Journal of Ethnopharmacology 154 (2014) 767–773

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Ethno-medicinal knowledge and plants traditionally used to treat anemia in Tanzania: A cross sectional survey Emanuel L. Peter a,d,n, Susan F. Rumisha b, Kijakazi O. Mashoto c, Hamisi M. Malebo d a

Health system and Policy Research, National Institute for Medical Research, Barack Obama Drive, P.O. BOX 9653, 2448 Dar es Salaam, Tanzania Disease Surveillance and GIS, National Institute for Medical Research, Barack Obama Drive, P.O. BOX 9653, 2448 Dar es Salaam, Tanzania c Health Policy and Advocacy, National Institute for Medical Research, Barack Obama Drive, P.O. BOX 9653, 2448 Dar es Salaam, Tanzania d Department of Traditional Medicine Research, National Institute for Medical Research, P.O. Box 9653, Dar es Salaam, Tanzania b

art ic l e i nf o

a b s t r a c t

Article history: Received 21 February 2014 Received in revised form 29 April 2014 Accepted 2 May 2014 Available online 14 May 2014

Background: Ethnopharmacological relevance: Indigenous communities have often served as rich repositories of empirical knowledge on medicinal plants used for anemia. Use of these plants need to be validated with respect to their efficacy and safety so as to provide scientific basis of their use. Quantifying presence of medicinal plants used for anemia treatment, validating indigenous knowledge and extent of its use in rural Mkuranga district, Tanzania is the main focus of this paper. Methods: A cross sectional study conducted in May and December 2013 at Mkuranga District of Coastal region of Tanzania. Forty key informants including traditional healers, religious leaders, community members and healthcare workers were interviewed using semi structured questionnaire. Eight focus group discussions were also conducted. Both interviews and focus group discussion gathered data on socio-demographics, general knowledge of anemia and plants used to correct anemia. In a brief field visit, all plants mentioned during the interview were collected and later identified. Both NVivo 10 and STATA softwares were employed for statistical analysis. Results: Out of 40 participants, 31 were traditional healers, majority were male (77.4%). Mean age of the participants was 55.7 715 years. About 45% had no any formal education and majority (80%) were married. Twenty eight plant species are used to treat anemia. Hibiscus sabdariffa was the most mentioned species. The species belongs to 24 families, with Euphorbiaceae (14.3%) having the largest number. Lawsonia inermis, Aloe sp, Uvaria acuminata, Parinari curatellifolia, Ozoroa reticulata, Manihot esculenta, Canthium sp and Afzelia quanzensis were the plant species in which their claimed use for anemia were novel. Conclusions: People in rural areas of Mkuranga district possess a rich traditional knowledge of medicinal plants species for anemia treatment. Researches on these plants showed promising anti-anemic activity. Analysis and documentation of this knowledge has not only helped the analysis and recognition of novel information, it also contributed to conserving it for future generations. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Ethnomedical Indigenous knowledge Medicinal plants Anemia Tanzania

1. Introduction The oldest recorded uses of medicinal plants in the treatment of human ailments and maintenance of health are found in the Sumerian clay slab from Nagpur, approximately 5000 years old, the Babylon circa 1770 B.C in the Code of Hammurabi and in ancient Egypt circa 1550 B.C (Petrovska, 2012). Much of the world's populations, especially in developing countries depend much on medicinal plants for primary health care requirements. Indigenous people have been the custodians of traditional n Corresponding author at: Health system and Policy Research, National Institute for Medical Research, 2448, Barack Obama Drive, P.O. BOX 9653, Dar es Salaam, Tanzania. Tel.: þ 255 764932508; fax: þ 255 2121360. E-mail address: [email protected] (E.L. Peter).

http://dx.doi.org/10.1016/j.jep.2014.05.002 0378-8741/& 2014 Elsevier Ireland Ltd. All rights reserved.

