Beneath the itch: a qualitative exploration of burden of scabies among urban street connected children in Ethiopia

Scabies, a neglected and stigmatizing skin disease, has complex effects on marginalized communities with limited access to healthcare. In Ethiopia, existing studies suggest that street connected children are particularly vulnerable to scabies and often hold misconceptions about its transmission and effects. However, there is a significant gap in evidence regarding the psychological, social, and economic consequences of scabies in this population. This qualitative study- guided by the biopsychosocial framework, investigates the psychosocial and economic impacts of scabies on street connected children in selected Ethiopian cities. We collected qualitative data from purposively selected children of the street who have been living in Addis Ababa, Hawassa, and Adama cities between May and March, 2024. Data collection methods included focus group discussions, individual in-depth interviews, and key informant interviews. To facilitate expression of self and social stigma associated with scabies, we employed participatory techniques such as drawing exercises. Audio recordings were transcribed and collaboratively coded by the research team, followed by thematic analysis of transcripts and field notes. Scabies infestation was found to have layered physical, psychological, and economic repercussions, exacerbated by the lack of accessible healthcare services. Street connected children reported experiencing both self-stigma and external stigma from peers and the broader community. Psychosocial impacts included exclusion from social activities, self-isolation, and feelings of loneliness and depression. Participants described how scabies eroded their ability to earn a living, noting that the time lost to illness combined with the burden of out-of-pocket medical expenses created overwhelming financial strain. In conclusion, the physical, psychosocial and economic impacts of scabies among street-connected children in Ethiopia is emblematic of broader structural inequities. Addressing scabies effectively requires a holistic approach that combines medical treatment with psychosocial support, economic inclusion, and policy-level recognition of street connected children’s health rights.

Scabies causes considerable morbidity, exacerbated by unavailability of a vaccine to prevent it, frequent treatment failure, and the lack of a practical, rapid, cheap and accurate diagnostic tool for timely detection (1). Diagnosis is frequently delayed and treatment is often wrongly applied, resulting in frequent complications and considerable public health burden (2). Scabies affects several skin sites, predominantly the hands (between the fingers), wrists, elbows, shoulders, and genital area (3). Several studies conducted in Ethiopia and elsewhere indicated a range of health complications of scabies, including intense itching that worsens at night and impacts quality of sleep among patients (4). Recent studies (5) also found intense itching followed by bleeding and small sores appearing around the palm and between the fingers of street connected children in Ethiopia. According to WHO (6), scabies can lead to skin infections and serious complications like septicemia, heart disease and kidney problems. Because its incubation period lasts approximately 4–6 weeks, people infested with scabies are a source of infection prior to treatment (7).

The psychosocial and economic burden of scabies on the persons infested with the condition, their families, and society at large have also been noted. Scabies affects quality of life through its disease symptoms, distorting self-perception, and the social stigma attached to its observable symptoms (8). The itch and visible rash often lead to poor quality of sleep, stigmatization and social exclusion, decreased concentration and academic achievement at school, interrupting school and work attendance (9–11). Scabies also places a significant financial burden on low-income families owing to the cost of treatment, school absenteeism, and missed workdays (12, 13). Further, it has a transmission risk impact where failure to recognize the condition, will place others at risk (12, 14). According to Light for the World (2024), these sociopsychological and economic impacts of scabies reinforce the vicious cycle of barriers to education and employment, low income, and disability.

According to WHO (6), scabies affects most disadvantaged populations, especially people living in crowded and impoverished conditions. Living in overcrowded conditions with no access to hygiene facilities, and under circumstances in which sharing of materials is a typical feature of the subculture (15), street connected children in Ethiopia are highly vulnerable to scabies and other dermatological conditions. Street-connected children’ (SCC) are defined as children working and/or living on the streets, without adequate adult supervision, for whom the street plays a significant role in their everyday lives and identities (16). In the context of lack of access to free healthcare services (17, 18), street connected children either have to ignore disease symptoms or incur out-of-pocket healthcare expenses when infested with scabies. Given their already stretched financial condition, this further undermines their overall wellbeing. The stigma and economic burden exacerbate their limited access to healthcare services.

