Traditional eye medicine use in microbial keratitis in Uganda(cid:403) a mixed methods study (cid:446)version (cid:697)(cid:402) peer

(cid:403) Traditional eye medicine (cid:442)TEM(cid:443) is frequently used to treat Background microbial keratitis (cid:442)MK(cid:443) in many parts of Africa(cid:404) Few reports have suggested that this is associated with a worse outcome(cid:404) We undertook this large prospective study to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment in Uganda(cid:404) (cid:403) In a mixed method prospective cohort study(cid:401) we enrolled Methods patients presenting with MK at the two main eye units in Southern Uganda between December (cid:697)(cid:695)(cid:696)(cid:701) and March (cid:697)(cid:695)(cid:696)(cid:703) and collected information on history(cid:401) TEM use(cid:401) microbiology and (cid:698)(cid:406)month outcomes(cid:404) We conducted qualitative interviews with patients(cid:401) carers traditional healers on reasons why people use TEM(cid:404) Outcome measures included presenting vision and at (cid:698)(cid:406)months(cid:401) comparing TEM Users versus Non(cid:406)Users(cid:404) A thematic coding framework was deployed to explore reasons for use of TEM(cid:404) (cid:403) Out of (cid:698)(cid:696)(cid:698) participants enrolled(cid:401) (cid:696)(cid:703)(cid:703) reported TEM use(cid:404) TEM Results Users had a delayed presentation(cid:402) median presenting time (cid:696)(cid:703) days versus (cid:696)(cid:699) included lack of confidence in conventional medicine(cid:401) health system breakdown(cid:401) poverty(cid:401) fear of the eye hospital(cid:401) cultural belief in TEM(cid:401) influence from traditional healers(cid:401) personal circumstances and ignorance(cid:404) (cid:403) TEM users had poorer clinical presentation and outcomes(cid:404) Conclusion Capacity building of the primary health centres to improve access to eye care and community behavioural change initiatives against TEM use should be encouraged(cid:404) TEM, Role of Traditional Healers, personal circumstances and Ignorance.


Abstract
Traditional eye medicine TEM is frequently used to treat Background microbial keratitis MK in many parts of Africa Few reports have suggested that this is associated with a worse outcome We undertook this large prospective study to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment in Uganda In a mixed method prospective cohort study we enrolled Methods patients presenting with MK at the two main eye units in Southern Uganda between December and March and collected information on history TEM use microbiology and month outcomes We conducted qualitative interviews with patients carers traditional healers on reasons why people use TEM Outcome measures included presenting vision and at months comparing TEM Users versus Non Users A thematic coding framework was deployed to explore reasons for use of TEM

Introduction
Microbial keratitis (MK) frequently leads to sight-loss from dense corneal scarring, or even loss of the eye, especially when the infection is severe and/or appropriate treatment is delayed 1 . MK has been described as a "silent epidemic", which leads to substantial morbidity, related to blindness and other consequences such as pain and stigma 2 . It is the leading cause of unilateral blindness after cataract in tropical regions and is responsible for about 2 million cases of monocular blindness per year 3 .
In Low and Middle-Income Countries (LMIC), use of Traditional Eye Medicine (TEM) for treatment of many eye conditions is a common practise 4-6 . In the few reported studies, TEM has been found to lead to complications such as corneal scarring and delayed presentation of patients to hospital resulting in poor outcomes 7,8 .
Literature on TEM use for MK is scanty. However, among the three papers from Sub-Saharan Africa (SSA), TEM use among patients with MK was reported to be associated with a severe presentation. These studies did not report clinical outcomes 9-11 . In addition, since most of the TEM involves plant products such as fresh leaves, it could have a major role in the pathogenesis of fungal keratitis, which has been associated with injuries involving vegetative matter 12,13 . Our experience in Uganda is that TEM is widely used to treat a number of eye conditions including MK. However, the drivers of this practice are not well understood.
The aim of this study therefore was to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment of MK in Uganda.

Ethical statement
This study adhered to the Declaration of Helsinki . Written informed consent in Runyankore, the local language, was obtained before enrolment. If the patient was unable to read, the information was read to them, and they were asked to indicate their consent by application of their thumbprint. The collected source data is stored in a secure database at Mbarara University of Science and Technology. An anonymised digital version was also uploaded in a secure server. The data will be kept for 7 years according to institutional policy.

