharmacies, or that just essential services, such as laser treatment for diabetic eye disease or modern glaucoma surgeries, are not available within the country. It is this unavailability that funnels people back to whatever alternatives they may have. Similarly, in the FGD with healers, participants noted that people come to them often after a negative experience from the hospital: “They are told to wait, or there is no doctor that day, so they return to us.” Quality of care is another aspect-a few respondents reported concerns over the competence of some providers or hygiene in facilities, to which again relates to system-wide resource constraints. A middle-aged male patient bluntly pointed out: “If our hospitals cannot guarantee consistent care, how can we trust them? At least with traditional treatment, we know its limits.” This epitomizes a practical mistrust born not of cultural bias but of witnessed shortcomings in the health system. Until the capacity and consistency of ophthalmic services improve, structural barriers will continue to push patients by default toward traditional solutions. In summary, Theme 3 identifies that even when there may be a general willingness by patients to obtain modern eye care, systemic barriers of financial costs, travel/logistical difficulties, and limitations in service provision pose significant challenges. Often these stand alongside the cultural preferences described in Themes 1 and 2 and provide a strong pull toward traditional eye care. Interventions aimed at improving eye health in Somalia will therefore need not only to build trust but also to remove these structural barriers. Table 2 Summary of major themes and sub-themes identified through thematic analysis Main theme Sub-theme Brief description Illustrative quotation (abbreviated) 1. Cultural legitimacy of traditional eye care 1.1 Ancestral wisdom Herbal and community eye remedies viewed as inherited, trusted family knowledge “Hospitals are new to us; herbs are in our blood.” (M 45 yrs, patient) 1.2 Spiritual healing (Quranic legitimacy) Healing perceived as divinely guided; Quranic water and prayers seen as safe and blessed “God’s cure has no side effects.” (F 41 yrs, patient) 2. Perceived efficacy and mistrust of modern ophthalmic treatments 2.1 Fear of surgery Cataract and other eye operations feared as risky or vision-threatening “I was afraid the doctors would damage my eyes.” (M 63 yrs, patient) 2.2 Concerns about drugs Modern drops viewed as harsh chemicals with side effects; herbs seen as natural “Those eye drops burn; herbs are natural.” (F 28 yrs, patient) 2.3 Trust in providers Healers perceived as empathetic and community-embedded; doctors as impersonal “My healer treats me like family.” (M 36 yrs, patient) 2.4 Balancing both worlds Some participants combine hospital care with spiritual or herbal remedies “I used both the hospital drops and Quran water.” (M 31 yrs, patient) 3. Structural barriers to hospital eye care 3.1 Financial constraints High out-of-pocket cost of surgery and drugs limits access “One eye operation costs more than I earn in months.” (M 50 yrs, patient) 3.2 Distance and security issues Travel, insecurity, and lack of transport reduce hospital visits “There is fighting on the roads, so I stayed with the local healer.” (F 48 yrs, patient) 3.3 Limited system capacity Few specialists, broken equipment, drug stock-outs erode confidence “They told me the machine was broken.” (M 42 yrs, patient) Caption Themes derived inductively from 30 semi-structured interviews and three FGDs analyzed in NVivo 12. Quotation identifiers indicate participant type, gender (F/M), and age. Discussion This qualitative study explores how Somali patients navigate between traditional and modern options of eye care and ascertains the roles of culture, trust, and structural factors in their choices. Our findings are complex: on one hand, traditional eye treatments enjoy strong cultural legitimacy and trust among patients, as part of ancestral practice and spiritual beliefs; on the other hand, modern ophthalmic treatments face considerable mistrust and are often practically impeded from access. These insights parallel findings from broader Somali healthcare studies while adding a specific focus on ophthalmology, an area previously understudied in the Somali context. One of the striking outcomes has been the deep embedding of traditional eye medicine in the respondents' culture. Herbal and spiritual remedies were framed by all participants as part of their Somali background. Indeed, this mirrors observations from Somalia and other similar settings: traditional healing is deeply embedded in the local culture (1). In Africa, traditional healers often hold a place of respect within communities, and because of their easy access and trusted position, are often the first point of care 14. Our study reinforces this dynamic: the Somali traditional eye healers are trusted not only for the remedies they provide but for the cultural meaning behind those remedies. The use of Quranic verses and prayers further amplifies this trust through the addition of a religious dimension. Prior literature has noted that many Somalis consider traditional medicine to be divinely guided(5), and our participants similarly conveyed that belief-that healing through spiritual means is blessed and therefore reliable. That suggests that any efforts to improve modern eye care acceptance need to respect and acknowledge the cultural and religious context. Dismissing traditional practices could result in alienating patients; one culturally sensitive approach might therefore include working with religious leaders or incorporating respectful acknowledgments of faith in healthcare delivery. The mistrust of modern ophthalmic treatments in Theme 2 is consistent with the pattern of mistrust in modern healthcare documented among Somalis both in-country and in diaspora communities. For instance, Somali immigrant women in the US have been reported to harbor distrust of Western medications and to prefer traditional or “natural” remedies,, for reasons such as fear of side effects or perception of over-medicalization. In Somalia, where the health system has been weakened by years of conflict, mistrust can be even more acute. Fears about eye surgery and pharmaceuticals expressed by participants reflect these sentiments. It is important to recognize that some of these fears are not unfounded: a lack of regulatory controls means that counterfeit or poor-quality medicines are a real problem in Somalia, as noted by participants and other sources,. Similarly, the outcome of surgical procedures can indeed be poor if conducted in suboptimal settings. Historically, in parts of Africa, the practice of traditional couching-an old method of dislocating the cataract lens-persisted because people either did not trust modern cataract surgery or did not have access to it. As one report noted, the demand for couching "reflects the lack of availability of modern cataract surgery or lack of faith in the outcome of modern cataract surgery". Our findings demonstrate a similar phenomenon in Somalia: some patients delayed or avoided cataract surgery due to lack of faith in the surgery, instead opting for traditional methods, albeit ineffective. It underlines another critical point: building trust in modern treatments is not solely about education regarding efficacy but also about demonstrating safety and reliability in practice. When patients witness or hear of successful outcomes within their community, trust can slowly build. On the other hand, one incident of a failed surgery can reinforce communitywide mistrust for many years. Structural barriers (Theme 3) came through as a strong force that not only reinforces reliance on traditional care but also amplifies mistrust in modern care. In the case of eye care, the high cost was a predominant structural barrier identified. Indeed, health financing in Somalia is almost entirely through out-of-pocket spending; over 40% of health expenditure is paid by individuals [13]. In such a context, it is understandable that people delay or avoid hospital care-it's often a major financial gamble for the household. The experiences of our participants are supported by broader observations of a weakly functioning, poorly resourced, inequitable health system within Somalia [20]. Thus, eye care, as a specialized service, is even less accessible outside of the few urban centers. The lack of ophthalmologists-less than 20 in the whole country-was a striking statistic reflected in frustrations of providers and difficulties of patients [2]. Such a shortage implies waiting and unmet needs; as was noted, if the hospital cannot see a patient either quickly or proximally, then whatever is available constitutes an option. It is important to note that the issues of structure and trust are mutually reinforcing-an unreliable system breeds mistrust, and mistrust reduces utilization of services, potentially feeding into further under-investment in those services. Comparing our findings with other regions, many themes resonate. In Ethiopia, for instance, traditional eye medicine is widely used – over 60% of adult ophthalmic patients in one hospital-based study had a positive attitude toward traditional eye medicine(4). Factors like rural residence and family tradition predicted higher use of traditional remedies(7), similar to what our Somali participants described (traditional practices being a family and community norm). The consequences of such practices, if harmful, have been documented: traditional eye treatments have led to severe complications like corneal scarring, infections (keratitis, endophthalmitis), and even blindness in various African settings(8). Some of our patient narratives hinted at negative outcomes from delays or harmful remedies (though we did not extensively report clinical outcomes, a few mentioned worsened conditions after using traditional methods too long). This underlines a public health urgency: unsafe traditional practices need to be addressed through community education(9). However, outright banning or discouraging traditional healers is unlikely to succeed (and could drive practices underground). Instead, as several participants and providers suggested, a more effective approach would be to constructively engage and educate traditional healers. Encouragingly, examples from other countries show that collaboration is possible. In Malawi and other African nations, initiatives have trained traditional healers on basic eye care and established referral links, leading to improved prevention of blindness (10). In Ethiopia, it’s recommended to educate healers on safe practices to reduce the burden of complications (11). Our data support similar strategies for Somalia: by training healers to recognize serious eye conditions and refer patients early (for instance, refer cataract cases to surgical camps or hospitals), and by discouraging the most dangerous practices, outcomes could improve. Traditional healers could become allies in eye health, helping bridge the gap of trust. Given their community clout, if healers can be convinced of the value of certain modern treatments (or at least the limitations of their own treatments), they can influence patients’ attitudes positively. Another crucial approach would be the incorporation of cultural and religious aspects into contemporary care. Given that many Somalis view healing in spiritual contexts, for instance, it may be beneficial for hospitals to take measures such as having religious counselors or imams participate in health education or simply allowing space for spiritual practices alongside treatment. As might be done in an eye hospital, for example, one could provide information that aligns treatment with