Study design and setting

The study employed a qualitative research design using multiple data collection approaches. The study was conducted in Addis Ababa (the capital city of Ethiopia), Hawassa, the biggest town in Sidama region, located 270 km from Addis Ababa and situated in the southern rift valley, and Adama town, a corridor town through which street connected children from South and Oromia regions pass before moving to Addis Ababa, as revealed by recent study (28). These three study towns were selected as locations which harbour large numbers of street connected children migrating from different Ethiopian regions, meaning diverse ethnic structures were included.

Study population and sampling

Sixty-six street connected children aged 7–15 participated in the study. We employed an iterative, purposive sampling strategy, leveraging a snowballing technique through participants’ contact networks. Recruitment and interviewing continued until data saturation was reached, at which point no new themes emerged and data collection ceased. All invited children agreed to participate. Since boys constitute most of the street connected child population, more male participants were recruited, while a snowballing approach was used to include girls. Children between the age of 7 and 15 were included because most previous studies documented that scabies infestation was higher in the younger age groups (25, 26). Children were selected based on the inclusion criteria such as spending most of their time on the street, being homeless, and willingness to share their experiences. Those outside the specified age range or spending minimal time on the street were excluded.

Snowballing methods also helped reach children affected by scabies. Scabies cases were diagnosed via clinical examination conducted by experienced Health Officers from public hospitals or local NGOs in the study locations who assisted the team on parttime basis during data collection period. Diagnostic protocols adhered to the 2020 International Alliance for the Control of Scabies (IACS) criteria for Clinical Scabies (Category B) (29). Specifically, participants were classified as having scabies if they presented with specific clinical signs, with subcategories B1, B2, or B3, including presence of scabies burrows; a typical distribution of lesions (e.g., involvement of the finger webs, wrists, ankles, or belt line) accompanied by an epidemiological history of contact; or typical male genital lesions (such as nodules or papules on the glans penis or scrotum) and a report of intense nocturnal pruritus’. Accordingly, 21 of the 66 children who participated in the study were diagnosed as active scabies patients.

In addition, 15 parents or caregivers and 15 Key Informants, including professionals, NGO leaders, and government officials/employees, provided diverse perspectives on the vulnerability of street connected children to scabies. To minimize snowballing bias, participants were selected from different locations identified through a transect walk at the start of data collection. This approach diversified recruitment across various street networks. Interviews continued until data saturation was reached (30).

Data collection

Data were collected by two experienced research assistants who also speak the local languages (Amharic and Oromifa respectively) from March to May 2024. Participatory data collection methods incorporating unstructured conversations/interactions, participatory group discussion (PGD) and individual in-depth interviews, were employed to collect data from children. Visual representation methods, such as ‘thematic draw and tell exercise,’ were chosen to better elicit children’s perspectives in a participatory and child-friendly manner during PGDs. These methods have been used for many decades in child development research and on various sensitive topics (31, 32). Icebreaker exercises, such as participatory games and stories, were employed to build rapport with the children before data collection. Before starting in each study site, a transect walk was conducted with regional facilitators to identify street hotspots and engage with the children. Informal leaders among the street connected children helped reach those affected by scabies through a snowballing approach, building trust and encouraging participation.

In-depth interviews and participatory group discussions (PGDs) were conducted in venues chosen by the children to maintain their privacy, such as their plastic shelters, NGO compounds, or religious institutions. Each in-depth interview lasted about 40 minutes, while PGDs, involving 4–6 children in separate male and female groups, lasted over an hour with breaks. The PGDs included drawing exercises where children depicted their daily lives and their views on scabies, followed by group discussions. In total, 28 in-depth interviews and 7 PGDs (4 with boys and 3 with girls) were conducted using checklists and guides to structure the sessions and ensure active participation.

