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Background The Q-method is a research approach that combines quantitative and qualitative techniques to study people’s subjectivity on a given theme. In Madagascar, antibiotic usage practices remain largely unstudied, particularly among pregnant and breastfeeding women. This study aims to use the Q-method to document the opinions of pregnant and breastfeeding women on antibiotic use practices in the Northwest region of Madagascar. Methods The Q-method was applied to 115 pregnant and breastfeeding women from two districts, one urban and one rural, in Northwest Madagascar. The participants ranked 36 statements about antibiotic use on a 7-point scale ranging from − 3 (strong disagreement) to + 3 (strong agreement). Principal component analysis (PCA) was used to analyze the rankings and identify groups of women with differing or similar viewpoints. The Wilcoxon and Kruskal-Wallis rank sum tests were employed to assess significant differences among participants in each group and to evaluate the differences between these groups. Additionally, semistructured interviews were conducted to explore the participants’ reasoning behind their rankings and to complement the quantitative findings. Results Among the 115 women, 51% (59/115) resided in urban areas, while 49% (56/115) lived in rural regions. PCA identified two main groups of women with distinct viewpoints on antibiotic use. Group 1 comprised 55.6% (64/115) of the women and consisted of women who only complied with medical indications and instructions by being vigilant. Group 2 represented 35.6% (41/115) of the respondents and included women who believed in antibiotic usage based on receiving information first from multiple sources (medical staff or personal experience or other nonmedical relatives). 10 women (8.8%) could not be classified under either of the two groups. Differences in opinions were observed in Group 1 based on age ( p = 0.004), marital status ( p = 0.013), educational level ( p = 0.007), gravidity ( p = 0.062), and area of residence ( p = 0.125), and in Group 2 based on educational level ( p = 0.065) and gravidity ( p = 0.127). Insights from the semistructured interviews enriched the interpretation of these groups’ classification. Conclusions Pregnant and breastfeeding women surveyed in Northwest Madagascar believe that the best approach to antibiotic use is to follow the recommendations of health care professionals. However, some rely on advice from others, whether medical or nonmedical. To improve adherence to antibiotic treatments based solely on medical prescriptions and ensure their proper use in Madagascar, the communication between health care providers and patients must be strengthened.

Background Malaria in pregnancy (MIP) increases the risk of poor maternal and infant outcomes. To reduce these risks, WHO recommends insecticide-treated net (ITN) use, intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and prompt case management. However, uptake of these interventions remains sub-optimal in Madagascar. A scoping review was conducted to determine the breadth and depth of information available during 2010–2021 about Madagascar’s MIP activities and to identify barriers and facilitators to MIP interventions uptake. Methods PubMed, Google Scholar, and USAID’s files (Development Experience Catalog) were searched using the terms “Madagascar AND pregnancy AND malaria,” and reports and materials from stakeholders were collected. Documents in English and French from 2010 to 2021 with data regarding MIP were included. Documents were systematically reviewed and summarized; results were captured in an Excel database. Results Of 91 project reports, surveys and published articles, 23 (25%) fell within the stated time period and contained relevant data on MIP activities in Madagascar and were categorized accordingly: eight (35%) quality of care, including health facility readiness, provider knowledge and commodity availability; nine (39%) care-seeking behaviour; and, six (26%) prevention of MIP. Key barriers were identified: nine articles mentioned SP stockouts; seven found limitations of provider knowledge, attitudes, and behaviours (KAB) regarding MIP treatment and prevention; and, one reported limited supervision. MIP care seeking and prevention barriers and facilitators included women’s KAB regarding MIP treatment and prevention, distance, wait times, poor service quality, cost, and/or unwelcoming providers. A 2015 survey of 52 health facilities revealed limited client access to antenatal care due to financial and geographic barriers; two 2018 surveys revealed similar findings. Self-treatment and care-seeking delays were reported even when distance was not a barrier. Conclusion Among the studies and reports on MIP in Madagascar, the scoping review frequently noted barriers that could be mitigated by reducing stockouts, improving provider knowledge and attitudes, refining MIP communication, and improving service access. There is a need for coordinated efforts to address the identified barriers is the key implication of the findings.