Participants
Due to the cultural complexity of TEM usage, we used a mixed methods approach. We prospectively enrolled patients with MK that consecutively presented to two tertiary eye hospitals in South-Western Uganda from December 2016 to March 2018. The case deinition of MK was the presence of a corneal epithelial defect (of at least 1mm diameter) with an underlying stromal iniltrate, associated with signs of inlammation (conjunctival hyperaemia, anterior chamber inlammatory cells, +/-hypopyon). We excluded those not willing to participate, those not willing to return for follow-up, pregnant women, lactating mothers, those aged below 18 years.

Quantitative assessment
We documented basic demographic information and ophthalmic history using ophthalmic nurses as part of the routine hospital work up. This included treatment received including prior use of TEM. For those who reported use of TEM, a detailed structured history was taken on what they had applied, source of the medicines, cost, how it was prepared, duration of use and any complications experienced. A detailed description of the cases evaluation has been previously presented. In summary, after measurement of the presenting visual acuity (Logarithm of Minimum Angle of Resolution), cases underwent a detailed clinical examination on a slit lamp using a structured protocol, including eyelid assessment, corneal ulcer features, anterior chamber (lare, cells, hypopyon shape and size) and perforation status. Corneal scrapes were collected for microscopy, culture (blood agar, chocolate agar, potato dextrose agar) and molecular diagnosis. HIV, Diabetes counselling and testing were offered, as per the Uganda Ministry of Health HIV testing protocol. Cases were treated according to the hospital protocol, which usually involved a brief admission for the irst few days. The study follow-up assessment schedule was days 2, 7, 21 and 90, to determine outcome. Patients were asked to return to the eye hospital for these reviews where their follow up data was collected as before. Additional assessments were conducted as clinically indicated. The primary outcome measure was inal best corrected vision at 3 months. See extended data 14 for questionnaire used.

Qualitative assessment
All interviews and discussion groups were conducted by AA. They were audio recorded and summarised. Additional contextual information provided such as patient emotions, environment and any other aspect the interviewer found noteworthy.
Firstly, at presentation, patients who reported to have used TEM were asked if they would be willing to discuss their experiences. For such patients, an interviewer would return later that evening or the next day when the patient was more relaxed. Interviews were conducted in the local language by a social

Amendments from Version 1
In this revised version, we have addressed all the reviewer comments in a point by point format. The main differences are: On lines 339-341, we have added a comment on why economic status was not significant in the multivariate analysis. Table 2 had been interchanged to show that TEM users had better presenting acuity than non TEM users, this has been corrected to show that TEM users had a worse vision.

Data in
On lines 364-365, we have acknowledged a limitation in not being able to enroll children and provided an explanation for this.
On Lines Line 48-55, we have provided a description on clinical examination and microbiological methods for the patients.
Typos in the abstract and in line 291 have been corrected.
Any further responses from the reviewers can be found at the end of the article REVISED scientist either at the hospital bedside (when quiet) or in the hospital compound depending on the patient's preference. The focus of the interview was to explore reasons why they had used TEM.
Secondly, we conducted informal group discussions (IGDs) with a sample of the MK patients involved in the study and relatives of people with MK on the practise and reasons why people use TEM. This was an opportunistic approach to allow lexible data collection. For example, a patient might present escorted by many family members and friends (common in this setting), such a group would then be invited to discuss issues around TEM. Such a naturally composed group was to result in a more relaxed discussion than a group of people who did not know each other who are brought together solely for the discussion.
Finally, we conducted in-depth interviews with traditional healers to learn about what they would usually do for people presenting with a problem like MK and why people go to them for treatment. Healers were identiied from a traditional healers' registry at the local council headquarters. A random sample of 15 traditional healers were contacted through their coordinator. Those willing to share their knowledge and practise in treating eye problems particularly MK were visited and interviewed at their home or shrine.
For all the groups, topic guides were developed using available literature and experiences of the local ophthalmologists treating patients with MK (see extended data 14 ). They included local understanding of MK, causes, treatment and experiences of using TEM. The guides were piloted among a few patients and modiied accordingly. The inal version was approved by all the authors who included senior social scientists (AA) and a professor (JS). In this report, our focus is on reasons why people use/do not use TEM. These were reviewed by one of the authors. They were then piloted among MK patients and revised accordingly. All interviews lasted about 30-45 minutes.

