Ethnobotanical Research of Plants Used in Traditional Medicine for The Treatment of Epilepsy in Southern Mozambique

Background Epilepsy is a chronic brain disease that affects about 50 million people worldwide, mainly in developing countries. It is treated with anticonvulsant drugs, but in some cases, conventional anticonvulsants have not been effective, leading patients to turn to alternative herbal treatments. The study aimed to identify plants used in traditional medicine for the treatment of epilepsy in southern Mozambique, record the parts used, the method of preparation as well as the mode of administration. The study was conducted between April to June 2019. 53 Traditional Medicine Practitioners were interviewed using a semi-structured questionnaire. The data was analyzed by calculating the Percentage of Citation (%FC) and Informant Factor Consensus (IFC). A total of 32 medicinal plants belonging to 18 botanical families were identied for the treatment of epilepsy in the southern part of Mozambique. The species, Hugonia orientalis Engl (22.64%), Maclura africana Bur (16.98%), Strychnos spinosa Lam (13.21%), Terminalia sericea Bruch ex DC (13.21%) and Manilkara mochisia (Bark) Dubard (11.32%) were the most cited. The families Annonaceae and Menispermaceae (4 species) were the most representative in number of species. The root was the most commonly used plant part (54.2%), the frequently used preparation mode was decoction (71%), and administration of the remedies was often by oral route. on these high IFC value of 0.83 (2 species and 7 reported uses). This indicates that there was a consensus in the use of the plants cited for the treatment of these diseases although they showed lower number of plants and reported uses. The category of nervous system diseases, which includes epilepsy showed an IFC of 0.52 (33 species and 68 reported uses).


Introduction
Epilepsy is a chronic non-communicable brain disease that affects about 50 million people worldwide [1]. The disease is characterized by recurrent seizures that may be partial when they involve one part of the body or generalized when they involve the whole body [1].
In Africa, epilepsy is estimated to affect about 80% of the population [1]. In Mozambique, epilepsy is the leading cause of mental health consultations, accounting for 48% of all mental health consultations [2].
Most cases of epilepsy are idiopathic, although in some cases they result from brain injury, stroke, brain tumor, genetic mutations, severe malaria and drug abuse [3].
Epilepsy can be controlled by anticonvulsant drugs such as phenytoin, carbamazepine and phenobarbital [4]. It is estimated that 70% of patients can control their seizures, on the other hand 30% of patients with focal lesions need other ways to ameliorate their seizures [5][6][7]. This fact leads patients to turn to alternative herbal treatments [5].
The World Health Organization estimates that 80% of the world population relies mainly on traditional medicine for primary health care [8]. In Mozambique, about 60% of the population relies on traditional medicine for primary health care [9].
There is growing interest in the use of natural sources as an alternative for developing new anticonvulsant drugs that are more effective than currently available anticonvulsants [10][11][12].
The present study was carried out with the aim of identifying the medicinal plants used in traditional medicine for the treatment of epilepsy, recording the parts used, the method of preparation, as well as the method of administration.

Study area
The study was conducted in the southern part of Mozambique, in the districts of Matutuine and Magude (Maputo Province), Mabalane (Gaza Province) and Funhalouro, Inharrime (Inhambane Province). These provinces were selected taking into account that in the southern part of the country, there is some traditional knowledge for the treatment and prevention of various plant-based diseases, including epilepsy [15]. Therefore, the provinces serve as the main source of medicinal plant collection by many traditional medicine practitioners in the southern part of Mozambique [15].  Fig. 1).

Data collection and plant identi cation
The study was carried out between April to June 2019. A semi-structured questionnaire was developed and administered individually to each Traditional Medicine Practitioner (TMP) according to their local language and with support from a local translator. This questionnaire aimed to obtain sociodemographic information such as age, years of experience, source of knowledge of traditional treatment and the plants used for the treatment of epilepsy.
Plants were mentioned by their vernacular names and the parts used methods of preparation as well as the mode of administration were identi ed.
Plants were collected during eldwork with the help of Traditional Medicine practitioners. Voucher species were deposited in the LMU herbarium at Eduardo Mondlane University, where they were scienti cally identi ed using dichotomous keys and herborized plant samples by comparison. The scienti c names were con rmed in the plant list (www.theplantlist.org). Accessed 27 May 2021.