Data analysis

We used a manual thematic analysis approach without the use of qualitative analysis software to interpret the qualitative data. The field team prepared verbatim transcriptions of all the audio recorded interviews. Other authors also checked a sample of interviews and transcriptions for validity and consistency of the transcriptions. Following verbatim transcription of the interviews, a hybrid deductive-inductive coding process was initiated. An initial coding framework was established deductively based on research objectives regarding vulnerability perceptions, while inductive codes were allowed to emerge organically from the transcripts to capture unanticipated participant insights. After reading, re-reading, and coding the text (systematically labeling or tagging specific segments of text with a short code of a word or a phrase that describes its meaning), the primary themes and sub-themes were merged with the main themes in a code book. The code book table facilitated display and interpretation of data. To ensure analytical rigor, two coders independently coded the transcripts. The coders met regularly throughout the process to compare findings; any coding disagreements were thoroughly discussed and resolved via mutual consensus until a final coding framework was established. The other authors also reviewed the themes and agreed on the coding framework before the analysis.

The drawings produced by the participants were analyzed using a systematic visual thematic analysis approach. Rather than treating them merely as illustrations, these drawings were treated as primary qualitative data. Visual symbols, depicted environments, and written labels within the drawings were coded and integrated into the main hybrid deductive-inductive coding framework. To ensure interpretive validity, the analysis of each drawing was directly cross-referenced and triangulated with the participant’s corresponding verbal explanations recorded during data collection.

Ethical considerations

Ethical clearance was obtained from the Institutional Review Board of the Ethiopian Sociologists, Social Workers, and Anthropologists Association (ESSWAA) (Ref: ESSSWA/L/AA/0536/2024). Participants were informed that their participation in the study would be voluntary. Informed consent or thumb prints were collected from all participants, and children provided assent to participate. To ensure informed consent, the purpose and methods of the study were explained repeatedly using an information sheet translated into the local language. Only children who fully understood and consented were included in the study.

For the 21 children identified with scabies, the research team arranged medical treatment through local structures and NGOs. These NGOs provide free medical treatments, regular follow-up clinical assessments, and ongoing access to broader social and health services designed to mitigate the systemic vulnerabilities of street-connected children. Confidentiality was maintained through the use of pseudonyms, and specific identifiers were de-identified during transcription, analysis, and reporting. Moderate incentives in cash were provided to compensate for the time spent during data collection.

Street connected children reported the many ways in which scabies adversely impacted their wellbeing. We classified findings into four major themes: scabies as a neglected burden, physical sequelae, psychosocial burden and economic burden.

Scabies as a neglected burden

Most street connected children and key informants acknowledged that despite the severity of scabies, the condition is often overlooked even by the children themselves. This neglect stems from competing priorities such as the urgent need to find food or habitual glue-sniffing, which numbs their immediate suffering and masks the burden of scabies. As we reported in an earlier article, many streets connected children perceive scabies as an unavoidable part of daily life. Consequently, they endure the condition for extended periods without treatment, bearing a heavy, silent burden. Explaining this, a boy in Adama shared this reflection during a PGD drawing exercise:

In my drawing, the two children have scabies but are sniffing glue despite their condition. After sniffing, they forget the pain and itching for a while. But that doesn’t mean they’re not suffering. The glue just gives them some relief. (Street connected child, 14, M, Adama)

Key informants pointed out that although the prevalence of scabies among street connected children is evident, the scale of the burden is underestimated. Their constant mobility makes it difficult to track who has received treatment and who hasn’t. One Key informant from the health sector- explained:

Our health policy is designed to serve marginalized populations by offering free medical services. However, due to the mobile nature of street connected children, these services often don’t reach them. As a result, they suffer the consequences of scabies more than any other group. (Key informant, M, FMOH, Addis Ababa)

During our field visits, we observed children taken from street corners to rehabilitation centers left untreated for visible scabies infections. The medical teams prioritized emergency care, while scabies was ignored. We witnessed groups of children pleading for treatment, but due to the condition’s neglect and low prioritization, they were left to suffer for days without care. A 15-year-old boys, infested by scabies in Hawassa said, … “there is clear partiality among the management providing medical care for us. They focus on emergency problems only, but scabies…. (stretching out his arms to show to the researchers) no one feels how I am suffering from this terrible disease.”