knowledge passed down from one generation to another on plant species used for different purposes such as medicine, pesticides, food, beverages, dyes, fragrances, resins, gums, arrow poisons and other purposes (Petrovska, 2012). Such ethno-medical knowledge in indigenous communities is on threat of disappearing. The threat is especially acute in cultures where information is passed orally rather than written and is exacerbated by modernization. Anemia, one of the oldest, most common and widespread blood disorder, is a public health problem in both developing and developed countries (WHO, 2008; Domínguez-Rodrigo et al., 2012). Globally, there are approximately 1.62 billion people having some form of anemia. Africa has disproportionately higher proportion of individuals affected by anemia, with prevalence of 67.6% in 2005 (WHO, 2008). Although anemia affects all individuals at all stages of life cycle, preschool children and women of reproductive

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age are the most vulnerable population groups (WHO, 2001). At least 59% of Tanzanian children between 6 and 59 months and 40% of women of reproductive age are anemic (Bureau of al., 2011). Iron deficiency which is a result of low intake of bioavailable dietary iron, is considered as the major causes of anemia (McLean et al., 2009). It was estimated that, 60% of all anemia cases are due to iron deficiency in non-malaria area while 50% in malaria endemic area (Stoltzfus, 2003). While iron deficiency contributes to most of the anemia cases, other causes should also be recognized. These include infection with hookworms, schistosomiasis, Malaria and HIV, other micronutrients deficiency, trauma and blood loss (WHO, 2001). In Tanzania, the major cause of iron deficiency anemia (IDA) are poor diet and low bioavailability of dietary iron (Tatala et al., 1998). Like other developing countries, large section of Tanzanian population is poor. Their staple foods are mainly cereals: maize, sorghum or rice, and in some areas the starchy tuber cassava. Although this diet met the energy and protein requirements to support an adequate growth rate, it obviously does not provide enough absorbable iron (Tatala et al., 1998). Inadequate consumption of meat, fish, or poultry, especially in poor families contribute substantially to iron deficiency anemia (Bhargava et al., 2001). Iron deficiency anemia has been considered as the most important contributing factor to the global burden of disease (WHO, 2002). It also has profound consequences on socio-economic development. Anemic adults and adolescents have reduced physical capacity and work performance (Edgerton et al., 1979). IDA has been known to negatively affect cognitive performance, behavior and physical growth of infants, preschool and school-aged children. In addition it has been recognized as the major risk factor for maternal and child mortality as well as negatively affect immune status and increase morbidity from infections in all age groups (Theresa and Scholl, 1994; WHO, 2001). Interventions to combat IDA in Tanzania have been implemented with little health gain. Inadequate access to quality medicine for anemia among the poor, unpleasant odor and adverse effects mainly constipation, diarrhea and epigastric pain associated with ferrous supplements contribute significantly to the limited success of the present interventions (Ekstrom et al., 1996; Ariani Impieri et al., 2009). Therefore, the need to search for better alternative therapy is evident. In Tanzania, interest in traditional medicine has appreciably increased in recent years as indicated by number of Tanzanian particularly rural dwellers use of traditional medicines (Wenzel, 2011). The gained popularity in traditional medicines could be because the medicines are easily accessible, associated with less adverse effects and economically affordable to the rural people (Eto, 2013). Although rural communities in Tanzania largely depend on traditional medicines to correct anemia, less attention has been paid to the immense wealth of knowledge about the medicinal uses of the local flora which exists amongst ethnic groups. The irretrievable loss of large amounts of this knowledge due to the extinction of plant species caused by climate change, urban expansion and destruction of habitat could be prevented to a large extent by proper documentation. In addition, documentation of this indigenous knowledge could also be an important step towards identifying the most promising medicinal plants that can be used against anemia at primary health care level. Therefore, this study aimed at quantifying presence of medicinal plants used for anemia treatment, validating indigenous knowledge and extent of its use in rural Mkuranga district, Tanzania.

2. Methods 2.1. Study design and setting A cross sectional study was conducted between May and December 2013 at Mkuranga District which is located between