Background Although it is accepted that long-lasting insecticidal net (LLIN) use is an effective means to prevent malaria, children aged 5 to 15 years do not appear to be sufficiently protected in Madagascar; the malaria prevalence is highest in this age group. The purpose of this research is to summarize recent qualitative studies describing LLIN use among the Malagasy people with a focus on children aged 5–15 years. Methods Qualitative data from three studies on malaria conducted between 2012 and 2016 in 10 districts of Madagascar were analysed. These studies cover all malaria epidemiological profiles and 10 of the 18 existing ethnic groups in Madagascar. A thematic analysis was conducted on the collected data from semi-structured interviews, direct observation data, and informal interviews. Results A total of 192 semi-structured interviews were conducted. LLINs are generally perceived positively because they protect the health and well-being of users. However, regional representations of mosquito nets may contribute to LLIN lower use by children over 5 years of age including the association between married status and LLIN use, which leads to the refusal of unmarried young men to sleep under LLINs; the custom of covering the dead with a mosquito net, which leads to fear of LLIN use; and taboos governing sleeping spaces for siblings of opposite sexes, which leads to LLIN shortages in households. Children under 5 years of age are known to be the most vulnerable age group for acquiring malaria and, therefore, are prioritized for LLIN use when there are limited supplies in households. In contrast, children over 5 years of age, who are perceived to be at less risk for malaria, often sleep without LLINs. Conclusions Perceptions, social practices and regional beliefs regarding LLINs and vulnerability to malaria contribute to the nonuse of LLINs among children over 5 years of age in Madagascar. Modifying LLIN policies to account for these factors may increase LLIN use in this age group and reduce disease burden.

Although its incidence has been decreasing during the last decade, malaria is still a major public health issue in Madagascar. The use of Long Lasting Insecticidal Nets (LLIN) remains a key malaria control intervention strategy in Madagascar, however, it encounters some obstacles. The present study aimed to explore the local terminology related to malaria, information channels about malaria, attitude towards bed nets, and health care seeking practices in case of fever. This article presents novel qualitative findings about malaria. Until now, no such data has been published for Madagascar. A comparative qualitative study was carried out at four sites in Madagascar, each differing by malaria epidemiology and socio-cultural background of the populations. Seventy-one semi-structured interviews were conducted with biomedical and traditional caregivers, and members of the local population. In addition, observations of the living conditions and the uses of bed net were conducted. Due to the differences between local and biomedical perspectives on malaria, official messages did not have the expected impact on population in terms of prevention and care seeking behaviors. Rather, most information retained about malaria was spread through informal information circulation channels. Most interviewees perceived malaria as a disease that is simple to treat. Tazomoka (\"mosquito fever\"), the Malagasy biomedical word for malaria, was not used by populations. Tazo (\"fever\") and tazomahery (\"strong fever\") were the terms more commonly used by members of the local population to refer to malaria related symptoms. According to local perceptions in all areas, tazo and tazomahery were not caused by mosquitos. Each of these symptoms required specific health recourse. The usual fever management strategies consisted of self-medication or recourse to traditional and biomedical caregivers. Usage of bed nets was intermittent and was not directly linked to protection against malaria in the eyes of most Malagasy people. This article highlights the conflicting understanding of malaria between local perceptions and the biomedical establishment in Madagascar. Local perceptions of malaria present a holistic vision of the disease that includes various social and cultural dimensions, rather than reflecting one universal understanding, as in the biomedical image. The consideration of this \"holistic vision\" and other socio-cultural aspects surrounding the understanding of malaria is essential in implementing successful control intervention strategies.

The management of preterm births remains a major challenge in Madagascar, given the lack of equipped facilities in rural areas, and the absence of precise data concerning the incidence of such births. The World Health Organization (WHO) recommends the kangaroo method (skin-to-skin contact) for the management of preterm infants. In this article, we examine the conditions for success and the obstacles facing kangaroo care in community settings in Madagascar. We performed a qualitative research, collecting data from the districts of Antananarivo and Mahajanga in 2021. In total, 54 semi-structured interviews and two focus group sessions were conducted with the parents of preterm infants and healthcare professionals. The obstacles identified by the research included incomplete and inaccurate knowledge, leading to heterogeneity in the practice of kangaroo care: arbitrary duration, lack of kangaroo care at night, exclusive breastfeeding, and only partially practiced skin-to-skin contact. We found that the conditions for success depended on: (1) the healthcare system, (2) local interpretations of pregnancy, and (3) the structure of the infant’s family. Failings of the medical system, cultural habits going against kangaroo care, and “nuclear” and/or “single parent” family structures undermine the application of this practice, jeopardizing upscaling efforts. We hope that the results of this research will guide community strategies for the management of preterm infants and kangaroo care.

