title: "The medicine from behind": The frequent use of enemas in western African traditional medicine.
abstract: BACKGROUND
  Purgative enemas form an integral part of African traditional medicine. Besides possible benefits, serious health risks of rectal herbal therapy have been described in literature. To design appropriate health education programs, it is essential to understand traditional herbal practices and local perceptions of health and illness. Little is known about the herbal ingredients of enemas in Sub-Saharan Africa and consumers' personal reasons to use them.
  
  
  OBJECTIVE
  To analyze the importance of enema use with regard to plant species used and illnesses treated in West and Central Africa, to understand the local health beliefs that underlie frequent enema use and to evaluate which recipes and practices could be beneficial or harmful.
  
  
  METHODS
  We extracted data from 266 ethnobotanical questionnaires on medicinal (in particular women's health and childcare) and ritual plant use in Ghana, Benin and Gabon. Plants mentioned during interviews were vouchered and identified in herbaria. Health issues treated by means of enemas were ranked according to the number of plant species used for a specific illness. We compared our results with findings of medical research on benefits and risks of enema use in Sub-Saharan Africa.
  
  
  RESULTS
  We recorded ca. 213 different plant species used in hundreds of recipes for rectal insertions, mostly in Ghana and Gabon. Stomachache, abdominal pain, female infertility and birth facilitation were treated with the highest number of plants species. Cleansing the intestines of young children to promote their health by getting rid of 'dirt', instead of treating constipation, was an important cultural practice that required the rectal application of herbal medicine, as well as other cultural bound health issues like stimulating children to walk at an early age. Tradition, the bitter taste of herbal medicine and the rapid effect of enemas were frequently mentioned reasons for enema use.
  
  
  CONCLUSIONS
  Literature indicates that although enemas can help to improve the hygienic conditions of a household with young infants, frequent enema use can pose serious risks like direct toxicity caused by harmful ingredients, mechanical injury and infections. In Africa, enemas containing herbal medicine are common methods of administering herbal medicine for a variety of diseases, rather than just medicinal treatments for constipation as previously thought. Health professionals should be aware of the extent of, and motivation behind enema use to develop culturally appropriate education programs, especially targeted at vulnerable groups such as elderly people, parents of young infants and pregnant women.
authors.affiliation: Naturalis Biodiversity Center, P.O. Box 9517, 2300 RA Leiden, The Netherlands; Wageningen University, Department of Biosystematics, Droevendaalsesteeg 1, 6708 PB, Wageningen, The Netherlands. Electronic address: tinde.vanandel@naturalis.nl.
authors.forename: Tinde
authors.initials: T
authors.lastname: van Andel
authors.affiliation: Leiden University, P.O. Box 9500, 2300 RA Leiden, The Netherlands. Electronic address: sabine_onselen@hotmail.com.
authors.forename: Sabine
authors.initials: S
authors.lastname: van Onselen
authors.affiliation: Leiden University, P.O. Box 9500, 2300 RA Leiden, The Netherlands. Electronic address: britt.myren@gmail.com.
authors.forename: Britt
authors.initials: B
authors.lastname: Myren
authors.affiliation: Naturalis Biodiversity Center, P.O. Box 9517, 2300 RA Leiden, The Netherlands; Leiden University, P.O. Box 9500, 2300 RA Leiden, The Netherlands. Electronic address: alexandratowns@gmail.com.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Towns
authors.affiliation: Naturalis Biodiversity Center, P.O. Box 9517, 2300 RA Leiden, The Netherlands; Wageningen University, Department of Biosystematics, Droevendaalsesteeg 1, 6708 PB, Wageningen, The Netherlands. Electronic address: diana.quiroz@naturalis.nl.
authors.forename: Diana
authors.initials: D
authors.lastname: Quiroz
mesh_terms: D000328:Adult; D000354:Africa, Western; D004733:Enema / Q000009:adverse effects / Q000295:instrumentation / Q000706:statistics & numerical data*; D019448:Ethnobotany; D020834:Ethnopharmacology; D005260:Female; D006266:Health Education; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D008297:Male; D016488:Medicine, African Traditional; D028321:Plant Preparations / Q000008:administration & dosage / Q000627:therapeutic use; D011247:Pregnancy; D013649:Taste
chemical_list: D028321:Plant Preparations
keywords: Botany; Constipation; Cultural bound health issues; Enemas; Ethnopharmacological field studies; Gastro-intestinal system; Traditional medicine Africa