71 080 52″ S latitude and 391 110 46″ E longitude (Fig. 1). Administratively, the district is divided into 18 wards with a total of 121 villages. According to the 2012 census, Mkuranga had a population of 222,921. The inhabitants are largely subsistence farmers with few engaged in fishing industries along the Indian Ocean. The staple foods are mainly starchy tuber cassava and cereals, maize or sorghum prepared as a stiff porridge (ugali). A variety of green vegetables, legumes, and occasionally fish also form a part of the diet. While the national prevalence of iron deficiency anemia among women of reproductive age is about 40%, the prevalence in Coastal region is unacceptably high (70.9%) (Bureau et al., 2011). In 2012 anemia was reported to be among the top ten causes of hospital admission in both pediatric and adult female wards in Mkuranga district hospital. Besides poor diet; the rich culture of depending on traditional medicines to treat various ailments makes Mkuranga the ideal study area. Two wards namely Magawa and Kiparang'anda (Fig. 1) were conveniently selected and a total of eight villages (Makombea, Magawa, Msonga, Nasibugani, Mdimni, Kiparang'anda, Kibululu and Magoza) were visited. Besides easy to reach, the selected villages share similar sociodemographic features with the rest of the villages in other wards.

2.2. Study participants and data collection A total of 40 key informants were interviewed using semistructured questionnaire. They were purposively selected to represent different groups within the population. The groups represented were traditional healers, knowledgeable individuals in the community, religious leaders and community health workers. In this community, traditional healers were regarded to possess extensive knowledge of traditional medicine. Focusing on local healers was therefore more likely to yield greater results. In addition, eight (8) focus group discussions (FDGs) were conducted. Prior to the survey, researchers requested community leaders to identify FGD's participants amongst community members. Then the researchers selected participants from the identified ones. The selected participants were believed to have information on medicinal plants and were likely to share. Both in-depth interviews and FDGs were conducted in Swahili, the Tanzania's official language. The principle of saturation determined number of FGDs. There were separate FGDs for both men and women. Each group comprised of 8–12 participants (Marshall & Rossman, 1999) and lasted between 1 and 1.30 h. All FGDs were tape recorded. Refreshments (soft drinks and snacks) were served to all discussion participants. Data collected were socio-demographics of the informants, general knowledge on anemia, plants used to treat anemia including local name, plant parts used, method of preparation, dosage and dosing frequency. The knowledge about anemia was assessed based on three items as follows: the causes, symptoms of anemia and diagnosis. Results were scored 0–3. Zero score means no knowledge while 3 means high knowledge. Besides interviews, brief field visits were organized with the informants and research team to collect plants mentioned during the interview. The collected plants were later taxonomically identified by a taxonomist and voucher specimens were deposited at the herbarium of department of botany in the University of Dar es Salaam in Tanzania. Literature search to establish proof of claims was done using different key words. Published journal articles were retrieved from google, googlescholar, Pubmed and Science direct. The strength and validity of information obtained from the informants was established based on similar ethnomedical claims in the literature or evidence of laboratory results of phytochemicals or pharmacological evidences that supports the claims.

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Fig. 1. A map of Tanzania showing study area-Mkuranga District in Pwani region.

Ethical clearance certificate with reference number NIMR/HQ/ R.8a/Vol.IX/1618 was obtained from the Medical Research Coordinating Committee (MRCC) of National Institute for Medical Research (NIMR) in Tanzania. Permission to conduct the study was also obtained from Regional, District and village authorities. Written consent was obtained from all informants. In case of FGDs, group consent was obtained after sufficient information about the study was given. It was clearly revealed to the participants that there would be no direct physical benefits due to their participation. However, clarification was made that results of the study could be beneficial to the entire community by helping them to better understand medicinal plants for anemia control. Participants were also informed that, the discussion was tape recorded so that the information could be used later during analysis. All information collected was kept confidential.

2.3. Data processing and analysis Interviews and FGDs were transcribed verbatim in Swahili. Each transcript was reviewed for accuracy by replaying the recorder whilst reading and translating the transcript. Transcripts were imported into NVivo 10, a computer software package for qualitative analysis, which was used for coding FGDs and interviews. Data was analyzed using thematic content approach as described by Krueger (1997). A code list from multiple readings of a number of transcripts was developed followed by open coding. Major themes and sub themes emerged from the data were identified. This helped to derive general conclusions that match with the intended objectives. Quantitative data was analyzed using STATA software. Frequency of citation of medicinal plants was summarized and assessed. Sign ranked test was applied to

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determine association between knowledge of medicinal plant for anemia and other variables recorded.

