Collaborating with Traditional Eye Medicine Practioners in South Western Nigeria: Towards Universal Eye Health of Community Medicine Health Education

Aim: To determine the magnitude of traditional eye medicine practitioners and the eye conditions they treat in a local community and proffer a form of continuous education to improve on their practices. Study Design : A prospective cross sectional study. Methodology: Traditional medical practitioners from 2 randomly selected local government areas [LGA] in Ogun State were invited for a one day seminar on primary eye care at the Babcock University Teaching Hospital, Ilishan -Remo. Ogun State in April 2013. Each respondent filled out an assistant administered questionnaire after a written consent. Results: Fifty six respondents took part in the study with 61% females. Age range was 28-73 years with a mean of 50.49 ± 11.24 years. 96.4% had at least primary education. Only 14.3% indicated that they treat eye conditions [TH] while 32.1% did not indicate if they treated or did not treat eye conditions. Eye conditions treated were red eyes, eye discharges and cataract. Medications used were mainly plant extracts, breast milk, urine mixture and other native mixtures. 25% gave their medications by direct instillation into the eyes while 62.5% was by direct instillation and incantation. Seventy five percent of the respondents that indicated treating eye conditions learnt the procedure from their 'masters' and 50% of them presently have trainees. 32.1% of the respondents declined answering our questionnaires but indicated interest in learning more about primary eye care. Conclusion: Reaching out to the traditional eye care practitioners is an essential tool towards achieving universal eye care in Nigeria.


Introduction
The Global Action Plan [GAP] 2014-2019, which was approved at the 66th World Health Assembly in May 2013 builds upon and replaces VISION 2020 and 2009-2013 Action Plans towards achieving Universal Eye Health [1]. It was noted that 285 million people are visually impaired worldwide, with 80% of these being of avoidable causes and 90% of this population are living in developing countries [2] like Nigeria. GAP is thus committed to reducing avoidable blindness and visual impairment by 25% by the year 2019 [1]. The poor structure of most African and especially the Nigerian Primary Eye Care System and the huge confidence clients in rural communities place on traditional healers makes it imperative for the existing orthodox eye care system to find a means of integrating Traditional healers into primary eye care in Nigeria. In certain African communities patronage of traditional healers [TH] is up to 80% of the population even though most of these practices lack evidence based science on its efficacy and safety [3]. This high patronage has been attributed to the simplicity, accessibility, mystical concept of practice and the fact that the TH reside within the community [3]. Some clients also believe that TM conserves a part of the African culture [4] and must be patronized. Some countries like China and India have actually integrated traditional medicine[TM] and orthodox health practices. In these countries, TM is generally accepted and regulated as an alternative medical therapy which generates a huge income [5] due to its high patronage. Another form of integration is also practiced in countries like Nepal where trained TH work in public health departments and are involved in health promotions to the community under the supervision of orthodox eye care givers [6].
In Nigeria, there are no population based estimates of traditional eye medicine [TEM] use or data comparing the frequency of good versus poor outcome. Most studies are hospital based, where the complications of the TM use/traditional practice are seen [7,8]. The National blindness survey carried out between 2005-2007 in Nigeria revealed that 46.1% of cataract surgeries documented during the survey were by couching which is usually carried out by the TH [8]. TEM was also implicated in 26.7% of non-trachomatous cornea scarring documented during the survey [8].
As we approach year 2020, prevention of avoidable/unnecessary complications of traditional eye medication/practices should be a strong advocacy point. The proper training of TEM practitioners in

Journal of Community Medicine & Health Education
basic eye anatomy and primary eye care is very important in achieving GAP, as the TH are usually the first point of contact before clients visit the orthodox eye centres. A tertiary eye hospital in Eastern Nigeria documented that 13.2% of patients seen over a 4 months period had used TEM before presentation [9]. This medications were usually plant extracts [9,10] which produce common complications like cornea opacities, glaucoma, optic atrophy, bullous keratopathy, uveitis, cataract, corneal ulcers etc. [7,10]. With just a few years to year 2020, it is hoped that a better understanding of the traditional eye care practice in Ogun State would stir up more awareness of these practices in Nigeria with the aim of preventing harmful TEM practices and reducing the avoidable blindness caused by its complications so as to achieve appropriate universal eye care in Nigeria by year 2020.

Aim
To determine the magnitude of traditional eye medicine practitioners in a local population.
To determine the common eye condition treated by the practitioners To proffer a regular form of continuous primary eye care education to prevent unnecessary treatment complications noticed within the community.