faith ("recovering sight is a blessing, and medicine can be a gift from God"). Such approaches have been suggested in other contexts to improve trust-namely, showing respect for, rather than asking patients to leave their beliefs at the clinic door. From a structural perspective, our findings strengthen the calls for improving eye care infrastructure in Somalia. When patients are eyewitnesses of neighbors regaining their eyesight from a surgery, it may well counteract the many years of skepticism. Similarly, financial risk protection-provided, for example, through donor-supported vouchers or a basic insurance scheme to cover the costs of eye surgery-would remove one of the major deterrents, namely cost. Given that the main reasons many stuck with traditional care included poverty, reducing out-of-pocket costs becomes a key strategy for changing behavior. It is also worth noting the few participants who advocated combining traditional and modern approaches because they represent a potential middle ground. As they have argued, integration at the patient level is already happening for some, as patients pray or use herbal washes while they are on medical treatment. Rather than viewing this as non-compliance, health professionals could acknowledge and guide safe concurrent practices. If a patient wants to use Quran Holly water subsequent to an eye surgery, for example, the provider can make sure it's hygienically prepared and does not replace important medications. These win-win compromises can help build rapport and trust in these encounters. Table 3 Comparison of trust factors influencing traditional and modern ophthalmic care choices among Somali patients Dimension of trust Traditional eye care (herbal / Quranic) Modern ophthalmic care (hospital / clinical) Implication for patient decision Cultural familiarity Deeply embedded in Somali culture; passed down through generations; seen as “our way.” Perceived as foreign or Western; lacks cultural resonance for many patients. Cultural alignment strengthens trust in traditional healers. Religious legitimacy Uses Quranic verses and prayers; viewed as spiritually blessed and safe. Often viewed as secular and purely technical; lacks overt spiritual element. Faith-based legitimacy drives preference for Quranic and herbal care. Provider–patient relationship Personal, informal, community-based; healers know families and treat on credit. Formal, time-limited encounters; some perceive doctors as distant or profit-oriented. Trust higher when providers show empathy and community engagement. Perceived safety / risk Natural ingredients considered gentle and harmless. Fear of surgical failure or drug side effects; anxiety over “cutting the eye.” Perceived safety determines first point of contact for care. Perceived efficacy Linked to spiritual success and community stories of recovery. Acknowledged as effective for severe disease but doubted for common ailments. Partial trust in hospitals for advanced conditions only. Accessibility and cost Easily available locally; flexible payment; minimal cost. Limited facilities, long waiting times, and high out-of-pocket costs. Affordability favors traditional options. Accountability and transparency Trust based on reputation, word of mouth, and visible dedication. Trust shaped by institutional reliability and consistent outcomes. Repeated positive hospital outcomes can rebuild confidence. Overall trust balance High community trust rooted in culture and faith. Variable trust, undermined by cost, fear, and limited capacity. Bridging both systems through cultural sensitivity can enhance uptake of modern eye care. Caption Table synthesizes comparative factors shaping trust and mistrust between traditional and modern ophthalmic care identified through thematic analysis of interviews and focus groups (n = 30). Limitations The following are limitations of this study. First, it was conducted in Mogadishu and included mostly participants who were accessible in an urban or peri-urban setting. Perspectives in more remote rural areas or other regions of Somalia (with potentially different traditions) may not be well represented here. Second, because this is a qualitative study, our objective was in-depth understanding rather than quantifiable prevalence of certain beliefs; hence, the insights are rich but not generalizable on a statistical basis. There could also be some selection bias in that those who were willing to discuss their experiences might be those more interested in the topic of traditional versus modern care. We attempted to mitigate this by purposive sampling, ensuring a variety of standpoints. In addition, all data were self-reported-the study relies on participants' narratives and perceptions, which can be affected by memory and social desirability. We did note that in focus groups, some participants might have downplayed their negative experiences with traditional medicine in front of healers, or vice versa, although the facilitator encouraged candid sharing, and we did obtain opposing opinions as well. Despite these limitations, the fact that several themes repeated themselves across interviews and groups does suggest that findings are resonant with common realities in this setting. Conclusion The choices that Somali patients make regarding eye care are shaped by a delicate interplay of trust, culture, and practical access. There is a strong cultural affinity toward traditional eye remedies in Somalia, a trust underpinned by ancestral knowledge and spiritual beliefs. Modern ophthalmic treatments, however, while medically advanced, are often met with mistrust, further undermined by economic and logistic challenges. For improved eye health outcomes in Somalia, there is a need for integrated solutions that bridge the divide between traditional and biomedical systems. Key recommendations that arise from this study include the following: (1) actively involving and training traditional eye healers in basic eye care and referral systems, so that they can continue their culturally valued role while safely guiding patients to hospitals when needed; (2) community-centered health education addressing misconceptions about modern eye treatments-for example, demystifying eye surgery and highlighting its success rate-and doing so in a culturally sensitive way, leveraging local leaders or religious figures to endorse messages; and (3) reducing structural barriers through the scale-up of affordable eye care services, such as free cataract surgery camps, mobile clinics in rural areas, and financial support for the poorest patients. Building trust is as important as building clinics: initiatives that show respect for Somali tradition, while gradually introducing modern care as complementary rather than adversarial, are likely to gain more acceptance. Ultimately, by combining thoughtfully traditional and modern approaches, Somalia can work its way to a more inclusive eye-care system respecting cultural values, gaining patient trust, and yielding effective treatments to prevent blindness. Such a model may not only bring better vision but could also serve as a template for culturally congruent improvements in health care on other aspects. Declarations Competing interests The authors declare no competing interests. Ethics approval and consent to participate Ethical approval for this study was obtained from the Somalia Ministry of Health Research Ethics Committee (Ref: MOH/1623/2025). All procedures were carried out in accordance with relevant ethical guidelines and regulations. Participants provided informed consent prior to interviews and discussions. Written informed consent was obtained from all participants, which included consent for de-identified quotes to be used in publications. Participants were assured of confidentiality and the right to withdraw from the study at any time. No personal identifying details are revealed in this report. Data availability The datasets (interview and focus group transcripts) generated and analyzed during the current study are not publicly available to protect participant confidentiality. Data may be made available in de-identified form from the corresponding author (Mf.Ismail) upon reasonable request, subject to approval by the relevant ethics committee and in compliance with data sharing policies. Funding This study did not get any particular financial support from public, commercial, or non-profit funding agencies. Authors' contributions Dr.Mohamed Farah Ismail conceived and planned the study, conducted the literature search, collecting questionnaire and interviews, executed data extraction, conducted statistical analysis, and prepared the manuscript. Prof. Intisar Khalafalla critically reviewed the methodology, validated the data, and revised manuscripts. All authors read and approved the final manuscript. Acknowledgments The authors appreciate the support from the Department of Ophthalmology, Kampala International University Teaching Hospital. References World Health Organization (WHO) Regional Office for the Eastern Mediterranean. Human resource development for eye care in Somalia . WHO EMRO News, 18 April 2012. (Accessed 05 Nov 2025). Jayte M, Mohamed AA, Hersi AM, Jama YM, Abdi AA, Nor IA. A qualitative study of patient choices between herbal and hospital care for infectious diseases in Somalia. Sci Rep. 2025 Sept 30;15(1):33945. Al-Hejeili M. Reciting verses in water for treatment a study from the perspective of hadith and jurisprudence. J Umm Al-Qura Univ Shariah Sci Islam Stud. 2022 Mar 1;88(1):75–86. Ferdjallah A, Hassan M. Traditional Somali Diaspora Medical Practices in the USA: A Scoping Review. J Relig Health. 2023 Aug;62(4):2412–35. Eticha BL, Alemu HW, Assaye AK, Tilahun MM. Attitude Towards Traditional Eye Medicine and Associated Factors Among Adult Ophthalmic Patients Attending University of Gondar Comprehensive Specialized Hospital-Tertiary Eye Care and Training Center, Northwest Ethiopia. Clin Optom. 2021 Dec;Volume 13:323–32. Bashir AM. Integration of traditional and modern medicine: a review of Somali healing practices. Ann Med. 2025 Dec 31;57(1):2546057. Dhakal K. NVivo. J Med Libr Assoc [Internet]. 2022 Apr 26 [cited 2025 Nov 14];110(2). Available from: https://jmla.pitt.edu/ojs/jmla/article/view/1271 Tassew WC, Assefa GW, Zeleke AM, Ferede YA. Prevalence and associated factors of herbal medicine use among patients living with chronic disease in Ethiopia: A systematic review and meta-analysis. Metab Open. 2024 Mar;21:100280. Ukponmwan CU, Momoh N. Incidence and complications of traditional eye medications in Nigeria in a teaching hospital. Middle East Afr J Ophthalmol. 2010 Oct;17(4):315–9. Chazan R, Wałajtys-Rode E, Droszcz P. [The effect of salbutamol on histamine release from basophils in vivo and in vitro]. Pol Tyg Lek Wars Pol 1960. 1990 July 16;45(29–31):598–600. Courtright P. Eye care knowledge and practices among Malawian traditional healers and the development of collaborative blindness prevention programmes. Soc Sci Med 1982. 1995 Dec;41(11):1569–75. Sherief ST, Sitotaw MS, Girma A. Prevalence of traditional eye medicine and self-treatment in Gurage Zone, Rural Ethiopia. BMC Complement Med Ther. 2024 July 4;24(1):255. Additional Declarations No competing interests reported. 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Patients\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePreventable blindness is also a significant healthcare issue in Somalia, as an estimated 1.2% of people in this nation find themselves blind, meaning more than 100,000 people in this population suffer from blindness because of cataracts as well as other eye-related infections [WHO]. However, in this population of just over 10\u0026ndash;15\u0026nbsp;million people, there only remain less than 20 eye specialists in this nation, making cataract surgery as well as treatments for people suffering from glaucoma an impossibility in this nation, most importantly in rural parts of this nation. The healthcare systems in this nation find itself in a conflict zone, causing this healthcare system to find it relying simultaneously on traditional medicine as well as an ineffective healthcare system in this nation (1).