Socio-demographic information of the interviewees
A total of 53 Traditional Medicine Practitioners (TMP) were interviewed. Of these 43 were female (81.1%) and 10 male (18.9%). In terms of provenance, 14 were from Maputo Province, 29 from Gaza and 10 from Inhambane. Age ranged from 30-84 years, of which 52.8% were between 50-69 years, which corresponded to the majority of the interviewees, followed by those aged 30-49 years (37.7%) and lastly, those aged 70 years or more (7.5%). The majority of the interviewees (81.1%) had 10-20 years of experience as PMT, followed by those who had less than 10 years (13.2%) and 30-40 years (7.5%).
Regarding their training, 69.8% of the practitioners were trained at home by another experienced practitioner (Mbava) a liated to the Traditional Healers Association of Mozambique (THAMO) and 24.5% learned their practices through the manifestations of familiar spirits that showed them the plants through visions or dreams (Table 1).

Traditional perception of epilepsy
Regarding the traditional etiology of epilepsy, most of the TMP (80%) stated that epilepsy is a disease caused by spell (action of evil spirits), on the other hand, some (20%) stated that the disease is caused by "Nhocane" which means snake or worm. This worm lives inside the belly of the child in the area below the navel. There are 2 types, "Nhoca ley tsongo" which means small female snake and "Nhoca ley Kulo" which means male or large snake. The latter is considered to be the main cause of epilepsy in children and adults. This worm comes from the mother's womb, being the place where the child contracts it during gestation. The main clinical manifestations of the disease during an epileptic seizure were: falling down, urinating, rolling eyes, foaming at the mouth, rigidity of the upper and lower limbs, trembling, teeth grinding, stomach pains, headaches and frights.

Plants used to treat epilepsy
A total of 32 medicinal plants belonging to 18 botanical families were identi ed for the treatment of epilepsy in southern Mozambique.  The most representative botanical families in number of species were Annonaceae and Menispermaceae with 4 species followed by Fabaceae and Loganiaceae with 3 species. The other families were represented by 1 or 2 species (shown in Fig. 2).
Most plants used for epilepsy treatment were shrubs (46.9%), followed by trees (28.1%), climbers (15.6%) and herbs (9.4%). The remedies are mainly administered orally. Apart from this mode, external administration of the remedies was also mentioned in the form of bath (2 species) and body massage (1 species) ( Table 2).
With regard to other reported uses, Terminalia sericea was the only species referred for treatment of various diseases such as epilepsy, diarrhea, bilharzia, colic and hemorrhoids.

Plant parts used, methods of preparation and level of Informant Factor Consensus (IFC)
The plant parts used by TMP for the treatment of epilepsy were the roots (54.2%), leaves (37.3%), bark (3.4%), branches and fruit (1.7%) shown in Fig. 3.
The Table 3 contains the informant factor consensus values (IFC) for different categories of diseases. Diseases of the digestive system (diarrhea, worms) showed a high IFC value of 0.83 (2 species and 7 reported uses). This indicates that there was a consensus in the use of the plants cited for the treatment of these diseases although they showed lower number of plants and reported uses. The category of nervous system diseases, which includes epilepsy showed an IFC of 0.52 (33 species and 68 reported uses).