Background Madagascar has restrictive abortion laws with no explicit exception to preserve the woman’s life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions. Methods We interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion. Results For 2005–2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4–23.0) per 1000 person-years among sexually active women (aged 18–49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8–37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not. Conclusions Incidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies.

IntroductionData regarding the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonates at the community level are scarce in low-income and middle-income countries (LMICs), where the burden of neonatal sepsis is high.Our study aims at identifying and quantifying the role of the different routes of ESBL-PE transmission for neonates, which are still undefined in the community in LMICs.Methods and analysisIn a semirural community in Madagascar, 60 mothers and their neonates will be recruited at delivery, during which a maternal stool sample and meconium of the newborn will be collected. Home visits will be planned the day of the delivery and next at days 3, 7, 14, 21 and 28. Stool samples from the newborn, the mother and every other household member will be collected at each visit, as well as samples from the environment in contact with the newborn (food, surfaces and objects). Sociodemographic data and factors which might drive ESBL-PE acquisition will also be collected.We will analyse the isolated ESBL-PE using DNA sequencing methods to characterise clones, resistance genes and plasmids of ESBL-PE. To analyse these data globally, we will develop novel analytical approaches combining mathematical modelling and statistics. Finally, mathematical simulations will be performed to test different strategies of control of ESBL-PE transmission to neonates.In complement, we will conduct an anthropological investigation to understand local environments and practices that would contribute to neonatal ESBL-PE acquisition. In-depth interviews with members of 16 households will be conducted and 4 mother–newborn pairs will be followed by a participants’ observations methodology.Ethics and disseminationThe study was approved by the ethical committee in Madagascar and by the institutional review board of Institut Pasteur, Paris, France.Findings will be reported to participating families, collaborators and local government; presented at national and international conferences and disseminated by peer-review publications.

Addressing complex global health challenges such as epidemic preparedness, environmental impacts, and equitable healthcare access requires collaborative and interdisciplinary efforts. Social sciences and humanities (SSH) play a crucial role in understanding the historical and social contexts of disease outbreaks and in shaping strategies and guidelines informed by lessons from past epidemics. Qualitative methods, central to SSH, offer valuable insights by uncovering real-world practices, social dynamics, and power structures that often remain invisible to quantitative approaches. Effective interdisciplinarity depends on strong leadership, shared vision, clear role definitions, and dedicated time for collaboration. However, these elements are often overlooked, limiting the integration of social sciences and the development of comprehensive solutions during epidemic responses. Here we share the experience of establishing SSH within the Pasteur Network members institutions in Africa and the creation of a dedicated social science network called the African SSH Pasteur Network. We describe the process of building this network to meet growing demands for SSH expertise in health research programmes and discuss the challenges encountered and strategies employed to sustain its development.