\u003c/p\u003e\u003cp\u003eFor Somalis, traditional medicine is more than an alternative healthcare system; it is an essential component of their cultural heritage(1). Procedures such as using herbal eye drops, applying khal (also known as Kohl), as well as Quranic water, which is water treated by recitations from the Quran, appear to be more available, cheaper, and more acceptable to their beliefs than Western biomedicine in healthcare facilities(2). In several African countries, including Somalia, traditional medicine for eyes is even more significant in that it is endowed with spiritual values, including Quranic healing, which is believed to be divine, thus increasing patient confidence in this healthcare modality(3). For Somalis, healthcare is generally believed to be from God, and healthcare approaches accompanied by prayers, as well as the use of holy water, appear to be more credible, safe, and acceptable to them than other healthcare approaches, including those in biomedicine(3). While this healthcare modality is more acceptable to Somalis, overdependence on traditional eye care approaches could lead to delayed healthcare, which may result in further complications of conditions that require urgent attention(1). In fact, it is worth mentioning that in East Africa, cases of severe complications resulting from traditional eye medications, which include infections of the cornea, as well as blindness for life, have been documented(4).\u003c/p\u003e\u003cp\u003eA general suspicion of present-day Western biomedical practices in Somalia is also a barrier to adopting hospital-based services(5). Present day eye treatments, for example, using medicinal drops in eyes, as in surgery, could be feared as suspicious(5). A lack of investment, as well as intermittent provision of eye treatments, has led to a loss of trust, including the idea of viewing a hospital as an establishment which is strange to, as well as having no relation to, Somali culture(1). Trust is an essential criterion in healthcare choice(3). Trust in this case also encompasses adjusted effectiveness, understanding, as well as expectations of safe conditions(3). Though other African research has been able to demonstrate that traditional beliefs also affect healthcare choice, little is known about trust in, as well as lack of trust in, healthcare, in this case eye treatments, in Somali clients in specific(1). A recent study in Somalia showed patient preferences between using herbal medicine and hospital care to treat infections, in which cultural acceptability as well as infrastructure contributed to patient choice(1).\u003c/p\u003e\u003cp\u003eThis paper seeks to fill this gap by exploring in-depth the views of Somali patients toward conventional eye treatments as opposed to traditional remedies for eyes. This paper seeks to look at cultural issues, structural impediments, as well as trust/mistrust issues that shape whether to get this kind of healthcare at a hospital facility as opposed to sticking to local healing practitioners in the community. This paper seeks to highlight issues connected to traditional healing methods, which in turn provides an avenue for suggesting an efficient integration of Somali culture into conventional ophthalmological work.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eFor this qualitative explorative study, individual interviews as well as focus group discussions were conducted to examine community views of traditional versus modern approaches to eye care in Mogadishu, Somalia.\u003c/p\u003e\u003cp\u003eA total of thirty individuals participated in this study, which took place from June to September of 2025 in Mogadishu.\u003c/p\u003e\u003cp\u003eThe reason for selecting this location is that it is Somalia\u0026rsquo;s capital, which is home to people from different backgrounds; also, this location provides an avenue where traditional practitioners coexist alongside different hospitals/medical facilities, including an eye hospital, in addition to having a high burden of ocular diseases such as cataracts, glaucoma, trachoma, etc., in a region suffering from poor facilities for eye care.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant selection and sample size justification\u003c/h3\u003e\n\u003cp\u003eThe respondents were purposively sampled to include views of three groups of people who participate in eye care decisions:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePatients (n\u0026thinsp;=\u0026thinsp;15)\u003c/b\u003e: These include adults who are at least 18 years old, who in the past year have sought either traditional medicine treatments or hospital-based eye care because of an eye condition, which could be cataracts, an ongoing eye infection, or symptoms of glaucoma, regardless of whether they are men or women, including persons of different ages to ensure that different patient experiences are incorporated.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTradition eye healers (n\u0026thinsp;=\u0026thinsp;10)\u003c/b\u003e: Those who have practiced for more than five years in providing community-based traditional eye care treatments. These include herbalists and religious healing practitioners who specialize in traditional treatments of eye disorders using approaches such as herbal eye drop treatments, spiritual healing, amongst others.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eOphthalmic care providers (n\u0026thinsp;=\u0026thinsp;5)\u003c/b\u003e: These include healthcare providers like ophthalmologists, ophthalmic clinical officers, or ophthalmic nurses working in eye clinics or in hospitals in Mogadishu.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eA planned target sample size of 30 individuals is informed by principles of thematic saturation, in which enough data is collected to answer our research question in such a way as to preclude the identification of substantially new information by further interviews[10]. In fact, upon analysis, enough data appeared to have been gained by the 25th interview as well as in our second focus group, in which few novel thoughts began to appear, suggesting an adequate sample size to draw upon for this research study.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThe data for this study were gathered using 30 in-depth interviews and 3 Focus Group Discussions (FGDs). One of the authors, who is Somali, spoke Somali and English, conducted all interviews in Somali to minimize language barriers. The interviews took place in a location of convenience to the respondent (e.g., for healthcare practitioners at the eye hospital, for clients and practitioners at community facilities or respondent\u0026rsquo;s residence). Interviews took approximately 45\u0026ndash;60 minutes per respondent, and all interviews were tape-recorded with individual respondent consent to participate in being interviewed, which would also give consent to have interviews taped.\u003c/p\u003e\u003cp\u003eAn open-ended interviewing guide was employed to guide interviews (see examples of open-ended questions below). Issues discussed using this guide included, but did not limit to, recent personal experience with eye treatments, criteria for choice between healer provider versus hospital provider, beliefs about effectiveness (e.g. herbal drops versus antibiotic drops, versus surgery) and safety of treatments, source of trust versus source of distrust in healer providers, cultural versus religious beliefs about eye disease and healing, as well as challenges encountered (e.g. money, accessibility, family involvement). Some examples of open-ended questions asked during an interview include:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;Can you tell me about what you did when you last had an issue with your eyes, and why did you choose that particular option?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;What is your opinion of the effectiveness as well as safety of the traditional remedies for eyes, in relation to hospital treatments such as eye drops, surgery, etc.?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;What are the main issues or concerns for you in relation to going to a hospital for an eye problem?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;How much do you trust the local eye healer (or eye doctor), and why?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;Do religious beliefs or family traditions affect how you treat eye problems?\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\"Have you, or does someone you know, experienced a poor or excellent result from either conventional care or hospital eye care?\"\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eFGD organization:\u003c/h3\u003e\n\u003cp\u003eA total of three FGDs were organized \u0026ndash; patient FGD (n\u0026thinsp;=\u0026thinsp;6 FGD participants), healer FGD (n\u0026thinsp;=\u0026thinsp;5 FGD participants), and provider FGD (n\u0026thinsp;=\u0026thinsp;4 FGD participants). The FGDs were organized by type of participant to allow for open, homogeneous discussion, thus allowing patients, healers, and providers to freely discuss without issues of dominance in inter-group discussions. The FGDs took approximately 90 to 120 minutes to complete, as in the patient FGD, for example, where issues of community attitudes and examples of patient discussions, including debate about herbal versus hospital treatments, took place. The healer FGD allowed for understanding of collective healer views of hospital collaboration, and in provider FGDs, examples of views of providers towards patient use of traditional medicine use could be understood. Additionally, all FGDs were audio-taped for ease of transcription.\u003c/p\u003e\n\u003ch3\u003eTranslation process\u003c/h3\u003e\n\u003cp\u003eAll interviews, as well as group discussions, took place in Somali language, which underwent transcription in Somali as well. A two-pronged approach to translating transcripts into English for analysis also took place here. First, this involved translating all Somali transcripts into English by the principal researcher here. Finally, for ascertaining meaning in English, this project utilized a bi-lingual research assistant to check English translations of transcripts for correctness against original Somali transcripts. Phrases expressing subtler meanings in cultures, such as references to healing in religious customs, for instance, also received collaborative consideration between the translators to identify an appropriate English equivalent in this study.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eFor this study, a thematic analysis methodology is employed, combining manual coding processes as well as using data analysis computer software (NVivo12). First, at this stage, the researchers manually engaged in multiple readings of all available transcripts to familiarze themselves, recording insights at this level. Subsequent development of an inductive codebook involved line-wise open coding of transcripts for principal ideas in phrases, which in turn were increasingly clustered to carry wider concepts suitably expressed as categories. These categories in turn underwent several cycles of refinement, subsequent merging into wider concepts suitably expressed as overarching themes, in an iterative manner[11]. For ease of coding, data management, as well as facilitated easy location of data for a code afterward, computer-assisted software (NVivo12) is used here as well. For increasing validity of this analysis, coding of randomly selected transcripts by both authors (who speak Somali fluently, as well as have prior experience in this area of analysis) is independently undertaken, for comparison of this coding, any discrepancies at code assignment phases being suitably addressed via consensus-building, modifying coding as needed here as well(6).