Dimensions of awareness of Female Genital Schistosomiasis among women and health care workers in rural Madagascar : a mixed methods approach

Background: Water-borne infections with S. haematobium are endemic in tropical re-gions. Chronic infection can cause Female Genital Schistosomiasis (FGS), possibly leading to severe gynecological conditions, including infertility. However, awareness of FGS prevention, diagnosis and treatment is limited. This study aims to identify and investigate dimensions of FGS awareness among women and healthcare workers (HCW) in the Boeny region of Madagascar. Methods: Mixed methods data collection involved cross-sectional survey of adult women (n=694), HCWs (n=93), and focus group discussions (Women; n=24, HCW; n=29). Quantitative results were described including proportions and 95% confidence intervals (CI) and measures of central tendency. Additionally, a FGS knowledge score was calculated. Qualitative analysis was conducted using a framework analysis ap-proach. Triangulation of quantitative and qualitative data is performed to determine the dimensions of awareness in the region. Results: Results show that 11.2% (CI [9.0–13.8%]) of women and 53.2% (CI [42.6–63.6%]) of HCW had heard of FGS. Among these, 34.6% (CI [24.1–46.2%]) women and 42.0% (CI [28.1–56.8%]) HCW were unaware of its characteristic gynecological symptoms. No significant differences were seen in the overall low knowledge score among HCW and women. In addition to confirming limited knowledge of the disease and treatment, qualitative analysis highlights influence on FGS awareness in the re-spondents’ daily life. While some women are aware that contact with infested water carries a risk of infection, their livelihoods depend on rice-farming, making preventive behaviors challenging and possibly leading to resignation. Although HCWs demon-strated proportionally more FGS awareness, uncertainties about treatment were ob-served. The triangulation determined four key dimensions of awareness in the region: Infrastructure, delivery of information, health behavior, and socio-structural factors. Conclusion: Overall, results show low levels of FGS awareness in a representative sample of Madagascar. Findings align with existing literature describing underreport-ing and undertreatment of FGS. Identifying gaps, barriers and facilitators in FGS awareness can inform the design of targeted FGS awareness campaigns to improve the health of women affected in Madagascar