Cette étude évaluative porte sur la mise en œuvre et les effets perçus d’une formation en présence sur le transfert de connaissances, qui s’appuie sur deux cours en ligne ouverts et massifs (massive open online course – MOOC). La formation ciblait des membres du personnel ainsi que des partenaires de l’Institut Pasteur de Madagascar. L’étude a suivi le modèle de Kirkpatrick pour évaluer les effets perçus de la formation et le cadre TIPEC (Technology, Individual, Pedagogy and Enabling Conditions) pour identifier les facilitateurs et les obstacles de sa mise en œuvre. La collecte des données a suivi un devis mixte convergent. Trente-deux personnes (32) ont répondu au questionnaire de préformation, dont 18 personnes au questionnaire postformation et 24 à des entretiens semi-dirigés cinq mois après la fin de la formation. La plupart des personnes ont indiqué que la formation à l’aide des MOOC et d’un accompagnement en présence a répondu à leurs besoins, bien que son intensité et son niveau élevé de difficulté aient été soulignés par certains. Le volet pratique de la formation ainsi que la présence d’une formatrice ou d’un formateur ont été jugés essentiels à l’apprentissage. Les résultats suggèrent que le format pédagogique adopté pourrait constituer un outil pertinent et accessible pour la formation continue des professionnels. Mots clés : Transfert des connaissances, renforcement des capacités, MOOC, évaluation, Madagascar Evaluation of Knowledge Translation Training at the Institut Pasteur de Madagascar Abstract:  This evaluative study focuses on the implementation and perceived effects of an in-person training program on knowledge translation, which is based on two massive open online courses (MOOCs). The training targeted staff members as well as partners of the Institut Pasteur de Madagascar. The study followed the Kirkpatrick model to evaluate the perceived effects of the training and the TIPEC framework (Technology, Individual, Pedagogy, and Enabling Conditions) to identify facilitators and barriers to its implementation. Data collection was guided by a convergent mixed-methods design. Thirty-two people completed the pre-training questionnaire, of these, 18 responded to the post-training questionnaire and 24 took part in semi-structured interviews five months after the training ended. Most participants indicated that the training, combining MOOCs with in-person support, met their needs, although some highlighted its intensity and high level of difficulty. The practical component of the training and the presence of a trainer were deemed essential to learning. The results suggest that the adopted pedagogical format may represent a relevant and accessible tool for the continuing education of professionals.             Keywords: knowledge translation, capacity building, MOOC, evaluation, Madagascar  

Control of dog-mediated rabies relies on raising awareness, access to post-exposure prophylaxis (PEP) and mass dog vaccination. To assess rabies awareness in Moramanga district, Madagascar, where rabies is endemic, two complementary quantitative and qualitative approaches were carried out in 2018. In the quantitative approach, a standardized questionnaire was administered to 334 randomized participants living in 170 households located less than 5 km from the anti-rabies treatment center (ARTC) located in Moramanga city (thereafter called the central area), and in 164 households located more than 15 km away from the ARTC in two rural communes (thereafter called the remote area). Logistic regression models were fitted to identify factors influencing knowledge and practice scores. The qualitative approach consisted in semi-structured interviews conducted with 28 bite victims who had consulted the ARTC, three owners of biting dogs, three ARTC staff and two local authorities. Overall, 15.6% (52/334) of households owned at least one dog. The dog-to-human ratio was 1:17.6. The central area had a significantly higher dog bite incidence (0.52 per 100 person-years, 95% CI: 0.31-0.84) compared to the remote area (0.22 per 100 person-years, 95% CI: 0.09-0.43) (p = 0.03). The care pathway following a bite depended on wound severity, how the dog was perceived and its owner's willingness to cover costs. Rabies vaccination coverage in dogs in the remote area was extremely low (2.4%). Respondents knew that vaccination prevented animal rabies but owners considered that their own dogs were harmless and cited access and cost of vaccine as main barriers. Most respondents were not aware of the existence of the ARTC (85.3%), did not know the importance of timely access to PEP (92.2%) or that biting dogs should be isolated (11.1%) and monitored. Good knowledge scores were significantly associated with having a higher socio-economic status (OR = 2.08, CI = 1.33-3.26) and living in central area (OR = 1.91, CI = 1.22-3.00). Good practice scores were significantly associated with living in central area (OR = 4.78, CI = 2.98-7.77) and being aware of the ARTC's existence (OR = 2.29, CI = 1.14-4.80). In Madagascar, knowledge on rabies was disparate with important gaps on PEP and animal management. Awareness campaigns should inform communities (i) on the importance of seeking PEP as soon as possible after an exposure, whatever the severity of the wound and the type of biting dog who caused it, and (ii) on the existence and location of ARTCs where free-of-charge PEP is available. They should also encourage owners to isolate and monitor the health of biting dogs. Above all, awareness and dog vaccination campaigns should be designed so as to reach the more vulnerable remote rural populations as knowledge, good practices and vaccination coverage were lower in these areas. They should also target households with a lower socio-economic status. If awareness campaigns are likely to succeed in improving access to ARTCs in Madagascar, their impact on prompting dog owners to vaccinate their own dogs seems more uncertain given the financial and access barriers. Therefore, to reach the 70% dog vaccination coverage goal targeted in rabies elimination programs, awareness campaigns must be combined with free-of-charge mass dog vaccination.