\u003c/p\u003e\u003cp\u003eThroughout analyses, measures of trustworthiness were incorporated, including peer debriefing (the research team discussed insights collectively, including whether interpretations appeared accurate to those who understood the context) and member checking to a moderate level of involvement, where a compilation of results was presented to representatives of study participants, including one healer and one patient, to check whether results accurately reflected insights from those perspectives). The results of thematic analysis included identification of three key themes, several of which fall under sub-themes, as follows, including recommendations from experts in addition to quotes from source material (participants, quotes of which are in English to provide clarity). While maintaining anonymity for individuals, actual identifying markers removed either entirely to ensure protection of confidentiality).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThree major themes emerged from interviews and FGDs in respect to trust, mistrust of current ocular treatments in relation to more traditional treatments available to Somali patients in Mogadishu. These include (1) The validity of traditional care for eyes, (2) efficacy of current ocular treatments in respect to mistrust of hospital-based ocular treatments, and (3) Structural issues of expectancy to formal ocular care. These include further subthemes, which include quotes for exemplification, as follows.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGender (M/F)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean age, years (range)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKey inclusion criteria\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 / 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (19\u0026ndash;70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdults who sought either traditional or hospital-based ophthalmic care within the past year\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTraditional eye healers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 / 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55 (33\u0026ndash;76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePractitioners providing herbal or Quranic eye treatments for \u0026ge;\u0026thinsp;5 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOphthalmic care providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 / 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (29\u0026ndash;45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOphthalmologists, ophthalmic nurses, or clinical officers working in Mogadishu eye units\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e30\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e19 / 11\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCaption\u003c/strong\u003e\u003cp\u003eParticipants were purposively selected to capture perspectives from patients, traditional healers, and biomedical eye-care professionals. All were residents of Mogadishu, Somalia, at the time of data collection (Nov\u0026ndash;Dec 2024).\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Cultural Legitimacy of Traditional Eye Care\u003c/h3\u003e\n\u003cp\u003eThis topic emphasizes the strong cultural and religious foundations of traditional eye healing in Somalia, as well as how this contributes to trust in traditional medicine for eyes. Forum contributors from both patient and practitioner perspectives discussed how traditional approaches to eye healing carry strong meanings of ancestral and religiously validated know-how, which makes them more acceptable than Western medicine to the community at large in Somalia. Two sub-topics to support this include traditional eye healing as ancestral wisdom, as well as Islamic healing in eye care.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 1.1\u003c/strong\u003e\u003cp\u003e\u0026ldquo;Our Ancestral Wisdom\u0026rdquo; - Herbal remedies as heritage. Both patients and healthcare practitioners often spoke of traditional eye care remedies as an aspect of heritage passed down from previous generations. The use of such remedies is a statement of Somali identity, an indigenous link to the past, to her traditions, customs, and beliefs passed down from previous generations. For instance, this healthcare practitioner, a 54-year-old man, explained, \u003cem\u003e\u0026ldquo;The know-how I possess to treat eyes has been passed down to me by my grandfather. His father passed it down to him before him. It is our family\u0026rsquo;s heritage. I get sought after because I possess the collective wisdom of our forefathers.\u0026rdquo;\u003c/em\u003e Likewise, this patient, a 30-year-old woman who suffers from frequent infections in her eyes, explained, \u003cem\u003e\u0026ldquo;I resorted to using those herbal drops from leaves because that\u0026rsquo;s what my mother and grandmother always did for my red eyes when I suffered from them as a child. That\u0026rsquo;s what bonded me to them\u003c/em\u003e. \u003cem\u003e\u0026rdquo;\u003c/em\u003e According to our culture, if it\u0026rsquo;s been of benefit to our ancestral generations past, then it must work for them as well.\u0026rdquo; As such, this heritage makes traditional remedies appear as far from alternative as possible, as they appear to be in line as the only natural choice for everyone concerned as they appear to be more naturalized to everyone concerned because, to them, going to a hospital to get such remedies constituting compelling commonality, they feel they require crossing an internal barrier in which they feel they\u0026rsquo;re going against their cultures as they say, for instance, this patient, a 45-year-old man, observed, \u003cem\u003e\u0026ldquo;Our hospital is brand new for us; but herbs run in our bloodstream.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory 1.2: Spiritual healing and Quranic legitimacy.\u003c/b\u003e Many participants discussed the use of Quranic practices of treating eye conditions reflect the important role religion plays in health. Traditional healers often recited Quranic verses over water to create \u0026ldquo;Quranic water\u0026rdquo; to be used as eye drops, or gave taweez (amulets) with prayers for protection of eyesight. Such practices instill the treatment with spiritual authority. One 41-year-old female patient recounted the following experience with an eye healer: \u003cem\u003e\u0026ldquo;When my eye was swollen, I went to a sheikh. He read Quran on water and told me to wash my eye with it. I felt comfort because it wasn't just medicine, it was Allah's words healing me.\"\u003c/em\u003e The perception that faith-driven treatment invites divine healing was a common thing. Several patients said that using Quranic remedies made them feel safe. Because \u003cem\u003e\u0026ldquo;God\u0026rsquo;s cure has no side effects.\u0026rdquo;\u003c/em\u003e By implication, hospital treatments sometimes were perceived to lack this spiritual dimension. One young male participant from the patient FGD remarked: \u003cem\u003e\u0026ldquo;Doctors just give you chemical drops or operations. They don\u0026rsquo;t pray for you. For us, healing is from Allah, so I trust something with Quran on it more than someth\u0026shy;ing from a pharmacy.\u0026rdquo;\u003c/em\u003e Traditional healers themselves empha\u0026shy;sized that their success depended on both the herbs and God\u0026rsquo;s blessing - a healer (male, 60) said, \u003cem\u003e\u0026ldquo;I always recite Bismillah (in the name of God) during the application of medicine to the eye, and \"no treatment works without God's will.\"\u003c/em\u003e This subtheme That is to say, religious legitimacy increases trust in traditional eye care. In predominantly Muslim Somalia, society, such an approach that incorporates spiritual care feels more holistic and therefore more trustworthy for many patients than A purely biomedical intervention.\u003c/p\u003e\u003cp\u003eIt is important to note that, although cultural legitimacy strongly favors traditional eye care, not all participants were completely dismissive of modern care. Some patients acknowledged that for certain serious conditions, such as mature cataracts or severe trauma, the \u0026ldquo;old ways\u0026rdquo; may not suffice. They indicated they would still combine both; for instance, undergoing surgery but also seeking prayers for success. The general feeling behind Theme 1 is, however, one of traditional practices being culturally \"ours \u0026ldquo;they possess a certain trustworthiness inherently derived from tradition and faith that modern means do not have in the eyes of many Somalis.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Perceived Efficacy and Mistrust of Modern Ophthalmic Treatments\u003c/h2\u003e\u003cp\u003eThe second dominant theme is focused on how study participants feel about contemporary eye treatments as practiced in hospitals, including skepticism about their safety/effectiveness as well as comparisons to traditional treatments. A common theme is a lack of trust in conjunction with fear of eye surgery, consequences of taking medicine, and providers' motives/intent. This lack of trust served to tip the scales in support of using traditional remedies as a first course of action in dealing with eye problems. Of course, many study volunteers did express awareness of the safety/effectiveness of contemporary treatments, but they conflict in themselves in this respect by having ambivalence toward them. There are a number of sub-themes which are listed below:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 2.1\u003c/strong\u003e\u003cp\u003eFear of surgery and \"the knife.\" Eye surgery, particularly cataract surgery, is another intervention people feared intensely. There\u0026rsquo;s a strong association with high risk, which is attributed to a lack of understanding as well as community stories of botched procedures passed down by association. In a patient FGD, consensus emerged quickly that \"no one goes for eye surgery unless they\u0026rsquo;re desperate.\" A 63-year-old patient presenting for cataract in his eye confessed to having postponed his surgery for two years, stating, \u003cem\u003e\"I was informed at the hospital that I have to do cataract surgery, but I feared going to the doctor because I'd heard of people coming back worse, even blind, in case of failure to recover. I have used an herbal paste in my eyes every day, praying that it would cure this cataract in my eyes.\"\u003c/em\u003e A woman presenting because of her child having an issue in her eyes explained, in a similar vein, \u003cem\u003e\"Because I'm afraid of having doctors damage my child\u0026rsquo;s eyes in surgery; they\u0026rsquo;re only going to cut eyes, which is quite scary to a parent.\"\u003c/em\u003e The mistrust is further increased by questions as to whether Somali facilities possess competent specialists, as well as safe conditions for surgical repairs, as several of them asked whether anything really worth doing is possible in these standards of surgical facilities in Somalia, as follows from this healer\u0026rsquo;s statement, \u003cem\u003e\"Our hospitals here aren\u0026rsquo;t like those in other countries; they probably lack the adequate equipment for repairs to work as they\u0026rsquo;re supposed to in better-versed countries in locations like ours; that\u0026rsquo;s why I give them advice first to try our medicine. Surgery should be a last option.