{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T16:19:24Z","timestamp":1791389964580,"version":"4.3.3"},"update-to":[{"DOI":"10.12688\/wellcomeopenres.15259.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2019,10,4]],"date-time":"2019-10-04T00:00:00Z","timestamp":1570147200000}}],"reference-count":21,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2019,10,4]],"date-time":"2019-10-04T00:00:00Z","timestamp":1570147200000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["207472"],"award-info":[{"award-number":["207472"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["098481"],"award-info":[{"award-number":["098481"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Queen Elizabeth Diamond Jubilee Trust Fund"}],"content-domain":{"domain":["wellcomeopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Wellcome Open Res"],"abstract":"<ns4:p>\n                    <ns4:bold>Background<\/ns4:bold>\n                    : Traditional eye medicine (TEM) is frequently used to treat 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.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Methods<\/ns4:bold>\n                    : In a mixed method prospective cohort study, we enrolled patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018 and collected information on history, TEM use, microbiology and 3-month outcomes. We conducted qualitative interviews with patients, carers traditional healers on reasons why people use TEM. Outcome measures included presenting vision and at 3-months, comparing TEM Users versus Non-Users. A thematic coding framework was deployed to explore reasons for use of TEM.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Results<\/ns4:bold>\n                    : Out of 313 participants enrolled, 188 reported TEM use. TEM Users had a delayed presentation; median presenting time 18 days versus 14 days, p= 0.005; had larger ulcers 5.6 mm versus 4.3 mm p=0.0005; a worse presenting visual acuity median logarithm of the minimum angle of resolution (Log MAR) 1.5 versus 0.6, p=0.005; and, a worse visual acuity at 3 months median Log MAR 0.6 versus 0.2, p=0.010. In a multivariable logistic regression model, distance from the eye hospital \u00a0and delayed presentation were associated with TEM use. Reasons for TEM use included lack of confidence in conventional medicine, health system breakdown, poverty, fear of the eye hospital, cultural belief in TEM, influence from traditional healers, personal circumstances and ignorance.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Conclusion<\/ns4:bold>\n                    : TEM users had poorer clinical presentation and outcomes. Capacity building of the primary health centres to improve access to eye care and community behavioural change initiatives against TEM use should be encouraged.\n                  <\/ns4:p>","DOI":"10.12688\/wellcomeopenres.15259.2","type":"journal-article","created":{"date-parts":[[2019,10,4]],"date-time":"2019-10-04T10:05:08Z","timestamp":1570183508000},"page":"89","update-policy":"https:\/\/doi.org\/10.12688\/wellcomeopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":13,"title":["Traditional eye medicine use in microbial keratitis in Uganda: a mixed methods study"],"prefix":"10.12688","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1049-3086","authenticated-orcid":false,"given":"Simon","family":"Arunga","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allen","family":"Asiimwe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eunice","family":"Apio Olet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Grace","family":"Kagoro-Rugunda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bosco","family":"Ayebazibwe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Onyango","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Newton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9251-2318","authenticated-orcid":false,"given":"Astrid","family":"Leck","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2371-5709","authenticated-orcid":false,"given":"David","family":"Macleod","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9883-668X","authenticated-orcid":false,"given":"Victor H.","family":"Hu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0583-5272","authenticated-orcid":false,"given":"Janet","family":"Seeley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1872-9169","authenticated-orcid":false,"given":"Matthew J.","family":"Burton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2019,10,4]]},"reference":[{"key":"ref-1","article-title":"Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases E-Book.","author":"J Bennett","year":"2014"},{"key":"ref-2","doi-asserted-by":"publisher","first-page":"622-623","DOI":"10.1136\/bjo.81.8.622","article-title":"Corneal ulceration in the developing world--a silent epidemic.","volume":"81","author":"J 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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.\n<b>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 339-341. Also to note is that SES\/Access\/poverty are all on a similar\/same causal path and do not function independently of each other.<\/b>\n<b>Comment: <\/b>Although the text of the results section states that TEM users had worse presenting acuity than non TEM users, the data in Table 2 appears to contradict this, and I suspect there may be an error in the table.\n<b>Response: We thank the reviewer for spotting this. We noticed that the data had been accidentally interchanged.&nbsp;It has been corrected in table 2.<\/b>\n<b>Comment<\/b>: This study confirms the finding of previous authors who noted that TEM use is 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.\n<b>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.<\/b>\n<b>Comment<\/b>: An unexpected finding is that TEM use in this population was usually independent of 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 &quot;Why has this happened to me?&quot;. This study would seem to indicate that the main motivation for most patients was a simple desire for faster and greater improvement in their symptoms.\n<b>Response: Indeed, this was surprising. Only 3% of the participants visited a traditional healer to obtain TEM. From our further exploration of this in the qualitative studies, our impression is that <i>\u201ceveryone in the community is a traditional healer\u201d<\/i> since the 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.<\/b>\n<b>Comment<\/b>: A less surprising finding is that outcomes were significantly worse for patients using 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.\n<b>Response: We thank the reviewer for acknowledging this new contribution.<\/b>\n<b>Comment<\/b>: One significant weakness in the study is the exclusion of children. In Tanzania we found that 50% of TEM users were aged 11 or younger. I suspect that the findings would be similar in children and adults, but the authors should acknowledge this weakness in the discussion.\n<b>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 3% of all microbial keratitis cases. However, this point has been acknowledged in the limitation. lines 364-365.<\/b>\n<b>Comment<\/b>: The ready availability of TEM in people's homes and gardens means that campaigns to 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.\n<b>Response: We thank the reviewer for this comment.<\/b>","URL":"https:\/\/wellcomeopenresearch.org\/articles\/4-89\/v2#referee-comment-3939","order":2,"name":"referee-comment-3939","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by the Wellcome Trust through a Senior Research Fellowship to MJB [207472 and 098481]. \nSA is supported by a Research Fellowship from the Commonwealth Eye Health Consortium, funded by The Queen Elizabeth Diamond Jubilee Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":3,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}