“Roselle has been widely used in our community for anemia prevention. This is because it often proves effective to treat anemia in many people” (FGD- Women, Mdimuni Village)

3. Results 3.1. Demographic characteristics A total of 31 traditional healers, 4 community health workers, 3 knowledgeable individuals and 2 religious leaders were interviewed. About 77.4% of the total participants were men. Mean age of the participants (N ¼40) was 55.7 715 years, majority (80%) were married and over half (53.13%) had primary education.

“Always we use Roselle for prevention of anemia. We make juice from its calyces and drink. Often, we advise pregnant women to use Roselle. It helps to prevent them from anemia as well as it improves appetite” (Village Health Worker-Mdimuni village) “We always use Roselle to prevent our family from anemia because going to hospital is very expensive. Hence we drink Roselle to prevent anemia problem before it occurred” (Religious leader-Mdimuni Village)

3.2. Knowledge about anemia In the present work, knowledge about anemia was assessed and the results showed that, majority (59.38%) of participants had high level of knowledge on anemia. The following translation is typical of quotes from respondents on the knowledge about anemia: “If a person has anemia, you can see the following symptoms; paleness of palm and eyes, dizziness, headache and increase of heart beat”

“I always use Roselle as the means to correct anemia, it is very effective. For example, my son had anemia and his blood was below 8 after using Roselle the blood raised to 12, Roselle is affordable and very useful for us with low income” (Village Health Worker-Mkuranga) Other plants with high frequency of mention include Vigna unguiculata mentioned by 10%, Cocos nucifera with 7.14% and Cucurbita maxima contributed to 5.7%. 3.3. Ethno-medicinal knowledge of plant species for anemia

(FGD. Men- Kiparang'anda village) “I came to realize that: if a person has anemia you can recognize by seeing him or her being tired and then his/her color changed to pale as well as losing appetite” (FGD Women, Kiparang'anda village) Majority of respondents also reported a wide spread use of various herbal medicines particularly Hibiscus sabdariffa plant for treating anemia. The following narratives illustrate;

All informants knew at least one medicinal plant used to treat anemia, with majority (59.38%) being aware of 3 or more medicinal plants. Participants reported to have obtained their knowledge from their parents, grandparents, and friends and by reading books. Irrespective of source of knowledge on medicinal plants, majority (59.38%) reported to teach others. Traditional healers with knowledge on many medicinal plants are 2.6 times more likely to pass the knowledge to others as compared to those with knowledge on few plant species, RR 2.6, CI ¼(1.1–5.9). A total of 28

Table 1 Medicinal plants used traditionally to treat anemia in Mkuranga district. S/N

Botanical name

Family

Voucher specimen

Vernacular name

Part used

Frequency of use

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Amaranthus hybridus L. Ozoroa reticulate (Baker f.) R and A. Fern Uvaria acuminate Oliv. Cocos nucifera L. Bidens pilosa L. Kigelia Africana (Lam.) Benth Adansomia digitata L. Afzelia quanzensis Welw. Parinari curatellifolia Benth. Ipomoea batatas (L.) Lam. Cucurbita maxima Duchesne. Phyllanthus reticulatus Poir. Manihot esculenta Crantz. Carica papaya L. Bridelia Micrantha (Hochst.) Baill Piliostigma thonningii Schum. Vigna unguiculata (L.) Walp Cassytha filiformis L. Aloe sp Lawsonia inermis L. Hibiscus sabdariffa Linn. Milicia excelsa Welw C.C. Berg Syzygium cumini (L.) Skeels Ximenia caffra Sond. Passiflora edulis Sims Sorghum bicolor (L.) Moench Canthium sp Rhoicissus tridentata Wild and Drum

Amaranthaceae Anacardiaceae Annonaceae Arecaceae Asteraceae Bignoniaceae Bombacaceae Caesalpiniaceae Chrysobalanaceae Convolvulaceae Cucurbitaceae Euphorbiaceae Euphorbiaceae Euphorbiaceae Euphorbiaceae Fabaceae Fabaceae Lauraceae Liliaceae Lythraceae Malvaceae Moraceae Myrtaceae Olacaceae Passifloraceae Poaceae Rubiaceae Vitaceae

5029 5048 5017 5027 5018 5024 5033 5023 5054 5035 5038 5047 5030 5025 5039 5026 5037 5014 5049 5052 5036 5022 5041 5040 5044 5046 5021 5020