\"\u003c/em\u003e These attitudes better demonstrate a pervasive distrust of surgical intervention, often for reasons of horror stories as well as an awareness of an underserved goal of eye refractions in Somalia in general, even to including personnel, as explained by an ophthalmic nurse during a provider-conducted FGD, \u003cem\u003e\"Many of our patients end up in our office having cataracts because they didn\u0026rsquo;t know what to do to get them cured at first; they feared going to surgery because they feared what is commonly known as \u0026lsquo;the knife,\u0026rsquo; as they didn\u0026rsquo;t trust the facility to provide competent specialists in either case, going so far as to try to avoid at all costs by using consultants at a coucher to cure them, which is much more dubious in that they only employ an obsolete technique of further pushing a thumb against what\u0026rsquo;s left of an eye to force out an optic lens to help restore full sight to an otherwise sightless patient, which is far more hazardous than our more complex surgeries.\"\u003c/em\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 2.2\u003c/strong\u003e\u003cp\u003eConcerns regarding medications, as well as possible side effects. Apart from surgery, another area of apprehension is using pharmaceutical eye drops, as well as tablets, from hospital pharmacies. A common understanding here is that current medications contain \"strong chemicals\" that may prove harmful to health. For instance, a 28, glaucoma patient, stated, \u003cem\u003e\"The doctor gave me eye drops for my high pressure, but I didn\u0026rsquo;t find them safe after going through the accompanying leaflet\u0026mdash;many possible complications! I only took them for a week, which made my eye burn, so I stopped using them altogether and turned to my traditional remedies.\"\u003c/em\u003e Being apprehensive is partly due to past negative reactions to using medications and partly because of unfamiliarity with them in general. Herbal medicine is more natural, as well as safe, in comparison to pharmaceutical medication, which is associated more with harsh \"chemicals.\" For example, a healer explained, \u003cem\u003e\"Our medicine is from plants,, so they should be safe as long as people use them properly. Hospital eye drops contain chemicals that might harm an eye or give people pain.\"\u003c/em\u003e Some individuals raised another issue, which is receiving low-quality, as well as counterfeit, medication from pharmacies of medicinal products in local markets who deal in medications, further increasing people\u0026rsquo;s apprehension towards \"modern\" medication in general, as another patient expressed, who bought antibiotic eye drops but didn\u0026rsquo;t work at all, suspecting it to be a low-quality, maybe even fake, product, stating, \u003cem\u003e\"How do I even trust what they give to me from the hospital pharmacy? At least I know what I'm taking from my herbs.\"\u003c/em\u003e This further shows people\u0026rsquo;s lack of confidence in using \"modern\" medication in general. Moreover, healthcare practitioners in this study have understood this kind of thinking, including, as an ophthalmologist explained, \u003cem\u003e\"Sometimes, we\u0026rsquo;re working with inappropriate medication consumers who stop using medication prematurely because they\u0026rsquo;re afraid of complications from medications, as they believe more in traditional treatments, thinking they\u0026rsquo;re more complete than regular approaches, which is difficult to convince them that using an antibiotic drop in an appropriate manner is sufficient to protect an eye from infections.\"\u003c/em\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory 2.3: Trust in providers - \"Doctor or herbalist, who cares?\u003c/b\u003e\" The topic of trust in caregivers also came up as another important consideration for many of the patients interviewed. Of course, they confessed to trusting an established healer from among them more than an unknown doctor in hospital settings for several reasons, including that established caregivers know them well enough to even treat them for free, as they have enough trust in them to respect them as close relatives, whereas hospital staff, in contrast, appear impersonal, only after money, but an established caregiver expressed this for a patient as follows: \u003cem\u003e\"If I go to a hospital, I might see a different doctor every time, and they barely have time to talk to me. The doctor barely has time to talk to them.\"\u003c/em\u003e A patient expressed better his understanding of this in this manner as well, \u003cem\u003e\"But my healer in my village knows me, my family, knows me, my children, everyone in my family. He follows up to see if I'm better, maybe even asks about whether I'm better from time to time to check if I'm recovering from what he treated me for. I trust him because he cares for me.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne traditional healer said \u003cem\u003e\"People come to me first because they know I won't turn them away for not having money, and I treat them like my own children We have earned trust over many generations. \"\u003c/em\u003e However, some respondents talked about unpleasant hospital experiences that made them less trusting, like impolite staff, lengthy wait times without a reason, or a previous incorrect diagnosis. \u003cem\u003e\"I went to the clinic for a painful red eye; the doctor gave me drops but didn't explain anything, my eye grew worse. After losing faith in them, I turned back to the herbal healer, who at least gave me consolation\u003c/em\u003e. \u003cem\u003e\"\u003c/em\u003e Recalled a female patient. Notably, some participants had a high level of trust in specific medical professionals, particularly if the provider had successfully treated a family member or demonstrated cultural sensitivity. According to one of the FGD providers, Somali patients are more likely to trust their doctors when they take the time to talk to them and, more intriguingly, when they accept traditional practices rather than completely rejecting them. I occasionally advise my patients to \u003cem\u003e\"I know Quran is a healer so continue washing with Quran water, but also use these drops to clear the infection,\"\u003c/em\u003e he said.\u003c/p\u003e\u003cp\u003eThey are more inclined to believe my advice when they perceive that I respect their beliefs. In conclusion, trust\u0026mdash;or lack thereof\u0026mdash;in the professionals providing contemporary ophthalmic care is inextricably linked to trust in that care. Unless the clinic experience is moderated by culturally sensitive care, many people find the community-based, compassionate approach of traditional healers to be more reliable than the formal, system-driven approach of clinics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory 2.4: Balancing both worlds \u0026ndash; emerging openness to integration.\u003c/b\u003e While most of them are polarized in their attitudes, some showed an emerging awareness of the complementarity of both worlds. For example, a patient, who is a young 31-year-old man, observed, \u003cem\u003e\u0026ldquo;When I had a corneal ulcer, I went to hospital for treatment because I knew it was serious. Even in hospital, I was doing my Quranic verses to recover from it, as well as an herbal solution at home to speed up healing. I think both work because Allah is in both treatments.\u0026rdquo;\u003c/em\u003e A traditional healer in his FGD also explained, \u003cem\u003e\"If I find a cataract person who cannot see because his cataract is very dense, I tell them, 'Surgery is available; get it.' I tell them, 'After I've prayed for them, I give them something to use at home for support.\u0026rsquo; Of course, things which only a hospital can provide, they cannot get here.\u0026rdquo;\u003c/em\u003e While this is an indication of a willingness to combine approaches if needed, what is most interesting is that this inclination to combine approaches is welcomed by eye specialists, who declared, \u003cem\u003e\"I myself do hot mind them using harmless traditional treatments like rinsing eyes using certain herbs, holy water, for example, as long as they don\u0026rsquo;t completely forget Western methods for more natural approaches which only harm in the long run.\"\u003c/em\u003e While this is only an indication of an opening to combining approaches if needed, this is an indication, of course, of an interest in complementing approaches if needed\u0026mdash;and assuming they, in turn, have better trust in biomedicine, they might find ways to complement approaches between biomedicine and traditional healing, as they otherwise reject biomedicine per se because of whence it came, to which, of course, they attribute holiness as well, which they also attribute to traditional healing, which, by definition, is also holiness, Holiness they attribute to both because they themselves attribute holiness to both by definition, by beliefs.\"\u003c/p\u003e\u003cp\u003eIn general, Theme 2 suggests that perceived efficacy and safety depend entirely on who is looking, as it is only a matter of time before many, if not all, of the current Somali patient population recognize traditional methods of dealing with eye problems as being more safe and trustworthy, in comparison to more modern approaches, which are met with a fair amount of suspicion.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Structural Barriers to Hospital-Based Eye Care Access\u003c/h2\u003e\u003cp\u003eThe third theme is focused on the challenges faced by people in seeking eye care services from hospitals or health facilities. These challenges cut across all facets of health, including the culture discussed earlier, making it difficult for people to present themselves to the biomedical sector for services. In Somalia, even if a patient desires to benefit from current medicine over traditional medicine, challenges such as costs, accessibility, and infrastructure work against them. Cost of care, infrastructure, and resource constraints in healthcare emerged as strong subthemes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSubcategory 3.1\u003c/strong\u003e\u003cp\u003eHigh cost of treatment and poverty. Financial issues were a great hindrance to seeking eye treatments from hospitals, as said by almost all of the informants. This is because healthcare in Somalia is mostly out of pocket, including specialist healthcare such as eye care, which could be quite expensive[13]. A fifty-year-old patient who is a maleness informant diagnosed with cataracts in both eyes said, \u003cem\u003e\u0026ldquo;The doctor told me I needed to have surgery to be able to see again. I won\u0026rsquo;t be able to afford even for one eye, which costs more than what my family makes in a month. I haven\u0026rsquo;t been able to do anything about it; I decided to treat myself using traditional methods, which is cheaper even if it won\u0026rsquo;t bring back my sight.\u0026rdquo;\u003c/em\u003e One of the informants also expressed her sentiments when she said that even to get to the hospital for receiving regular injections, including check-ups (e.g. in relation to diabetic eye disease) is expensive in terms of transport costs as well as lost workdays, which they cannot afford. For traditional practitioners, as they charge little to nothing, this is an even more economical solution as they even demand for payment in kind (at a later date). A young mother who took part in patient FGD explained, \u003cem\u003e\u0026ldquo;When my kid fell sick in the eyes, the hospital fees as well as medication would have set me back $20, which I did not have at the time of going for medication. I took him to a local healer who treated his eyes using a paste of herbs; I owed them a small amount for this sort of services, which costs nothing to get.