Analysis
Quantitative data were analysed using STATA v14. We compared demographic data, baseline clinical presentation and inal vision outcomes at 3-months of patients who reported to have used TEM versus those who had not. Appropriate tests of signiicance (chi2 for categorical data and Wilcoxon rank sum for continuous data) were employed. Multivariable logistic regression analysis was used to identify factors associated with TEM use. Initially, univariable regression was performed to generate crude odds ratios (OR). Variables with a p-value less than 0.1 were introduced in the multivariable model. A back stepwise approach was then used, until only the variables with a p-value of less than 0.05 were retained. Adjusted OR were reported for the inal model. Summary tables of proportions were constructed to describe the source, cost, complications and duration of use of TM.
For the qualitative data, all interviews were recorded with an audio recorder (Olympus WS-853 Digital Stereo Voice Recorder) and transcribed into summaries. These were independently reviewed several times by two of the authors (SA and JS). A coding framework was developed, and data were then manually coded. Emerging themes around reasons why people used/did not use TEM are presented. Speciic conversation response clips from the respondents that supported the generated themes were extracted from the audio recordings and used as illustrative statements.

Results
We enrolled 313 people with MK, of whom 188 (60%) reported TEM use ("TEM Users") and 125 said they did not use TEM ("TEM Non-Users"). The demographic characteristics of both groups are shown in Table 1 (see underlying data 14 ). There were some differences between TEM Users and Non-Users. TEM Users lived further from the eye unit, were more frequently farmers, were less likely to be married and had progressed less in formal education.
The clinical characteristics of both groups are shown in Table 2. There was evidence that the condition of TEM Users was worse than TEM Non-Users at presentation. The TEM Users presented later, had larger corneal ulcers (both iniltrate and epithelial defect), more frequent hypopyons and poorer vision.
We modelled factors associated with TEM use (Table 3). After adjusting for potential confounders, distance from the eye hospital and delayed presentation were associated with TEM use. Whereas, there was less TEM use among those who were married, had a history of trauma and a high education level.
At 3-months, 260 patients completed their follow-up. There was no systematic baseline difference between patients who were seen at 3-months and those that were not. The inal LogMAR visual acuity was worse among TEM Users, median 0.6 (IQR 0-2.5), compared to TEM Non-Users, 0.2 (IQR 0-1.5), p=0.010.
Among the 188 patients who reported TEM use, 137 (73%) used TEM after they had been to a government health facility (secondary TEM use). TEM was mostly made from fresh leaves [154, (82%)]; the commonest preparation method was to freshly squeeze them [145, (77%)]. Most patients obtained TEM either from their home garden (40%) or from a neighbour (54%), only 5 patients (3%) obtained TEM from a traditional healer. TEM was generally free, 169 (90%) reported not to have spent any money to obtain it.
The qualitative study involved a total of 38 participants: 11 traditional healers, 21 MK patients who had used TEM and 6 MK patients who had not used TEM. The baseline characteristics of these individuals are presented in Table 4. Overall, it was a mix of male and female, young and old, not educated and highly educated. In addition, three informal group discussions (IGDs) were conducted, each with around 15 participants (these were naturally composed groups of patients who had used or not used TEM, relatives and friends).
The major factors coming out as the reasons for using TEM included lack of consumer conidence in conventional medicine, health system breakdown, poverty, fear, cultural belief in  Log MAR: Logarithm of the minimum angle of resolution.
*These were calculated as the geometrical means using the MUTT protocol 15 . The upper limits exceeded normal corneal diameter for some lesions, which extended up to the sclera. Raised slough was when the corneal infiltrate profile was raised, flat slough was when the profile was flat while no slough is when there was no debris noted. The difference in presenting vision and infiltrate sizes remained significant even after adjusting for delayed presentation. Lack of awareness to the dangers of TEM Interestingly, most participants did not think using TEM could be dangerous. "Traditional eye medicine doesn't damage the eye, it just rinses or cleanses it" (a 46-year old male charcoal burner). "There are no risks of using traditional eye medicine because when one fails to get healed, she or he goes somewhere else or to hospitals" (an 85-year female farmer). In addition, some thought it was better than conventional medicine and did not have any side effects like most conventional medicines. A 59-year old traditional healer said, "Our herbal medicine is fresh not preserved."