This neglect was also powerfully illustrated through the children’s drawing exercises. Scabies was depicted as a double burden, compounding their already marginalized lives and their limited access to essential health services. (see Figure 1). For instance, a 13-year-old boy in Hawassa, explaining his artwork of a child sitting alone under a tree and scratching helplessly, said: “In the picture, you see a lonely child enduring the pain, with no way to get help. He’s thinking about both hunger and scabies. That’s what life is like on the street…”

Similarly, one girl in Adama described her drawing this way:

I drew three children sitting together, huddling under rags to shield themselves from the burning sun. All three have scabies. You can see the spots on their arms and legs. In the distance, a policeman is approaching with a stick and gun to chase them away. Our lives are always challenging, and we have to survive each one. When health problems like scabies hit, they just make a bad situation worse. (Street connected child, 15, F, Adama)

Morbidity and physical sequalae

The impact of scabies on the health and wellbeing of street connected children, including sleeplessness, especially at night, bleeding and wounding of the skin, and fear of potential complications on vital organs has been reported. We also observed children’s wounds created by severe itching during data collection. Explaining the burden related to sleep disturbance through her drawing, a 12-year-old girl in Addis Ababa, noted, “I drew two children. The infested one fell asleep in the sun because he did not sleep well at night due to itching while his friend sat down next to him begging for money for his treatment”.

In addition, another boy in Hawassa said:

Scabies is highly concerning, forcing intense scratching and shouting aloud.

It completely disrupts sleep at night, causing severe discomfort.

While other health problems can be forgotten, this prevents rest.

Scabies uniquely impairs both your daily activities and nightly rest.

(Street connected child, 13, M, Hawassa)

Street connected child

Although most children were unaware of the possibility of secondary infections resulting from scabies, some shared personal experiences that appeared to involve complications due to untreated cases. For example, one girl in Addis Ababa recounted,

I saw one of our male friends who was severely infested by scabies. His skin was bleeding, and his hands were covered in pus-filled pimples. During the day, while he slept, flies swarmed around his wounds, making his condition even worse. He was in a lot of pain. (Street connected child, 14, F, Addis Ababa)

Health professionals are concerned about the situation where lack of such awareness and limited attention to treatment leads to secondary infections.

…when scabies is left untreated, it may lead to further internal complications due to severe infections on the skin. As patients aggressively scratch the skin in response to an extended itchy feeling, the scratch could create a fertile ground for bacterial infections leading to severe morbidity. (Key Informant, Dermatologist, Hawasa)

In addition to the physical toll caused by untreated scabies, the study highlights the dangerous consequences of self-administered traditional or unconventional treatments, particularly among street connected children. Due to limited access to medical care and widespread misinformation, some children reported resorting to hazardous substances in an attempt to relieve symptoms, often with alarming outcomes. For instance, one account tells the story of a child who suffered serious harm after using kerosene as a home remedy for scabies.

Home remedies are highly dangerous; a friend applied kerosene for scabies itching and tragically caught fire while lighting a cigarette. He sustained severe burns and we rushed him to the health center. We hadn’t sought proper medical care earlier because we carelessly thought scabies was just a minor issue. Honestly, I didn’t know what to say.” (Street connected child, 15, M, Hawassa)

Street connected child

Another child applied a homemade treatment derived from boiled leaves, but during application, the fluid accidentally entered his eyes, leading to painful irritation and potential long-term eye damage.

Following a recommendation, I tried treating scabies using the white sap of kinchib, a local fencing plant. While squeezing it onto my skin, the sap accidentally splashed into my eyes, causing severe irritation and redness. The harmful fluid left my eyes inflamed for days and failed to cure the underlying infestation. Although this traditional remedy provided temporary relief, the intense itching soon returned. (Street connected child, 14, M, Adama)

Street connected child

Reported psychosocial impact

Experience of external stigma

Affected or infested street connected children disclosed experiences of stigma even from other street connected children because of their condition and marginalization from the activities deemed significant in the context of street life, including exclusion from playing and eating food together. A drawing by a 12-year-old girl in Hawassa (see Figure 2). explains this finding. Describing her picture, she said, … “In my drawing you see these two children seating together eating leftovers they collected while the affected child in the other corner is sitting alone, being chased away.” Another child reported:

They hate me. When my hands bleed and pus appears on my skin, they hate me when they see that. When we eat food, they don’t want to eat with me, and provide me my share to eat alone. When I ask them, they tell me that it is because of the wound on my hands. Now, my condition is improving and the children will no longer hate me.” (Street connected child, M, 14, Hawassa)