\u0026rdquo;\u003c/em\u003e The end result is that even if trust exists to level of scarcity in healthcare, people would end up in traditional because of finances anyway.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory 3.2: Distance, transportation, and security challenges.\u003c/b\u003e Physical access to eye care facilities is another structural hurdle, especially for those outside Mogadishu. Several patient participants were actually from rural areas or smaller towns who traveled to Mogadishu\u0026rsquo;s eye hospital as a last resort. They described arduous journeys and, in some cases, insecurity on the roads. One elderly patient who eventually went to Mogadishu for treatment said: \u003cem\u003e\u0026ldquo;I lived for years with poor vision because going to the city was difficult. There is fighting on the roads sometimes, and it costs a lot to travel. So I relied on a local healer. Only when I nearly went blind did my sons take me to the capital.\u0026rdquo;\u003c/em\u003e Even within Mogadishu, transportation can be difficult due to traffic, cost of fuel, and for women, needing a family member to accompany them for safety. A female participant noted: \u003cem\u003e\u0026ldquo;I cannot go alone to the hospital \u0026ndash; it\u0026rsquo;s too far and my husband has to take time off work to bring me. It\u0026rsquo;s not easy, so we try other remedies first.\u0026rdquo;\u003c/em\u003e These logistical issues mean that convenience and proximity strongly influence care-seeking. Traditional healers, by contrast, are typically embedded in local communities (often \u0026ldquo;just a walk away\u0026rdquo; as one participant put it). They also may offer flexible hours \u0026ndash; some healers will see patients in the evenings at home \u0026ndash; whereas hospital clinics have limited hours. Additionally, participants mentioned that hospitals in Somalia can be chaotic or require long waiting times once you get there, which is another deterrent for someone who has traveled far. The structural challenges of distance and transport therefore reinforce the preference to \u0026ldquo;try something nearby\u0026rdquo; before undertaking a burdensome trip to a formal eye clinic.\u003c/p\u003e\u003cp\u003e\u003cb\u003e Subcategory 3.3: Limited capacity and quality of eye care services.\u003c/b\u003e Underlying many of the above issues is the stark reality that Somalia\u0026rsquo;s formal eye care capacity is extremely limited. Participants pointed out systemic problems, such as the country having a very few number of trained ophthalmologists, intermittent supplies of medical equipment and medications, and no widespread primary eye care programs. One of the hospital-based providers in our study frankly said: \u003cem\u003e\u0026ldquo;We are only a handful of eye doctors in the entire country. The waitlist for surgery at our hospital is long. We do what we can, but we\u0026rsquo;re overwhelmed.\u0026rdquo;\u003c/em\u003e Patients themselves are aware of these limitations. One patient who had tried seeking care at a government hospital explained: \u003cem\u003e\u0026ldquo;They told me the machine to check my eyes was broken and I should come back in a month. That made me gives up on them. Meanwhile, the healer in my village was at least doing something for me right away.\u0026rdquo;\u003c/em\u003e Others mentioned either medicines are never available in the hospital pharmacies, or that just essential services, such as laser treatment for diabetic eye disease or modern glaucoma surgeries, are not available within the country. It is this unavailability that funnels people back to whatever alternatives they may have. Similarly, in the FGD with healers, participants noted that people come to them often after a negative experience from the hospital: \u003cem\u003e\u0026ldquo;They are told to wait, or there is no doctor that day, so they return to us.\u0026rdquo;\u003c/em\u003e Quality of care is another aspect-a few respondents reported concerns over the competence of some providers or hygiene in facilities, to which again relates to system-wide resource constraints. A middle-aged male patient bluntly pointed out: \u003cem\u003e\u0026ldquo;If our hospitals cannot guarantee consistent care, how can we trust them? At least with traditional treatment, we know its limits.\u0026rdquo;\u003c/em\u003e This epitomizes a practical mistrust born not of cultural bias but of witnessed shortcomings in the health system. Until the capacity and consistency of ophthalmic services improve, structural barriers will continue to push patients by default toward traditional solutions.\u003c/p\u003e\u003cp\u003eIn summary, \u003cb\u003eTheme 3\u003c/b\u003e identifies that even when there may be a general willingness by patients to obtain modern eye care, systemic barriers of financial costs, travel/logistical difficulties, and limitations in service provision pose significant challenges. Often these stand alongside the cultural preferences described in Themes 1 and 2 and provide a strong pull toward traditional eye care. Interventions aimed at improving eye health in Somalia will therefore need not only to build trust but also to remove these structural barriers.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of major themes and sub-themes identified through thematic analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBrief description\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIllustrative quotation (abbreviated)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Cultural legitimacy of traditional eye care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1 Ancestral wisdom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHerbal and community eye remedies viewed as inherited, trusted family knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;Hospitals are new to us; herbs are in our blood.\u0026rdquo; (M 45 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.2 Spiritual healing (Quranic legitimacy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealing perceived as divinely guided; Quranic water and prayers seen as safe and blessed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;God\u0026rsquo;s cure has no side effects.\u0026rdquo; (F 41 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Perceived efficacy and mistrust of modern ophthalmic treatments\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1 Fear of surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCataract and other eye operations feared as risky or vision-threatening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;I was afraid the doctors would damage my eyes.\u0026rdquo; (M 63 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.2 Concerns about drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModern drops viewed as harsh chemicals with side effects; herbs seen as natural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;Those eye drops burn; herbs are natural.\u0026rdquo; (F 28 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.3 Trust in providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealers perceived as empathetic and community-embedded; doctors as impersonal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;My healer treats me like family.\u0026rdquo; (M 36 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.4 Balancing both worlds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSome participants combine hospital care with spiritual or herbal remedies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;I used both the hospital drops and Quran water.\u0026rdquo; (M 31 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3. Structural barriers to hospital eye care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1 Financial constraints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh out-of-pocket cost of surgery and drugs limits access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;One eye operation costs more than I earn in months.\u0026rdquo; (M 50 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.2 Distance and security issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTravel, insecurity, and lack of transport reduce hospital visits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;There is fighting on the roads, so I stayed with the local healer.\u0026rdquo; (F 48 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.3 Limited system capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFew specialists, broken equipment, drug stock-outs erode confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ldquo;They told me the machine was broken.\u0026rdquo; (M 42 yrs, patient)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCaption\u003c/strong\u003e\u003cp\u003eThemes derived inductively from 30 semi-structured interviews and three FGDs analyzed in NVivo 12. Quotation identifiers indicate participant type, gender (F/M), and age.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explores how Somali patients navigate between traditional and modern options of eye care and ascertains the roles of culture, trust, and structural factors in their choices. Our findings are complex: on one hand, traditional eye treatments enjoy strong cultural legitimacy and trust among patients, as part of ancestral practice and spiritual beliefs; on the other hand, modern ophthalmic treatments face considerable mistrust and are often practically impeded from access. These insights parallel findings from broader Somali healthcare studies while adding a specific focus on ophthalmology, an area previously understudied in the Somali context.\u003c/p\u003e\u003cp\u003eOne of the striking outcomes has been the deep embedding of traditional eye medicine in the respondents' culture. Herbal and spiritual remedies were framed by all participants as part of their Somali background. Indeed, this mirrors observations from Somalia and other similar settings: traditional healing is deeply embedded in the local culture (1). In Africa, traditional healers often hold a place of respect within communities, and because of their easy access and trusted position, are often the first point of care 14. Our study reinforces this dynamic: the Somali traditional eye healers are trusted not only for the remedies they provide but for the cultural meaning behind those remedies. The use of Quranic verses and prayers further amplifies this trust through the addition of a religious dimension. Prior literature has noted that many Somalis consider traditional medicine to be divinely guided(5), and our participants similarly conveyed that belief-that healing through spiritual means is blessed and therefore reliable. That suggests that any efforts to improve modern eye care acceptance need to respect and acknowledge the cultural and religious context. Dismissing traditional practices could result in alienating patients; one culturally sensitive approach might therefore include working with religious leaders or incorporating respectful acknowledgments of faith in healthcare delivery.