Mchicha Mkutano Msharifu Mnazi Myegelele Mlegeya Mbuyu Mkongo Mbula Matembele Maboga Madini Kisamvu Papai dume Mkalati Msekela Mbaazi Mlangamia Mwalovela Hina Mdamu damu Mvule Mkeche Mpingi Mpesheni Mtama Bwanashokola Mkakaka

Leaves Root Roots Roots, leaves Leaves Stem barks Stem bark Roots Leaves Leaves Leaves Leaves, root barks Leaves Roots Stem bark Stem bark Leaves, seeds Stem Leaves Leaves Leaves, calyces Roots Roots, stem bark Roots Leaves Seeds Roots Leaves

2 1 1 5 1 2 1 1 1 2 4 1 1 1 1 1 6 1 1 2 23 1 1 1 2 2 1 1

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3.4. Proof of claims of medicinal plants used by Mkuranga people

25

To verify the claim on medicinal plants used in Mkuranga district, literature search were conducted for all 28 plant species documented. Majority (67.9%) of these plant species were found to have similar ethnomedical claims in other countries or their phytochemical compositions support their therapeutic indications or have been proven pharmacologically as effective in man or animal model trials (Table 2). However, Lawsonia inermis, Aloe sp, Uvaria acuminata, Parinari curatellifolia, Ozoroa reticulata, Manihot esculenta, Canthium sp and Afzelia quanzensis were the plant species in which their claimed use for anemia were novel and not found in literature.

20 Number of use report

771

15

10

5

0 Sorghum bicolor

Kigelia africana

Passiflora edulis

Lawsonia inermis

Ipomoea batatas

Amaranthus hybrid

Cucurbita maxima

Cocos nucifera

Vigna unguiculata

Hibiscus sabdariffa

Medicinal Plants Fig. 2. Medicinal plants and frequency of citations.

50.0%

Percent of mention

40.0%

30.0%

20.0%

10.0%

0.0% Root bark

Stem

Calyces

Seeds

Stem bark

Roots

Leaves

Plant parts used Fig. 3. Medicinal plant parts used by Mkuranga people.

different plant species were recorded in the present survey for the treatment of anemia (Table 1). The species belongs to 24 families, with Euphorbiaceae (14.3%) being the most frequent recorded family followed by Fabaceae-caesalpinioideae (7.1%). Other families had one species each. Among the plant species documented, Hibiscus sabdariffa L was the most cited medicinal plant (33%) (Fig. 2). Our study revealed that, main parts of plants used for medicinal purpose are the leaves (42.4%) followed by roots (27.3%) (Fig. 3). In some plants like Hibiscus sabdariffa and Vigna unguiculata multiple parts are used.

4. Discussion Overall, the survey revealed 28 medicinal plants belonging to 24 families that are used to treat anemia in Mkuranga District, Tanzania. Our findings are consistent with two surveys, one conducted among 27 traditional healers in Côte-d'Ivoire whereby 20 species of medicinal plants were discovered used as antianemic while the other conducted in Ferkessedougou and Tiassale in Côte-d'Ivoire in which thirty plant species covering 22 families were recorded (Koffi et al., 2010; 2012). Gbadamosi et al., 2012 reported ten medicinal plant species used for treatment of anemia in Nigeria. The variation in number of plants with anti-anemic effect reported in other studies would be due to the differences in indigenous culture of the communities, differences in the availability of medicinal plant species and investigation methods used. It could also be explained by the differences in locality weather conditions. In our study, leaves and roots were the major plant parts used among all plant species identified. Our findings are in agreement with other ethnomedical studies where plants are used for treatment of anemia (Lyimo et al., 2003;Gbadamosi et al., 2012; Koffi et al., 2012). This could be because collection and processing of leaves is easy. Furthermore, harvesting leaves does not damage the plant substantially as compared to the collection of stem and root barks (De Wet et al., 2013). The use of leaves could therefore imply that Mkuranga people are aware of environmental conservation. Majority of plant species used in Mkuranga ethnomedicine belong to the family Euphorbiaceae. The Euphorbiaceae comprises of nearly 322 genera and 8910 species (Bingtao et al., 1997). It is among the largest flowering plant families consisting of plants of great medicinal and nutrition importance (Webster, 1986). The worldwide distribution of the family exposes its members, to all sorts of habitats to which they must adapt, therefore inducing a large variety of secondary substances that are employed for survival (Mwine & Van Damme, 2011). This could explain their prominence in the ethnomedicine of the Mkuranga people. In the present study, Hibiscus sabdariffa (Malvaceae) was the most cited plant species against anemia. This therapeutic indication has been confirmed in other studies (Babalola et al., 2001;Ali et al., 2005; Falade et al., 2005; Maregesi et al., 2013). The tremendous use of this plant species could be a good indicator of therapeutic efficacy and lack of obvious toxicity. However, to be certain about these claims the need for scientific evaluation of its safety and efficacy in this locality is warranted. Among the plant species confirmed to have anti-anemic potential, Hibiscus sabdariffa, Cucurbita maxima, Sorghum bicolor, Ipomoea batatas, Amaranthus hybridus and Bidens pilosa were found to have both iron and ascorbic acid (Table 2). Ascorbic acid contributes to absorption of non-heme iron present in these plants into the body. This could justify their potential as anti-anemic in ethnomedicine of people of Mkuranga. However, Rhoicissus tridentata and Cassytha filiformis were found to have