Social stigma from the community toward children infested by scabies was widely reported by respondents. This was particularly evident in how individuals hesitated to approach street connected children, viewing them as carriers of the disease. As one boy shared,

In this town, it’s common for street connected children to go door to door asking residents for food. Sometimes, as soon as someone realizes a child is infested with scabies, they chase us away. Some people refuse to hand us food directly, showing clear dislike and avoidance. (Street connected child, 11, M, Adama)

Street connected children’s experiences of stigma related to scabies were reported from various perspectives, with several underlying factors influencing their reactions to the condition. Some children noted that peer responses toward infested individuals depended largely on their closeness and status within their social group. They believed that children with scabies rarely faced exclusion or judgment from their own clique, but rather from members of other groups. One 13-year-old boy, in Addis Ababa shared, “I’ve never been stigmatized by friends or excluded from my group. We are close friends and treat each other like siblings in the family. It’s only kids from other groups who say bad things about me because of scabies.” A key informant from the Social Affairs Office in Hawassa noted, “…within peer groups, children often demonstrate a sense of solidarity and mutual support. When a member was infested by scabies, others were likely to offer help rather than ostracize them.”

Although most children believed that the likelihood of stigma within their peer groups was relatively low, owing to close-knit relationships and a sense of mutual care, some accounts from infested children revealed that stigmatization and bullying were still evident, especially in more severe cases. These behaviors often surfaced during interpersonal conflicts, even among members of the same group. The following excerpts illustrate this perspective:

If my friend who doesn’t have scabies and I were playing together, and we happened to quarrel, he would insult me by calling me ‘ ikekam ’ and demean me because of the scabies I’m suffering from. (Street connected child, 13, F, Hawassa)

In my drawing, I tried to illustrate how children affected by scabies experience alienation from their peers, especially when they are not close friends. Three children are shown playing together because they are not infested, while another child is isolated from the group, facing insults and ridicule due to his illness. (Street connected child 11, M, Adama)

Children’s experience with self-stigma

Children reported experiencing self-stigma related to scabies, a theme vividly expressed in their drawings. Many depicted themselves or others taking deliberate actions to conceal infested parts of their bodies due to fear of ridicule or judgment. One boy explained his drawing by saying:

This boy (pointing to the image) is trying to cover his infested hand with a long-sleeved shirt. He doesn’t want others to see it, he’s afraid they’ll mock him. His face looks sad. (Street connected child, 12, M, Addis Ababa)

A key informant emphasizing this behavior said:

We’ve observed children trying to hide their scabies when they first arrive here. They are unaware of the disease’s broader consequences and often neglect treatment. Fear of stigma keeps them away from seeking help. (Key Informant, COC, M, Hawassa)

Beyond fear of ridicule, some children expressed feelings of shame and disgrace associated with scabies. A 15-year-old girl shared:

“I’m scared of scabies. As a girl, I don’t want to endure the stigma or humiliation. It’s shameful for a female to appear in public with scabies. If I get it, I’d rather isolate myself until I’m treated. Even small symptoms make people assume your whole body is infected. And boys don’t like girls with scabies.” (Street connected child, 16, F, Hawassa)

Reported economic impact

The community reaction towards affected children has been explained by people withholding work or alms to those who are infested by scabies for fear of transmission. This action affects the child’s ability to earn. A child in the PGD exercises explaining his drawing reported the following:

My drawing shows a homeless boy with scabies begging out of hunger. A passing woman initially intends to give him money, but steps back upon noticing his wounds and pus, fearing infection. Left completely helpless, the boy lacks money for food, let alone clinic visits or medicine. He remains there suffering in isolation because people are too afraid of his condition to approach him.” (Street connected child, 12, M, Adama)

Street connected child

This concern was echoed by several key informants who reported widespread community hesitance to offer jobs to children affected by scabies due to fear of contamination. One informant explained:

People hesitate to employ visibly infested youth, who rely on begging or street work for survival. Stigma and shame drive these children to withdraw from income-generating activities entirely. Lacking money, treatment priorities drop below basic daily survival needs. In desperation, they turn to unsafe healthcare alternatives, triggering secondary health complications. (Key Informant, M at COC, Hawassa)