\u003c/p\u003e\u003cp\u003eThe mistrust of modern ophthalmic treatments in \u003cb\u003eTheme 2\u003c/b\u003e is consistent with the pattern of mistrust in modern healthcare documented among Somalis both in-country and in diaspora communities. For instance, Somali immigrant women in the US have been reported to harbor distrust of Western medications and to prefer traditional or \u0026ldquo;natural\u0026rdquo; remedies,, for reasons such as fear of side effects or perception of over-medicalization. In Somalia, where the health system has been weakened by years of conflict, mistrust can be even more acute. Fears about eye surgery and pharmaceuticals expressed by participants reflect these sentiments. It is important to recognize that some of these fears are not unfounded: a lack of regulatory controls means that counterfeit or poor-quality medicines are a real problem in Somalia, as noted by participants and other sources,. Similarly, the outcome of surgical procedures can indeed be poor if conducted in suboptimal settings. Historically, in parts of Africa, the practice of traditional couching-an old method of dislocating the cataract lens-persisted because people either did not trust modern cataract surgery or did not have access to it. As one report noted, the demand for couching \"reflects the lack of availability of modern cataract surgery or lack of faith in the outcome of modern cataract surgery\". Our findings demonstrate a similar phenomenon in Somalia: some patients delayed or avoided cataract surgery due to lack of faith in the surgery, instead opting for traditional methods, albeit ineffective. It underlines another critical point: building trust in modern treatments is not solely about education regarding efficacy but also about demonstrating safety and reliability in practice. When patients witness or hear of successful outcomes within their community, trust can slowly build. On the other hand, one incident of a failed surgery can reinforce communitywide mistrust for many years.\u003c/p\u003e\u003cp\u003eStructural barriers \u003cb\u003e(Theme 3)\u003c/b\u003e came through as a strong force that not only reinforces reliance on traditional care but also amplifies mistrust in modern care. In the case of eye care, the high cost was a predominant structural barrier identified. Indeed, health financing in Somalia is almost entirely through out-of-pocket spending; over 40% of health expenditure is paid by individuals [13]. In such a context, it is understandable that people delay or avoid hospital care-it's often a major financial gamble for the household. The experiences of our participants are supported by broader observations of a weakly functioning, poorly resourced, inequitable health system within Somalia [20]. Thus, eye care, as a specialized service, is even less accessible outside of the few urban centers. The lack of ophthalmologists-less than 20 in the whole country-was a striking statistic reflected in frustrations of providers and difficulties of patients [2]. Such a shortage implies waiting and unmet needs; as was noted, if the hospital cannot see a patient either quickly or proximally, then whatever is available constitutes an option. It is important to note that the issues of structure and trust are mutually reinforcing-an unreliable system breeds mistrust, and mistrust reduces utilization of services, potentially feeding into further under-investment in those services. Comparing our findings with other regions, many themes resonate. In Ethiopia, for instance, traditional eye medicine is widely used \u0026ndash; over 60% of adult ophthalmic patients in one hospital-based study had a positive attitude toward traditional eye medicine(4). Factors like rural residence and family tradition predicted higher use of traditional remedies(7), similar to what our Somali participants described (traditional practices being a family and community norm). The consequences of such practices, if harmful, have been documented: traditional eye treatments have led to severe complications like corneal scarring, infections (keratitis, endophthalmitis), and even blindness in various African settings(8). Some of our patient narratives hinted at negative outcomes from delays or harmful remedies (though we did not extensively report clinical outcomes, a few mentioned worsened conditions after using traditional methods too long). This underlines a public health urgency: unsafe traditional practices need to be addressed through community education(9). However, outright banning or discouraging traditional healers is unlikely to succeed (and could drive practices underground). Instead, as several participants and providers suggested, a more effective approach would be to constructively engage and educate traditional healers. Encouragingly, examples from other countries show that collaboration is possible. In Malawi and other African nations, initiatives have trained traditional healers on basic eye care and established referral links, leading to improved prevention of blindness (10). In Ethiopia, it\u0026rsquo;s recommended to educate healers on safe practices to reduce the burden of complications (11). Our data support similar strategies for Somalia: by training healers to recognize serious eye conditions and refer patients early (for instance, refer cataract cases to surgical camps or hospitals), and by discouraging the most dangerous practices, outcomes could improve. Traditional healers could become allies in eye health, helping bridge the gap of trust. Given their community clout, if healers can be convinced of the value of certain modern treatments (or at least the limitations of their own treatments), they can influence patients\u0026rsquo; attitudes positively.\u003c/p\u003e\u003cp\u003eAnother crucial approach would be the incorporation of cultural and religious aspects into contemporary care. Given that many Somalis view healing in spiritual contexts, for instance, it may be beneficial for hospitals to take measures such as having religious counselors or imams participate in health education or simply allowing space for spiritual practices alongside treatment. As might be done in an eye hospital, for example, one could provide information that aligns treatment with faith (\"recovering sight is a blessing, and medicine can be a gift from God\"). Such approaches have been suggested in other contexts to improve trust-namely, showing respect for, rather than asking patients to leave their beliefs at the clinic door.\u003c/p\u003e\u003cp\u003eFrom a structural perspective, our findings strengthen the calls for improving eye care infrastructure in Somalia. When patients are eyewitnesses of neighbors regaining their eyesight from a surgery, it may well counteract the many years of skepticism. Similarly, financial risk protection-provided, for example, through donor-supported vouchers or a basic insurance scheme to cover the costs of eye surgery-would remove one of the major deterrents, namely cost. Given that the main reasons many stuck with traditional care included poverty, reducing out-of-pocket costs becomes a key strategy for changing behavior.\u003c/p\u003e\u003cp\u003eIt is also worth noting the few participants who advocated combining traditional and modern approaches because they represent a potential middle ground. As they have argued, integration at the patient level is already happening for some, as patients pray or use herbal washes while they are on medical treatment. Rather than viewing this as non-compliance, health professionals could acknowledge and guide safe concurrent practices. If a patient wants to use Quran Holly water subsequent to an eye surgery, for example, the provider can make sure it's hygienically prepared and does not replace important medications. These win-win compromises can help build rapport and trust in these encounters.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of trust factors influencing traditional and modern ophthalmic care choices among Somali patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension of trust\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraditional eye care (herbal / Quranic)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModern ophthalmic care (hospital / clinical)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eImplication for patient decision\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCultural familiarity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeeply embedded in Somali culture; passed down through generations; seen as \u0026ldquo;our way.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerceived as foreign or Western; lacks cultural resonance for many patients.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCultural alignment strengthens trust in traditional healers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReligious legitimacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUses Quranic verses and prayers; viewed as spiritually blessed and safe.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOften viewed as secular and purely technical; lacks overt spiritual element.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFaith-based legitimacy drives preference for Quranic and herbal care.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProvider\u0026ndash;patient relationship\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePersonal, informal, community-based; healers know families and treat on credit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFormal, time-limited encounters; some perceive doctors as distant or profit-oriented.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTrust higher when providers show empathy and community engagement.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived safety / risk\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNatural ingredients considered gentle and harmless.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFear of surgical failure or drug side effects; anxiety over \u0026ldquo;cutting the eye.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePerceived safety determines first point of contact for care.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived efficacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLinked to spiritual success and community stories of recovery.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcknowledged as effective for severe disease but doubted for common ailments.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePartial trust in hospitals for advanced conditions only.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccessibility and cost\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEasily available locally; flexible payment; minimal cost.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLimited facilities, long waiting times, and high out-of-pocket costs.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAffordability favors traditional options.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccountability and transparency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTrust based on reputation, word of mouth, and visible dedication.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTrust shaped by institutional reliability and consistent outcomes.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRepeated positive hospital outcomes can rebuild confidence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall trust balance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh community trust rooted in culture and faith.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVariable trust, undermined by cost, fear, and limited capacity.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBridging both systems through cultural sensitivity can enhance uptake of modern eye care.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCaption\u003c/strong\u003e\u003cp\u003eTable synthesizes comparative factors shaping trust and mistrust between traditional and modern ophthalmic care identified through thematic analysis of interviews and focus groups (n\u0026thinsp;=\u0026thinsp;30).