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Table 2 Literatures that support medicinal plants traditionally used to treat anemia. Botanical name (Family)

Literature to support the therapeutic claims

Hibiscus sabdariffa Linn (Malvaceae)

Reported in an ethnopharmacological investigations of plants used by Abbey and Krobou people for the treatment of anemia in Côte- d'Ivoire (Koffi et al., 2010). Both leaves and calyces contain sizable amount of minerals-calcium, magnesium, potassium, sodium, iron and zinc as well as organic acids-ascorbic acids, malic acid, tartaric acids, citric acid (Ali et al., 2005; Falade et al., 2005; Maregesi et al., 2013; Babalola et al., 2001). Pharmacologically, Hibiscus sabdariffa extract was tested in both animal and human models results showed elevated hematocrit and hemoglobin (Adigun et al., 2006). Seeds contain iron (Abizari et al., 2012;Towo et al., 2003). Pharmacological investigations conducted in schoolchildren confirm its hematinic activity in human (Abizari et al., 2012). Reported in an ethnopharmacological investigations of plants used by Abbey and Krobou people for the treatment of anemia in Côte- d'Ivoire to treat anemia (Koffi et al., 2010). Leaves contain Iron and vitamin C (Nwaoguikpe et al., 2013;Orech et al., 2007). A significant action of Cucurbita Maxima against anemia was noted in a group of rats treated for 4 weeks (Manokaran et al., 2010). In addition, Cucurbita maxima showed the potential to treat sickle cell anemia (Nwaoguikpe et al., 2013). Dried stem used in treatment of anemia and cough in Cote d'Ivoire (Koffi et al., 2012). It contains ascorbic acid, iron, zinc, alkaloids and saponins (Falade et al., 2005;Oladiji et al., 2007;Gbadamosi et al., 2012). Pharmacologically, anti anemic activity was studied in animal models, the result thus supports the traditional use of Sorghum bicolor as a remedy for anemia (Ogwumike, 2002). Similar findings were reported in another study (Oladiji et al., 2007). Contains iron as one of its mineral constituents. This justify their nutraceutical use as hemoglobin enhancer (Maregesi et al., 2013). Leaves contain vitamins-thiamine, riboflavin, niacin, folate, Vitamin B6, B5, ascorbic acid and vitamin E. It is also rich in minerals such as iron, magnesium and zinc (Mosha and Gaga, 1999; Osime et al., 2008; Panda and Sonkamble, 2012). It enhanced hemopoietic activity in rat (Osime et al., 2008). The use of this plant in treatment of anemia and cough was reported in Cote d'Ivoire (Koffi et al., 2012). Leaves contain significant amount of iron and vitamin C (Koffi et al., 2012; Lyimo et al., 2003; Mosha and Gaga, 1999; Odhav et al., 2007; Orech et al., 2007). In India, Syzygium cumini bark extract is used for treatment of anemia, bark and seeds are also used for diabetes (Jayamohan et al., 2013). Mentioned in the management of malaria in Kenya (Njoroge and Bussmann, 2006).