Some key informants also highlighted the economic burden of scabies, particularly its broader systemic impact. One health bureau representative in Addis Ababa explained,

In my view scabies may cause dual economic effect. It affects patients by forcing them to withdraw from daily economic activities. Beyond the individual level, the condition contributes to a cumulative strain on healthcare demanding more resources for treatment. (Key Informant, M, Health Bureau, Addis Ababa)

A professional from social affairs sector also noted:

Homeless individuals often face significant barriers to accessing healthcare, including lack of insurance, transportation challenges, and negative attitudes from healthcare providers. These barriers can lead to delayed diagnosis and treatment, worsening the economic burden. (Key Informant, M, Social Affairs Department, Adama)

The dire circumstances that street connected children face significantly compromise their general welfare, and scabies exacerbates these challenges, adding an additional layer of burden. Our findings indicate that the physical impacts such as widespread skin infections, persistent itching, and disrupted sleep are prevalent among the respondents. Limited access to treatment and low health-seeking behaviors among street connected children further aggravate the situation, delaying necessary medical intervention and potentially leading to severe complications inherent to untreated scabies. While this study did not evaluate the long-term physical complications of scabies among street connected children, existing literature suggests that untreated scabies can result in serious adverse outcomes, including bacterial infections and kidney diseases (1, 33). This highlights the need for more clinical investigations to verify these outcomes in street connected children specifically.

The study highlighted participant perspectives regarding a critical gap in the response to scabies among street connected children, suggesting that both infested individuals and key stakeholders have contributed to the worsening burden of the disease. Interviews indicated that street connected children often downplay the severity of scabies, believing it will resolve on its own, which reportedly discourages them from seeking timely treatment and perpetuates their suffering. This localized subjective pattern closely resembles behavioral trends observed in low-income settings toward other neglected diseases like podoconiosis (34) where patients also minimize symptoms and delay care. Compounding the issue, stakeholders including healthcare providers and policymakers demonstrate limited awareness effectively sidelining street connected children from essential health services. From the narratives collected, the perceived lack of targeted support in environments where these children live intensifies disease transmission and traps them in a cycle of neglect and reinfection.

This finding revealed a complex web of implications that extend beyond the immediate clinical symptoms of scabies, highlighting its profound impact on the physical health and daily functioning of the interviewed street connected children. At the most immediate level, scabies manifests as a painful and persistent skin condition; the participants’ narratives indicate that it evolves into chronic health consequences marked by relentless itching, particularly at night. According to the children’s accounts, this nocturnal discomfort leads to significant sleep disruption, which in turn causes daytime exhaustion and diminished physical capacity. Within this cohort, such exhaustion resulted in critical impairments for children whose survival depends on alertness, mobility, and resilience in often harsh environments. These qualitative descriptions of physical distress closely align with established dermatological studies, where scabies is quantifiably associated with severe itching and sleep disturbance, particularly in children living in overcrowded or resource-poor environments (25, 26, 29). The visible skin damage not only signals ongoing physical suffering but also increases susceptibility to secondary infections, compounding the health burden and potentially leading to more severe medical complications. These reported physical ailments are not isolated; they intersect with the children’s broader living conditions, where limited access to hygiene, healthcare, and rest exacerbates their vulnerability.

Moreover, the emotional toll of chronic discomfort and sleep deprivation evident in both verbal accounts and visual expressions points to a deeper psychosomatic impact, where physical suffering bleeds into psychological distress. This interplay between physical and emotional hardship undermines their ability to engage in daily activities, from seeking food and shelter to maintaining social connections. In sum, the findings underscore that scabies, in this context, is not a minor dermatological issue but a marker of systemic neglect, with cascading effects on health, functionality, and overall well-being. Addressing it requires a holistic public health response that integrates medical treatment with broader support for the structural determinants of health