Discussion
This study investigated the extent of TEM use by people with microbial keratitis, and how this impacts their clinical presentation and outcome. We went on to explore more deeply the speciic practices and the reasons and beliefs behind using TEM. The use of TEM in Southern Uganda in the treatment of MK is common (60%), and more frequent than that previously reported from Malawi (34%) and Tanzania (25%) 9,10 . Importantly, we found that people who used TEM presented later with a more severe clinical picture and they ended up with worse inal visual acuity outcomes at 3-months, compared to those who had not used TEM.
Our indings are similar to previous reports from Malawi, which found that patients who had used TEM presented later than those who had not used TEM 9,16 . The previous studies, however, did not examine inal outcomes, after the infection had been treated. MK is a disease where prompt treatment is critical if one is to improve the likelihood of a good outcome. We know from prior literature that once an infection is advanced, treatment does relatively little to change its course 17 . The clear conclusion from earlier studies from South Asia and East Africa is that effective treatment of MK should be started as early as possible to save the eye and achieve the best possible outcomes 18,19 .
In this study we combined both quantitative modelling approaches and complementary qualitative approaches to investigate not only "what" but also "why" people use TEM. In the explanatory multivariable model, increasing distance to the eye hospital, lower education level, an onset not linked to trauma and not being married were associated with TEM use. These were explored further in the informal group discussions (IGDs). These discussions the major reported reasons for using TEM were around consumer conidence in the health system, access, poverty and cultural inluence.
Importantly, we found that most people who used TEM did so after irst visiting a government health facility. This is consistent with the IGDs, in which people felt that conventional medicine was not helping, leading them to resort to alternative approaches. This conclusion could be a result of inappropriate treatment. However, even with appropriate treatment, the clinical response can be slow, especially for fungal keratitis. Patients need to be properly counselled to manage expectations. Another important aspect is good pain management on top of the anti-microbial treatment. Patients reported that desperation due to pain made them more likely to try many options to ind relief. This initial early contact point with the formal health system represents an opportunity to improve the diagnosis and treatment of people with MK, through providing enhanced training, diagnostic tools and medication in the primary care setting.
Lack of appropriate ophthalmic medicines is a major challenge. For example, the best current evidence indicates that topical natamycin is the treatment of choice for ilamentous fungal keratitis 20 . However, this is currently not readily available in the main ophthalmic units Uganda or elsewhere in SSA. It is certainly not available in more isolated locations. Therefore, patients with a fungal MK will not access effective treatment until they arrive in a major eye unit. Natamycin was added to the WHO Essential Medicines List in 2018, which will hopefully result in greater availability soon.
Limited access to eye care was a major driver of TEM use. This was evident in the regression modelling, with increasing TEM use with increasing distance to the eye hospitals. The majority of TEM users came from districts relatively far away where no eye care facilities were situated. This was a strong and frequently articulated theme in the interviews and discussions. Multiple people commented on the lack of eye health services in the nearby health facilities, the long distances to the eye hospital and poverty is a major barrier to access (because of the high transport and other direct costs). Several people also highlighted that government health centres near to them have no eye specialists or treatment and do not treat eye conditions. Pharmacies simply sell available eye drop medication, with no examination; frequently these are steroid and antibiotic combinations which may result in more harm than good in fungal keratitis. Unfortunately, Uganda still grapples with a severe shortage of human resources and infrastructure for eye health 21 .
Although the regression model did not demonstrate a relationship between economic status and TEM Use, during the IGDs poverty was reported to be a major driver for using TEM. In the model, there were only a handful of people in the upper economic status which may have obscured this relationship. The majority of the patients were subsistence farmers and therefore not able to readily afford the cost of medicines and transportation. In contrast, TEM could be accessed closer to home at almost no cost. Most of the patients used got the TEM from their nearby gardens or from the neighbour and applied it freshly squeezed into the eye. People who are married may have access to greater household inancial resources, possibly explaining why being married was associated with less TEM use.
We found that TEM use was linked to strong cultural beliefs and this seemed related to the level of education. In the model, people with no or little education were more likely to use TEM. It was worrying that people did not perceive TEM use as potentially dangerous. This was also reinforced by messages from traditional healers and older members of the community who carry a high level of respect. Public health orientated messaging and health education need to particularly focus on and work with these groups. There is some evidence from Malawi and Nigeria, where ophthalmologists worked with traditional healers to lower the use of TEM, that changes are possible 7,16 . Although, in our context, only 3% of TEM users consulted a traditional healer, their place in society cannot be underestimated and it would be in our best interest to bring them on board.

Strengths/limitations
The use of a mixed methods approach provided a more informative data on reasons for using TEM for MK in Uganda. To the best of our knowledge, this was the irst study in SSA that looked at 3-month outcomes of people who had used TEM for treatment of MK. Although a sensitive topic, it was noted that participants and traditional healers were willing to talk about their TEM experiences. We did not have any evidence that people withheld information. The large numbers were enough to have a well powered study to explore factors associated with TEM use. Inclusion of children would have provided a more overall understanding of this topic, however, this was not practical in out setting.

Conclusion
TEM use is an important factor in the presentation and outcome of MK in Uganda, leading to delayed presentation to hospital, a poor presentation and a worse outcome. Cultural beliefs, access to the health system (due to poverty and long distances) and inherent challenges in the primary health centres (lack of knowledge, medicines, equipment and supplies) are major drivers of TEM use. Sensitisation of the people and capacity building in the primary health centres will be a step in the right direction to mitigate these effects.