Discussion
In the present study, most of the TMP interviewed were female (81.1%) compared to male (18.9%). This is due to the fact that women are responsible for the primary health care of their families, particularly children [19]. Most of the TMP were aged between 50-69 years. Generally older people use more traditional remedies than young people and this traditional knowledge tends to disappear in the young layer [20]. This fact may be coupled with lack of interest in traditional practices, on the part of young people.
Traditional perceptions regarding the etiology of epilepsy are common in different regions of Africa. For example, in Tanzania, Congo and Guinea-Bissau most traditional doctors also believed that epilepsy is caused by witchcraft [21][22][23]. Therefore, health programs should be developed in rural communities to clarify the causes of epilepsy in order to reduce or eliminate the existing myths and taboos surrounding the disease.
The families Annonaceae and Menispermaceae were most representative in number of species (4 species). According to Auditeau et al [24], species belonging to these families are characterized for presenting anticonvulsant properties. In Mozambique Hugonia orientalis is commonly used in traditional medicine for the treatment of Malaria, diarrhea and wounds [25,29]. Maclura africana is used in traditional medicine for treatment of respiratory diseases and helminthiasis [25,30]. Strychnos spinosa is used for the treatment of helminthiasis, venereal diseases, hernia, snake bite, earache [25,31]. In Madagascar it is used as anti-dandruff, and anti-u [27].
Dichloromethane extracts of Strychnos spinosa leaves possess e cient anti-plasmodial and anti-trypanosomal activity [28,32]. Terminalia sericea is commonly used in Mozambique for treatment of, dysentery, helminthiasis, hemorrhoids, colic and female infertility [9,25,31]. In South Africa it is often used to treat diarrhea [26]. Terminalia sericea also exhibits e cient anti-oxidant activity, activity and anti-HIV-through inhibition of the enzyme alphaglucosidase [33][34]. Extracts of Terminalia sericea root possess e cient anti-mycobacterial activity due to the presence of ellagitannins, ellagic acid and stilbene glycoside [35].

Parts of the plant used, method of preparation, administration and Informant Factor consensus (IFC)
The root (54.2%) was the part of the plant most used for the treatment of epilepsy in southern Mozambique. Similarly, in Tanzania, roots are frequently used for the treatment of epilepsy [22]. The wide use of the roots by practitioners of traditional medicine is based on the perception that the therapeutic power is most concentrated in this part of the plant [36].
The commonly used mode of preparation is decoction (71%). Moshi et al [22] reported that decoction is also frequently used for treatment of epilepsy in Tanzania. This is because it is believed that active ingredients are easily extracted by boiling the plants, coupled with this, traditional medicine practitioners do not have much conventional knowledge about the ways of extracting active ingredients in plants [37].
The administration of the remedies was mainly by oral route. The preference of the method by traditional medicine practitioners may be due to the fact that the remedy administered orally is easily absorbed by the body [36]. Apart from oral administration, administration by means of bath and massage has been mentioned. This method is also common in India, where the administration of the remedies is through baths [38]. This method is usually coupled with traditional beliefs for the removal of evil spirits and puri cation of the body.
With respect to Informant Factor consensus (IFC), the highest level of consensus was observed in the category of digestive system diseases (diarrhea, roundworms) (0.83), despite the category containing the lowest number of species and reported uses. Similar results have been reported in several studies where the highest level of IFC was observed in the category with the lowest number of species and reported uses [17,29,39]. The category of nervous system disorders, which includes epilepsy showed an IFC of 0.52. This reinforces the fact that different types of plants were cited by traditional medicine practitioners for the treatment of epilepsy [29].

Anticonvulsant activity
Of the plants used for treatment of epilepsy in southern Mozambique, only two (2) species, namely: Annona senegalensis Pers and Senna occidentalis (L) Link, showed anticonvulsant activity [40][41][42][43][44][45]. No published studies on the anticonvulsant activity of the remaining species were found (Table 4). The stem bark and root extracts of Annona senegalensis are e cient in inhibiting Pentylenetetrazole (PTZ)-induced seizures [40,41]. Likewise the methanol extracts and methanol fraction of Annona senegalensis leaves caused signi cantly (p < 0.05) inhibition of Pentylenetetrazole-induced seizures [44]. The anticonvulsant activity of this plant may be due to the presence of kaurenoic acids, speci cally the compound kaur-16-en-19-oic acid isolated from the root bark, as it showed e cient anticonvulsant activity by delaying the onset of myoclonic spasms and tonic-clonic phases of PTZ-induced seizures and maximal electroshock seizures [42].
The ethanoic extract of Senna occidentalis seeds at a dose of 400mg/kg body weight possesses potent anticonvulsant activity [45]. These ndings reveal that these plants may be promising for the development of new antiepileptic drugs, although they are not among the most commonly cited plants for the treatment of epilepsy in southern Mozambique.