Study design
Cross sectional study

Methodology
Traditional medical practitioners/birth attendants from 2 randomly selected local government areas [LGA] in Ogun State[Ijebu-Ode and Ikenne LGA] were located and invited for a one day seminar on Evaluation of their common practises in conjunction with the obstetrics, paediatric surgery unit and public health department at the Babcock university Teaching Hospital, Ilishan -Remo. Ogun State in April 2013. Questionnaires were administered by an assistant after signing a written consent. Data was collected in line with Helsinki's declaration and analysed using SPSS version 15

Results
Fifty six respondents took part in the study with 61% being females. The mean age in years [yrs] of respondents was 50.49 ± 11.24 [Range: 28-73 yrs] [ Table 1]. Fifty seven percent of the respondents were Christians, 30% were Muslims while 13% were traditional worshippers. Secondary education was completed by 53.6% of the respondents, 26.8% had primary education, 16% had undergone tertiary education while only 3.6% had no form of formal education [ Table 2].Only 14.3% indicated that they treat eye conditions in their clinics/ traditional homes [TH] while 32.1% did not indicate if they treated or did not treat eye conditions [ Table 3]. Eye conditions indicated as being treated were red eyes, eye discharges, cataract and other types of loss of vision and the age group treated ranged from new born babies to the aged. The content of the medications used ranged from plant extracts, breast milk, urine mixture and other native mixtures which were not disclosed. Twenty five percent of those treating eye conditions gave their medications by direct instillation into the eyes, 12.5% was by incantations only while 62.5% was by a combination of both.    Seventy five percent of the respondents that indicated treating eye conditions said they learnt the procedure from their 'masters' and 50% of them presently have trainees whom they are training in eye care despite no basic anatomic or physiological understanding of the eye. All the respondents that indicated treating eye conditions said they have encountered some complications of their treatment and usually refer their clients to the nearest secondary or tertiary eye centre. All the respondents indicated interest in learning more about primary eye care even though 32.1% of the respondents declined completing the vital aspects of our questionnaires

Discussion
Over 80% of the respondents were noted to have undergone at least primary education with a few more having a postgraduate degree. This shows a high degree of literacy amongst the respondents. Eighty seven percent of the respondents were also noted to belong to the two main religious faiths in Nigeria and not necessarily traditional worshippers as would have been expected.
Only 14.3% of the respondents indicated that they treat eye conditions in their clinics while 32.1% declined to indicate if they treated eye conditions or not. This latter group may have been silent because as documented in previous studies they believe their art is by "divine instructions" not to be exposed [3]. None of the respondents had any formal training on the basic anatomy or physiology of the eye as 75% of those that indicated treating eye conditions said they learnt it from their "masters" and 50% of them already had trainees they are teaching similar practices whether right or wrong. As expected, the respondents made no specific diagnosis before treatment and could only indicate treating red eyes, discharging eye, cataract and poor vision. All the respondents indicated having encountered treatment complications which necessitated referrals of the client to the nearest general hospital for further management. Previous studies have documented high incidence of complications from TEM [9,10]. The National blindness survey also documented that TEM was implicated in 26.7% of the non trachomatous cornea scarring in Nigeria [8], it was also noted that Couching by TH accounted for 46.1% of all the cataract surgeries documented during the survey and this was associated with very poor vision [8].
Traditional healing practices is said to reflect the cultural beliefs of a society [11], and it would therefore require effective communication between the orthodox health care professional and the community to bring about a positive change of attitude towards TH [12] due to language barrier, difference in level of education and different priorities in life. In year 2007, a survey of 101 Nigerian ophthalmologists (41 consultants, 6 diplomates, 54 residents) revealed that 57.6% were against collaboration with TEM practitioners but the authors recommended regulation and monitoring of the TEM practitioners to discourage their harmful practises like couching of the lens13 but this is yet to take effect after seven years.
As far back as year 2000, Courtright et al. [13] also noted that collaboration with the TEM Practitioners will reduce blindness in the rural areas because the TEMP could bridge the gap between the community and the district eye care providers. They also noted that this collaboration would enable discovery of their harmful practises and induce change. They further noted that criticizing them would not make them disappear or cease treating eye diseases [14]. Furthermore for GAP to be effective in any country, it has to be initiated by the countries government and implemented at all levels of health care [1].
As Nigeria joins the world this year to celebrate World sight day with the theme 'No more avoidable blindness', if we only concentrate on uncorrected refractive errors, cataract, glaucoma, diabetic retinopathy, onchocerciasis, macular degeneration and retinopathy of prematurity without considering and taking action on the damaged caused by traditional eye care practitioners, it would be difficult to achieve the GLOBAL ACTION PLAN by 2019.

Conclusion
With just five years for the global action plan, Nigeria needs to embrace and promote the training of traditional eye medicine practitioners so as to discourage harmful practices that can increase the prevalence of blindness.

Recommendations
Following the conclusion of this study and the interest of all the participants to undergo basic training in primary eye care, an annual training programme was adopted and it is hoped that similar programmes can be adopted nationwide as we pursue the global action plan.