The study’s findings highlight that among our participants there was a perceived gap in health literacy regarding the complications of scabies, particularly the risk of secondary infections. While the interviewed children frequently recognized immediate symptoms such as itching and rash their accounts revealed a limited awareness about the potential for more severe outcomes and long-term morbidity. This stands in stark contrast to established global evidence, such as WHO reports, which formally link scabies to serious systemic complications like septicemia and kidney disease (9). Within our cohort, this subjective lack of awareness was illustrated by the children’s inability to associate untreated scabies with serious complications like bleeding, pus-filled lesions, and infestations exacerbated by environmental factors, including flies attracted to open wounds. The children’s firsthand accounts of experiencing or witnessing such complications highlight the lived consequences of what they described as inadequate treatment and poor hygiene conditions. These observations suggest that beyond clinical intervention, there is an urgent need for health education and community-based awareness campaigns. Such efforts should aim to empower children and caregivers with the knowledge to recognize early signs of infection and seek timely treatment, while also addressing environmental determinants that contribute to disease severity. This multifaceted approach is essential to prevent avoidable suffering and to break the cycle of reinfection and neglect.

A particularly alarming dimension of the findings was the widespread use of hazardous home remedies. The mention of “risky coping mechanisms” suggests that in the absence of formal care, children infested by scabies may resort to harmful practices such as excessive scratching or using unsafe substances to manage their symptoms, further endangering their health. These improvised treatments not only failed to cure the condition but, in some cases, caused serious harm including burns and eye injuries. Similar patterns have been documented in other low-resource settings, where misinformation and desperation drive the use of unsafe remedies, despite their risks (35). Such practices reflect both the desperation of affected children and the systemic neglect that leaves them without safe, effective treatment options. This underscores the urgent need for targeted public health interventions, as emphasized in WHO guidelines for managing scabies in vulnerable populations (9).

Findings also reveal the profound psychosocial toll of scabies on street connected children, with stigma emerging as a central theme shaping their daily experiences and health behaviors. Children reported being excluded from vital social activities such as eating and playing, often facing rejection from peers and community members who perceived them as contagious. These experiences were not only verbalized but also powerfully illustrated through drawings, underscoring the emotional weight of isolation. Similar patterns of social exclusion have been documented in other stigmatizing NTDs, such as lymphatic filariasis and leprosy, where visible symptoms trigger avoidance and discrimination (36, 37). While some children described solidarity within close-knit peer groups, stigmatization was still prevalent, especially during interpersonal conflicts or when symptoms were visibly severe. This mirrors findings from podoconiosis studies, which show that peer support can buffer stigma, though tensions may still provoke discriminatory behavior (34).

Community-level stigma further compounded the participants’ marginalization, with the children describing instances where residents avoided contact and denied visibly-affected children food. Importantly, the internalization of stigma led to what appeared to be self-stigmatizing behaviors; participants reported hiding symptoms and avoiding treatment out of shame or fear of ridicule. These qualitative findings align with broader literature; for instance, a systematic review of skin-related NTDs found that concealment and delayed care are common responses to stigma, often worsening disease outcomes (38). This reported self-imposed isolation was particularly pronounced among girls, who associated scabies with social disgrace and gendered expectations - a dynamic echoed in studies on genital schistosomiasis and podoconiosis, where women report heightened shame and social withdrawal due to cultural norms (39, 40). Together, these participant insights highlight the urgent need for stigma-sensitive interventions that address both external discrimination and internalized shame, as emphasized in global policy analyses on NTDs (41).

Our findings highlighted the perceptions of street connected children about the consequences of scabies on their economic life, causing them financial strain. Previous studies (5) have reported the impact of scabies on the economic wellbeing of street connected children in Ethiopia through restricting their physical mobility. A systematic review (42) also found that scabies impacted the daily living routines, and hence earnings, of people affected, the impact being more pronounced among people already living at subsistence level. The treatment cost of scabies was equated to one week of household cash earnings in a community where scabies was the second most common skin disease (43, 44). As street connected children suffer from the condition, it restricts their ability to move through the city and secure work. Most people were reportedly unwilling to give jobs like carrying luggage to street connected children infested with scabies, leading children to hide their affected hands inside a plastic bag or their own jackets (45). Another study (46) explored the impact of scabies on the quality of life of children from an impoverished community, including dressing differently due to feelings of shame, restrictions on leisure activities, and stigmatization. The same study also noted that women and girls felt more restricted compared to men and boys.