If applicable is the statistical analysis and its interpretation appropriate Yes
Are all the source data underlying the results available to ensure full reproducibility Yes The authors conclude that TEM is more likely to be used if patients have less access to Comment effective eye care facilities Although poverty was cited by many participants as a driver for TEM use it was not significant in the multivariate analysis This may be explained by the paucity of higher SES patients in both groups I think it is likely that poverty does contribute to TEM use alongside the other factors Response We agree with the reviewer that poverty does contribute to TEM use and was indeed reported by many participants In the multivariable model there were only a handful of people in the upper economic status which may have obscured this relationship We have added this comment in lines Also to note is that SES Access poverty are all on a similar same causal path and do not function independently of each other Although the text of the results section states that TEM users had worse presenting Comment acuity than non TEM users the data in Table appears to contradict this and I suspect there may be an error in the table Response We thank the reviewer for spotting this We noticed that the data had been accidentally interchanged It has been corrected in table This study confirms the finding of previous authors who noted that TEM use is Comment associated with a greater risk of hypopyon The underlying assumption of this article is that all patients had microbial keratitis prior to TEM use However it is possible that some may have had self limiting or minor conditions such as a corneal abrasion or conjunctivitis The introduction of unsterile preparations on to a compromised ocular surface may have led to de novo development of microbial keratitis Response We agree with the reviewer and feel the same way However there was no way of objectively ascertaining this fact We intend to explore this in our future studies An unexpected finding is that TEM use in this population was usually independent of Comment traditional healers I have always assumed that TEM use is partly driven by a desire for answers that western medicine is not good at providing particularly Why has this happened to me This study would seem to indicate that the main motivation for most patients was a simple desire for study would seem to indicate that the main motivation for most patients was a simple desire for faster and greater improvement in their symptoms Response Indeed this was surprising Only of the participants visited a traditional healer to obtain TEM From our further exploration of this in the qualitative studies our impression is that since the everyone in the community is a traditional healer knowledge of the herbs is common among the community members However this does not negate the role of the healers since they are strong advocates for TEM use A less surprising finding is that outcomes were significantly worse for patients using Comment TEM Previous studies have not been able to obtain outcome data as it can be difficult for these patients to return for review It is valuable to have clear evidence that TEM use is harmful Response We thank the reviewer for acknowledging this new contribution One significant weakness in the study is the exclusion of children In Tanzania we Comment found that of TEM users were aged or younger I suspect that the findings would be similar in children and adults but the authors should acknowledge this weakness in the discussion Response We thank the author for this comment Although we provided care for children who presented with Microbial Keratitis the design of our study enrolled only adults due to pragmatic reasons such as being able to test people for HIV subjecting children under general anaesthesia for corneal scrapping and ethical approvals for a vulnerable group In addition we found out during the pilot phase that microbial keratitis was not very common among children in our setting accounting for only about of all microbial keratitis cases However this point has been acknowledged in the limitation lines The ready availability of TEM in people s homes and gardens means that campaigns to Comment reduce the use of TEM are unlikely to be successful Prevention of blindness programmes would be better to focus on improving the delivery of eyecare and raising the quality of the care delivered Anecdotally I can report that TEM use was widespread in a poor part of rural Tanzania but almost non existent in the relatively developed Central Province of Kenya My experience would appear to support the authors conclusion that improving rural eye care will lead to a decline in the harms caused by TEM Response We thank the reviewer for this comment Methods Clinical examination and microbiological methods are not described at all A Comment description would allow better understanding of how the data was collected Response We thank the reviewer for this comment The detailed assessment of the patients has been described in a different report under review however we have revised the manuscript and summarised patient assessment Line Analysis Page results last but one line The word farmer is spelt wrongly with one Comment r missing

Response We thank the author for spotting this It has been corrected Line
There is no data on what type of organisms were involved in the microbial keratitis in Comment the two study groups If microbiology was done as is claimed in methods there should be results of the same Similarly how were the patients treated in the control group that did not receive traditional eye medicine These are important determinants of the outcome in the two groups that have been compared My comments of partly satisfied are related to these issues Response We would like to draw the attention of the reviewer to the last section of table which summarises the types of organisms in the two groups Although the proportion of fungal keratitis was more common among the people who had used TEM the evidence of this difference was weak We agree with the reviewer that treatment for people with keratitis should consider the history of use of TEM since that could influence the organisms involved especially in the absence of a good microbiology support However treatment of the participants in our study was dependant on the microbiological findings Discussion Para line if one is improve the likelihood of a good outcome This Comment sentence is incorrect with a missing word to Response We thank the author for spotting this It has been corrected Line n a Competing Interests