Vigna unguiculata (L.) Walp (Fabaceae) Cocos nucifera L. (Arecaceae) Cucurbita maxima Duchesne (Cucurbitaceae) Sorghum bicolor (L.) Moench (Poaceae)

Kigelia Africana (Lam.) Benth (Bignoniaceae) Ipomoea batatas (L.) Lam (Convolvulaceae) Amaranthus hybridus L. (Amaranthaceae)

Syzygium cumini (L.) Skeels (Myrtaceae)

Rhoicissus tridentate Wild and Drum (Vitaceae) Piliostigma thonningii Schum (FabaceaeAnimal model showed no significant effect on Hemoglobin level (Kayode et al., 2012). caesalpinioideae) Whole plant used in treatment of anemia in Cote d'Ivoire. It also contain significant amount of iron (Koffi et al., 2012). Phyllanthus reticulatus Poir (Euphorbiaceae) Milicia excelsa Welw C.C. Berg (Moraceae) Stem bark used in treatment of anemia and cough in Cote d'Ivoire (Koffi et al., 2012). The plant contains significant amount of iron (Koffi et al., 2012). Cassytha filiformis L. (Lauraceae) Reported use include inflammation, intestinal worms, dermal problems, tooth problems, diabetes, influenza, headaches, stomachaches, malaria, cough, asthma, diarrhea (Said et al., 2013). Carica papaya L. (Euphorbiaceae) Increases hemoglobin in sickle cell animal model (Afolabi et al., 2012). Other uses were also reported (Aravind et al., 2013). Bridelia Micrantha (Hochst.) Baill Leaves used in treatment of anemia, intestinal worms and tonic in Cote d'Ivoire. Bridelia micrantha contain significant amount (Euphorbiaceae) of iron (Koffi et al., 2012). It is also reported used for yellow fever, malaria, amenorrea and dysmenorrhea (Moshi et al., 2012). Adansonia digitata L. (Bombacaceae) Contains significant amount of iron. Used in treatment of anemia in Cote d'Ivoire (Koffi et al., 2012). Bidens pilosa L. (Asteraceae) Leaves contain significant amount of iron and vitamin C (Odhav et al., 2007; Steyn et al., 2001).

antimalarial activity (Njoroge & Bussmann, 2006; Said et al., 2013). Although there is no literature on anti-anemic effect, use of these plants against anemia in Mkuranga could indicate their potential benefits against anemia per se or through treatment of malaria. Interestingly, use of Lawsonia inermis, Aloe sp, Uvaria acuminata, Parinari curatellifolia, Ozoroa reticulata, Manihot esculenta, Canthium sp and Afzelia quanzensis for treatment of anemia were reported for the first time as there was no literature to retrieve. Further scientific validation of this local remedy may encourage its use in this habitat or adoption in area with similar medical conditions while health care resources are stretched.

5. Conclusions People in rural areas of Mkuranga district possess rich traditional knowledge of medicinal plants species for anemia treatment. Researches on majority of these plants showed promising anti-anemic activity. Analysis and documentation of this ethnomedical knowledge has provided novel information for further scientific attention in the treatment of anemia. Thus, the study not only helped the analysis and recognition of this novel information, it also contributed to conserving it for future generations.

Authors' contributions EP conceived of the study and participated in its design, data acquisition and draft the manuscript. SFR participated in design, data analysis and development of manuscript. KOM participated in design of the study, data acquisition and review of manuscript. HMM made inputs in analyzing data, drafted and reviewed the manuscript. All authors read and approved the final manuscript.

Acknowledgment We are grateful to Mr. Haji O. Sulemani, a Plant Taxonomist at the Department of Botany, University of Dar es Salaam in Tanzania for taxonomical identification and authentication of the plant materials studied in this project. We thank research assistants for field data collection. We thank all participants for sharing their invaluable indigenous knowledge. The authors express their gratitude to Grand Challenges Canada-stars in Global health round 4 for financially supporting this project (Grant number 0272-01). References Abizari, A., Moretti, D., Zimmermann, M.B., Armar-klemesu, M., & Brouwer, I.D. (2012). Whole Cowpea Meal Fortified with NaFeEDTA Reduces Iron Deficiency

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