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cp\u003eThe following are limitations of this study. First, it was conducted in Mogadishu and included mostly participants who were accessible in an urban or peri-urban setting. Perspectives in more remote rural areas or other regions of Somalia (with potentially different traditions) may not be well represented here. Second, because this is a qualitative study, our objective was in-depth understanding rather than quantifiable prevalence of certain beliefs; hence, the insights are rich but not generalizable on a statistical basis. There could also be some selection bias in that those who were willing to discuss their experiences might be those more interested in the topic of traditional versus modern care. We attempted to mitigate this by purposive sampling, ensuring a variety of standpoints. In addition, all data were self-reported-the study relies on participants' narratives and perceptions, which can be affected by memory and social desirability. We did note that in focus groups, some participants might have downplayed their negative experiences with traditional medicine in front of healers, or vice versa, although the facilitator encouraged candid sharing, and we did obtain opposing opinions as well. Despite these limitations, the fact that several themes repeated themselves across interviews and groups does suggest that findings are resonant with common realities in this setting.\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe choices that Somali patients make regarding eye care are shaped by a delicate interplay of trust, culture, and practical access. There is a strong cultural affinity toward traditional eye remedies in Somalia, a trust underpinned by ancestral knowledge and spiritual beliefs. Modern ophthalmic treatments, however, while medically advanced, are often met with mistrust, further undermined by economic and logistic challenges. For improved eye health outcomes in Somalia, there is a need for integrated solutions that bridge the divide between traditional and biomedical systems. Key recommendations that arise from this study include the following: (1) actively involving and training traditional eye healers in basic eye care and referral systems, so that they can continue their culturally valued role while safely guiding patients to hospitals when needed; (2) community-centered health education addressing misconceptions about modern eye treatments-for example, demystifying eye surgery and highlighting its success rate-and doing so in a culturally sensitive way, leveraging local leaders or religious figures to endorse messages; and (3) reducing structural barriers through the scale-up of affordable eye care services, such as free cataract surgery camps, mobile clinics in rural areas, and financial support for the poorest patients. Building trust is as important as building clinics: initiatives that show respect for Somali tradition, while gradually introducing modern care as complementary rather than adversarial, are likely to gain more acceptance. Ultimately, by combining thoughtfully traditional and modern approaches, Somalia can work its way to a more inclusive eye-care system respecting cultural values, gaining patient trust, and yielding effective treatments to prevent blindness. Such a model may not only bring better vision but could also serve as a template for culturally congruent improvements in health care on other aspects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Somalia Ministry of Health Research Ethics Committee (Ref: MOH/1623/2025). All procedures were carried out in accordance with relevant ethical guidelines and regulations. Participants provided informed consent prior to interviews and discussions. Written informed consent was obtained from all participants, which included consent for de-identified quotes to be used in publications. Participants were assured of confidentiality and the right to withdraw from the study at any time. No personal identifying details are revealed in this report.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe datasets (interview and focus group transcripts) generated and analyzed during the current study are not publicly available to protect participant confidentiality. Data may be made available in de-identified form from the corresponding author (Mf.Ismail) upon reasonable request, subject to approval by the relevant ethics committee and in compliance with data sharing policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not get any particular financial support from public, commercial, or non-profit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr.Mohamed Farah Ismail conceived and planned the study, conducted the literature search, collecting questionnaire and interviews, \u0026nbsp;executed data extraction, conducted statistical analysis, and prepared the manuscript. Prof. Intisar Khalafalla critically reviewed the methodology, validated the data, and revised manuscripts. All authors read and approved the final manuscript. Acknowledgments The authors appreciate the support from the Department of Ophthalmology, Kampala International University Teaching Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization (WHO) Regional Office for the Eastern Mediterranean. \u003cem\u003eHuman resource development for eye care in Somalia\u003c/em\u003e. WHO EMRO News, 18 April 2012. (Accessed 05 Nov 2025).\u003c/li\u003e\n\u003cli\u003eJayte M, Mohamed AA, Hersi AM, Jama YM, Abdi AA, Nor IA. A qualitative study of patient choices between herbal and hospital care for infectious diseases in Somalia. Sci Rep. 2025 Sept 30;15(1):33945.\u003c/li\u003e\n\u003cli\u003eAl-Hejeili M. Reciting verses in water for treatment a study from the perspective of hadith and jurisprudence. J Umm Al-Qura Univ Shariah Sci Islam Stud. 2022 Mar 1;88(1):75\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eFerdjallah A, Hassan M. Traditional Somali Diaspora Medical Practices in the USA: A Scoping Review. J Relig Health. 2023 Aug;62(4):2412\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eEticha BL, Alemu HW, Assaye AK, Tilahun MM. Attitude Towards Traditional Eye Medicine and Associated Factors Among Adult Ophthalmic Patients Attending University of Gondar Comprehensive Specialized Hospital-Tertiary Eye Care and Training Center, Northwest Ethiopia. Clin Optom. 2021 Dec;Volume 13:323\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003eBashir AM. Integration of traditional and modern medicine: a review of Somali healing practices. Ann Med. 2025 Dec 31;57(1):2546057.\u003c/li\u003e\n\u003cli\u003eDhakal K. NVivo. J Med Libr Assoc [Internet]. 2022 Apr 26 [cited 2025 Nov 14];110(2). Available from: https://jmla.pitt.edu/ojs/jmla/article/view/1271\u003c/li\u003e\n\u003cli\u003eTassew WC, Assefa GW, Zeleke AM, Ferede YA. Prevalence and associated factors of herbal medicine use among patients living with chronic disease in Ethiopia: A systematic review and meta-analysis. Metab Open. 2024 Mar;21:100280.\u003c/li\u003e\n\u003cli\u003eUkponmwan CU, Momoh N. Incidence and complications of traditional eye medications in Nigeria in a teaching hospital. Middle East Afr J Ophthalmol. 2010 Oct;17(4):315\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eChazan R, Wałajtys-Rode E, Droszcz P. [The effect of salbutamol on histamine release from basophils in vivo and in vitro]. Pol Tyg Lek Wars Pol 1960. 1990 July 16;45(29\u0026ndash;31):598\u0026ndash;600.\u003c/li\u003e\n\u003cli\u003eCourtright P. Eye care knowledge and practices among Malawian traditional healers and the development of collaborative blindness prevention programmes. Soc Sci Med 1982. 1995 Dec;41(11):1569\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eSherief ST, Sitotaw MS, Girma A. Prevalence of traditional eye medicine and self-treatment in Gurage Zone, Rural Ethiopia. BMC Complement Med Ther. 2024 July 4;24(1):255.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Somalia, Ophthalmology, traditional medicine, Eye health, Qualitative researc","lastPublishedDoi":"10.21203/rs.3.rs-8143403/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8143403/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe prevalence of avoidable blindness is also high in the Somali population against the backdrop of a fragile health system and a widespread use of traditional eye remedies. What patients experience during transitions between modern ophthalmology and traditional eye practices remains unclear\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe study used a qualitative exploratory approach and took place in Mogadishu, Somalia (June and September, 2025). Semi-structured interviews were undertaken with a sample of 30 participants (15 patients, 10 traditional eye healers, and 5 ophthalmic care providers), with additional data garnered through three formal focus group discussions stratified for the different categories of participants. The data consisted of translations into English and analyzed using the NVivo 12 program.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFindings are presented in the form of three overarching themes. \u003cb\u003e(1) \u0026ldquo;Cultural legitimacy of traditional eye care\u0026rdquo;\u003c/b\u003e: The herbal and Islamic treatments were presented as a cultural inheritance that is \u0026ldquo;divinely ordained,\u0026rdquo; thus creating a degree of authenticity and \u0026ldquo;externality\u0026rdquo; of the hospital modality. \u003cb\u003e(2)\u003c/b\u003e \u0026ldquo;\u003cb\u003eEfficacy and distrust of modern eye care practices\u0026rdquo;\u003c/b\u003e: Participants showed concern over eye surgery and \u0026ldquo;powerful chemicals\u0026rdquo; used in eye drop formulations, and doubted the sincerity of the providers and the consistency of the system at the Somali hospital. \u003cb\u003e(3) \u0026ldquo;Barriers and facilitators of eye care at the Somali hospital and beyond\u0026rdquo;\u003c/b\u003e: The distance, insecurity, and lack of capacity within Somali ophthalmology led to a persistence of local traditional practices even when patients were aware of the advantages of the modern system.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe final conclusions are that decisions relating to eye care for Somali patients are complex and interlink closely with cultural, religious, relationship, and structural issues. The following are required if avoidable blindness is to be alleviated: (i) traditional eye healers must be drawn into the early referral and diversion away from harmful practices, and (ii) culturally specific counseling must be undertaken, taking into account religion and custom but also seeking to demystify surgery and medications. Trust and infrastructure are essential and must be addressed if eye care success is to be achieved in Somalia.\u003c/p\u003e","manuscriptTitle":"Trust and Mistrust in Traditional and Modrn Ophthalmic Treatments: A Qualitative Study Among Somali Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 08:51:59","doi":"10.21203/rs.3.rs-8143403/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-01T07:29:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-24T09:27:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T14:39:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-19T14:36:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-11-18T09:01:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"799dc1e3-2b42-4327-964c-f28a3df8424e","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":58371358,"name":"Health sciences/Diseases"},{"id":58371359,"name":"Health sciences/Health care"},{"id":58371360,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-12-01T07:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-21 08:51:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8143403","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8143403","identity":"rs-8143403","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}