The financial constraints caused by scabies can lead to delayed diagnosis and treatment as the street connected children have to rely on out-of-pocket contributions to get healthcare services. The vast majority of street youth survive on highly unstable, small incomes. In contrast, from the participants’ perspective, even the most basic, first-line medical treatments for scabies at public pharmacies or private drug shops are financially out of reach. This is exacerbated by the absence of an inclusive healthcare policy to facilitate access to healthcare services for the street connected children in Ethiopia (47). Such disregard for the social protection needs of street connected children may have resulted from the government’s attitude towards child streetism in general. A study (48) noted that street connected children in Ethiopia are considered to be criminals or at least to have the mentality of committing crime both by the government and by society in general. This significantly shapes how the government responds to the healthcare needs of street connected children infested with scabies. Street connected children are also stigmatized by healthcare professionals, affecting their health-seeking behavior and limiting their access to services. Previous studies have revealed that healthcare staff have negative attitudes towards street connected children (49), who report stigma from health professionals making them worry they would be refused treatment (50).

Neglect and denial of healthcare access have significant implications on the wellbeing of individual street connected children and the broader healthcare system. At the individual level, it worsens the condition by intensifying secondary complications and the economic burden for treating these complications (51). Failure to treat scabies could cause implications such as acute rheumatic fever, rheumatic heart disease, poststreptococcal glomerulonephritis and invasive bacterial infections complications (44). Further, secondary bacterial infections could contribute to the morbidity and mortality caused by scabies (52). At the systemic level, the high prevalence of scabies among street connected children can place strain on the healthcare system particularly in resource-limited settings. Clinics and hospitals may need to dedicate more resources to treating scabies and its complications, potentially diverting resources from other essential services. Investment in scabies prevention and control may therefore reduce the direct and indirect cost of scabies treatment in the longer term (53).

The findings align closely with the biopsychosocial theory, which emphasizes that health outcomes are shaped not only by biological factors but also by psychological and social dimensions. In the case of street connected children with scabies, the biological burden of persistent itching, secondary infections, and sleep disruption intersects with psychological distress from chronic discomfort and stigma, while social exclusion, hazardous coping practices, and economic marginalization compound their vulnerability. This multidimensional interplay illustrates how scabies is not merely a dermatological condition but a biopsychosocial challenge, where neglect of any one domain perpetuates suffering and reinforces cycles of poor health, social isolation, and diminished functionality.

Strengths and limitations of the study

This research represents one of the few studies conducted in Ethiopia that specifically explores the perspectives of street connected children regarding scabies. To ensure depth and authenticity in the data, we employed a range of qualitative methods, including interviews, focus group discussions, and participatory visual techniques such as “draw and tell” exercises. These creative tools proved highly effective in engaging street connected children, allowing them to express their experiences in a more comfortable and meaningful way. Additionally, the involvement of peer facilitators among the street connected children who were trained to assist in participant recruitment and data collection helped build trust and reduce social desirability bias, thereby enhancing the credibility of the findings. Despite these strengths, the study has limitations. It was conducted in only three urban centers, which may restrict the generalizability of the results to other regions or contexts. Additionally, this study explores the subjective, reported economic consequences from the participants’ perspectives and does not constitute a quantified, objective economic evaluation. Furthermore, as the findings are based solely on qualitative data, future research incorporating quantitative methods would be valuable to validate and expand upon these insights, potentially informing broader public health interventions and policy responses.

By sensitizing key stakeholders about the psychosocial and economic impacts of scabies, the findings could be used to advocate for reduced stigma and increased access to health services for street connected children in Ethiopia. The study informs development organizations to intervene on addressing stigmatizing attitudes related to scabies and barriers to healthcare access in impoverished communities. Consequently, not only that stigma and sufferings from illness are reduced, the risk of secondary health complications to the street connected children and future burden on the health system at large are minimized. Peer-led education and integrating interventions to control scabies among street-connected children via existing health structures and strong advocacy are of paramount importance. Building on this formative work, a pilot intervention to test the feasibility of this approach is recommended to effectively control burden of scabies among these vulnerable populations.